Department of Population Health Sciences, Duke University School of Medicine, and Duke-Margolis Center for Health Policy, Durham, North Carolina.
Duke-Margolis Center for Health Policy.
J Healthc Manag. 2021;66(3):227-240. doi: 10.1097/JHM-D-20-00155.
Accountable care organizations (ACOs) need confidence in their return on investment to implement changes in care delivery that prioritize seriously ill and high-cost Medicare beneficiaries. The objective of this study was to characterize spending on seriously ill beneficiaries in ACOs with Medicare Shared Savings Program (MSSP) contracts and the association of spending with ACO shared savings. The population included Medicare fee-for-service beneficiaries identified with serious illness (N = 2,109,573) using the Medicare Master Beneficiary Summary File for 100% of ACO-attributed beneficiaries linked to MSSP beneficiary files (2014-2016). Lower spending for seriously ill Medicare beneficiaries and risk-bearing contracts in ACOs were associated with achieving ACO shared savings in the MSSP. For most ACOs, the seriously ill contribute approximately half of the spending and constitute 8%-13% of the attributed population. Patient and geographic (county) factors explained $2,329 of the observed difference in per beneficiary per year spending on seriously ill beneficiaries between high- and low-spending ACOs. The remaining $12,536 may indicate variation as a result of potentially modifiable factors. Consequently, if 10% of attributed beneficiaries were seriously ill, an ACO that moved from the worst to the best quartile of per capita serious illness spending could realize a reduction of $1,200 per beneficiary per year for the ACO population overall. Though the prevalence and case mix of seriously ill populations vary across ACOs, this association suggests that care provided for seriously ill patients is an important consideration for ACOs to achieve MSSP shared savings.
责任医疗组织（ACO）需要对投资回报有信心，才能对医疗服务交付进行改变，优先照顾重病和高费用的医疗保险受益人。本研究的目的是描述有医疗保险共享储蓄计划（MSSP）合同的 ACO 中重病受益人的支出情况，以及支出与 ACO 共享储蓄的关系。该人群包括使用医疗保险主受益人汇总文件（100%的 ACO 归因受益人与 MSSP 受益人的文件相关联）确定的有严重疾病的 Medicare 收费服务受益人（2014-2016 年）（N=2,109,573）。在 MSSP 中，ACO 中严重疾病的低支出和风险承担合同与实现 ACO 共享储蓄相关。对于大多数 ACO 而言，重病患者约占支出的一半，占归因人群的 8%-13%。患者和地理（县）因素解释了高支出和低支出 ACO 之间每年每位重病受益人的人均支出差异的 2,329 美元。其余的 12,536 美元可能表明由于潜在可改变的因素而存在差异。因此，如果 10%的归因受益人患有重病，那么 ACO 从人均严重疾病支出最差的四分之一提高到最佳四分之一，那么 ACO 人群中的每位受益人每年可节省 1,200 美元。尽管 ACO 之间重病人群的流行率和病例组合有所不同，但这种关联表明，为重病患者提供的护理是 ACO 实现 MSSP 共享储蓄的一个重要考虑因素。
