Sol Price School of Public Policy, University of Southern California, Los Angeles.
Health Policy Research Center, Mongan Institute, Massachusetts General Hospital, Boston.
JAMA Health Forum. 2021 Dec 10;2(12):e214122. doi: 10.1001/jamahealthforum.2021.4122. eCollection 2021 Dec.
Geographic variation in Medicare spending is often used as a measure of wasteful spending. A 2013 Institute of Medicine report found that postacute care was a key contributor of geographic variation from 2007 to 2009. However, payment reforms and antifraud efforts implemented after the passage of the Affordable Care Act (ACA) may have reduced geographic variation in spending, especially postacute care spending.
To investigate how geographic variation in Medicare fee-for-service per-beneficiary spending changed from 2007 to 2018 before and after passage of the ACA.
This cross-sectional study included all fee-for-service Medicare enrollees 65 years or older from January 1, 2007, to December 31, 2018. The fee-for-service Medicare Geographic Variation Public Use File was used to group hospital referral regions (HRRs) in each year into deciles (10 equal groups) based on per-beneficiary total spending. The difference between the per-beneficiary monthly spending in each decile and the national mean, as well as the ratio of per-beneficiary total spending in the top deciles to that of the bottom decile, were reported. Data analysis occurred from July 22, 2019, to October 21, 2021.
Per-beneficiary spending on hospital inpatient, hospital outpatient, physician, and postacute care (and type of postacute care).
There were 27.2 million fee-for-service beneficiaries in 2007 (58.0% women) and 28.3 million beneficiaries in 2018 (55.9% women). Per-beneficiary Medicare spending was $9691 in 2007 and $9847 in 2018 (using inflation-adjusted 2018 dollars). Geographic variation in Medicare spending was stable from 2007 to 2011 and then declined steadily from 2012 to 2018. The ratio of per-beneficiary total Medicare spending in the HRRs in the top decile to the bottom decile was 1.68 in 2007 ($415 monthly difference in spending) but only 1.56 ($361 monthly difference in spending) in 2018 (estimated change, -0.12 [95% CI, -0.21 to -0.02]; = .01). Focusing on specific spending categories, the only statistically significant reductions in geographic variation were found for home health; the ratio of home health spending among HRRs in the top to bottom deciles of total Medicare spending fell from 5.14 in 2007 to 3.45 in 2018 (change, -1.69 [95% CI, -3.30 to -0.09]; = .04).
Geographic variation in total per-beneficiary Medicare spending fell from 2007 to 2018, with home health spending being a key factor associated with geographic variation. The ACA's value-based payment programs and enhanced integrity efforts in home health provide a possible explanation for the decrease.
医疗保险支出的地域差异通常被用作衡量浪费性支出的指标。2013 年医学研究所的一份报告发现，2007 年至 2009 年期间，后期护理是造成地域差异的一个关键因素。然而，平价医疗法案（ACA）通过后实施的支付改革和反欺诈措施可能已经降低了支出的地域差异，尤其是后期护理支出的地域差异。
调查在 ACA 通过之前和之后，2007 年至 2018 年间医疗保险按受益人头付费的地域差异如何变化。
设计、设置和参与者：本横断面研究纳入了 2007 年 1 月 1 日至 2018 年 12 月 31 日期间所有 65 岁及以上的按人头付费的医疗保险受保人。使用按人头付费的医疗保险地域差异公共使用文件，将每个年度的医院转诊区域（HRR）按照受益人头总支出分为十分位数（10 个相等的组）。报告了每个十分位数的受益人头每月支出与全国平均值之间的差异，以及最高十分位数的受益人头总支出与最低十分位数的受益人头总支出的比值。数据分析于 2019 年 7 月 22 日至 2021 年 10 月 21 日进行。
医院住院、医院门诊、医生和后期护理（及后期护理类型）的受益人头支出。
2007 年有 2720 万按人头付费的受益人和 2018 年有 2830 万受益人的（55.9%为女性）。2007 年的医疗保险受益人头支出为 9691 美元，2018 年为 9847 美元（使用通胀调整后的 2018 年美元）。2007 年至 2011 年，医疗保险支出的地域差异保持稳定，然后从 2012 年到 2018 年稳步下降。HRR 中最高十分位数和最低十分位数的受益人头总医疗保险支出的比值在 2007 年为 1.68（支出差异为每月 415 美元），而在 2018 年仅为 1.56（支出差异为每月 361 美元）（估计变化，-0.12 [95% CI，-0.21 至 -0.02]； = .01）。在关注特定支出类别时，仅发现家庭健康的地域差异有统计学意义的减少；HRR 中家庭健康支出最高十分位数与最低十分位数的比值从 2007 年的 5.14 降至 2018 年的 3.45（变化，-1.69 [95% CI，-3.30 至 -0.09]； = .04）。
从 2007 年到 2018 年，医疗保险受益人头总支出的地域差异下降，家庭健康支出是与地域差异相关的一个关键因素。ACA 的基于价值的支付计划和家庭健康方面的强化诚信措施可能解释了这种下降。
