Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, 610 Walnut Street, Madison, WI, 53726, USA.
Harvard University, T.H. Chan School of Public Health, 677 Huntington Avenue Kresge, 4th Floor, Boston, Massachussetts, 02115, USA.
Healthc (Amst). 2021 Mar;9(1):100460. doi: 10.1016/j.hjdsi.2020.100460. Epub 2021 Jan 4.
Medicare's accountable care organizations (ACOs)-designed to improve quality and lower spending-were associated with growing savings in previous studies. However, savings estimates may be biased by beneficiary sorting among providers based on healthcare needs and by providers opting into the program based on anticipated gains.
Using Medicare administrative claims (2009-2014), we compared annual spending changes after provider organizations joined ACOs to changes in non-ACOs (controls). To address provider selection, using novel data to identify non-ACO organizations, we restricted controls to comparably large provider organizations. To address beneficiary selection, we (a) estimated within-organization (including non-ACO comparison organizations) spending changes, (b) estimated within-beneficiary spending changes, (c) incorporated beneficiaries without qualifying healthcare expenses, and (d) used a fixed beneficiary ACO assignment using the pre-ACO period.
Each year, 19% of Medicare beneficiaries switched provider organizations. Spending was higher for switchers than stayers ($3163, p < .001) and grew more the next year ($2004; p < .001). Starting from a baseline regression modeled on previous ACO evaluations, estimated savings varied widely as we sequentially introduced methods to address selection. Combining methods, however, generated more stable estimated ACO savings of $46 (p = .022), averaged across cohorts.
When implementing a comprehensive suite of methods to adjust for provider and beneficiary selection, we estimated ACO savings that grew over time. Our estimates are in line with, but smaller than, previous estimates in the literature. Implementing piecemeal adjustments produced misleading results.
Our results confirm the importance of selection for savings estimates and for provider organizations managing costs and quality. Attribution rules that consider multiple years may help mitigate the impact of beneficiary churn for providers and payers. Implementing payment reform by randomizing early participants, or implementing fully across selected markets, may better serve efforts to evaluate and improve payment models.
Level 3.
医疗保险的问责制医疗组织（ACO）旨在提高质量并降低支出，在之前的研究中与不断增长的储蓄相关联。然而，储蓄估计可能会受到基于医疗需求在提供者之间进行的受益人选配的影响，也可能会受到提供者根据预期收益选择参与该计划的影响。
使用医疗保险管理索赔数据（2009-2014 年），我们将加入 ACO 的提供者组织的年度支出变化与非 ACO （对照）的支出变化进行了比较。为了解决提供者选择问题，我们使用新数据来确定非 ACO 组织，将对照限定在可比的大型提供者组织中。为了解决受益人选配问题，我们（a）估计了组织内（包括非 ACO 比较组织）的支出变化，（b）估计了受益人的支出变化，（c）纳入了没有合格医疗费用的受益人，（d）使用了在 ACO 之前时期的固定受益人的 ACO 分配。
每年有 19%的医疗保险受益人更换提供者组织。与留守者相比，换组织者的支出更高（$3163，p<0.001），次年的支出增长更多（$2004；p<0.001）。从之前 ACO 评估的模型回归开始，我们逐步引入了针对选择的方法，从而使估计的储蓄变化范围广泛。然而，将方法结合起来，产生了更稳定的 ACO 储蓄估计值$46（p=0.022），跨越队列平均。
当实施一整套综合方法来调整提供者和受益人选配时，我们估计了随着时间的推移而增长的 ACO 储蓄。我们的估计与文献中的先前估计相符，但较小。实施零碎调整会产生误导性结果。
我们的结果证实了选择对储蓄估计和提供者组织管理成本和质量的重要性。考虑多年的归因规则可能有助于减轻受益人选配变化对提供者和付款人的影响。通过随机选择早期参与者实施支付改革，或者在选定的市场中全面实施，可能会更好地服务于评估和改进支付模式的努力。
3 级。
