Zhang Jessica J, Reuben David B, Walling Anne M, Zingmond David S, Damberg Cheryl L, Wenger Neil S, Xu Haiyong, Ikesu Ryo, Kaneshiro Gillian S, Klomhaus Alexandra, Gotanda Hiroshi, Tsugawa Yusuke
Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles.
National Clinician Scholars Program, University of California, Los Angeles.
JAMA Health Forum. 2025 May 2;6(5):e250731. doi: 10.1001/jamahealthforum.2025.0731.
Individuals with dementia may receive high-intensity care at the end of life (EOL) that does not align with their preferences and is costly. Medicare Accountable Care Organizations (ACOs) are an alternative payment model that aims to incentivize high-quality care and lower spending.
To compare EOL care processes, outcomes, and health care spending between Medicare beneficiaries with dementia in a Medicare Shared Savings Program (MSSP) ACO and non-ACO.
DESIGN, SETTING, AND PARTICIPANTS: This quasi-experimental study of EOL care used a nationally representative 20% random sample of Medicare fee-for-service beneficiaries with dementia (age ≥66 years) who died from 2017 to 2020. Difference-in-differences and event study design approaches were used to compare outcomes between beneficiaries attributed to MSSP ACO vs those who were not. Data were analyzed from June 2023 to December 2024.
MSSP ACO entry from 2017 to 2019 vs non-ACO.
Differential changes in 5 areas: (1) billing for advance care planning; (2) palliative care counseling in last 6 months of life; (3) hospice in last 6 months of life; (4) high-intensity care in last 30 days of life (ie, emergency department visit, hospitalization, intensive care unit admission, in-hospital death, cardiopulmonary resuscitation or mechanical ventilation, feeding tube placement); and (5) health care spending in last 6 months of life.
Of 162 034 eligible Medicare beneficiaries (mean [SD] age, 85.0 [7.9] years; 94 304 female [58.2%]), 51 191 (31.6%) were attributed to MSSP ACO. Adjusted trends in outcomes were similar between ACO and non-ACO groups before ACO entry. The difference-in-differences analyses found no evidence that EOL care processes or outcomes (eg, hospice in last 6 months of life, -0.4 percentage points [pp]; 95% CI, -1.4 pp to 0.5 pp; P > .99) or spending (eg, total health care spending in last 6 months of life, -$632; 95% CI, -$1377 to $113; P = .96) differed between beneficiaries treated in ACOs vs non-ACOs. The event study design also showed no evidence of differential changes in outcomes between the 2 groups. Sensitivity analyses using inverse probability weighting yielded similar results.
Using nationally representative data on beneficiaries with dementia at EOL, this quasi-experimental study found no evidence that EOL care processes, outcomes, or spending changed with ACO entry for Medicare fee-for-service beneficiaries vs non-ACO beneficiaries. Alternative payment models to ACOs may be needed to coordinate high-quality care with lower spending for beneficiaries with dementia at the EOL.
患有痴呆症的个体在生命末期（EOL）可能会接受高强度护理，这与他们的偏好不符且成本高昂。医疗保险责任医疗组织（ACO）是一种替代支付模式，旨在激励高质量护理并降低支出。
比较医疗保险共享节约计划（MSSP）ACO中的痴呆症医疗保险受益人与非ACO中的受益人在生命末期护理流程、结果和医疗保健支出方面的差异。
设计、设置和参与者：这项关于生命末期护理的准实验研究使用了2017年至2020年期间死亡的具有全国代表性的20%医疗保险按服务收费受益人的随机样本（年龄≥66岁），这些受益人患有痴呆症。采用差异中的差异和事件研究设计方法来比较归因于MSSP ACO的受益人与未归因于此的受益人之间的结果。数据于2023年6月至2024年12月进行分析。
2017年至2019年进入MSSP ACO与未进入ACO。
五个方面的差异变化：（1）预先护理计划的计费；（2）生命最后6个月的姑息治疗咨询；（3）生命最后6个月的临终关怀；（4）生命最后30天的高强度护理（即急诊就诊、住院、重症监护病房入院、院内死亡、心肺复苏或机械通气、放置喂食管）；（5）生命最后6个月的医疗保健支出。
在162034名符合条件的医疗保险受益人中（平均[标准差]年龄为85.0[7.9]岁；94304名女性[58.2%]），51191名（31.6%）归因于MSSP ACO。在ACO进入之前，ACO组和非ACO组的调整后结局趋势相似。差异中的差异分析没有发现证据表明生命末期护理流程或结果（例如，生命最后6个月的临终关怀，-0.4个百分点[pp]；95%置信区间，-1.4 pp至0.5 pp；P>.99）或支出（例如，生命最后6个月的总医疗保健支出，-$632；95%置信区间，-$1377至$113；P=.96）在ACO治疗的受益人与非ACO治疗的受益人之间存在差异。事件研究设计也没有显示两组之间结局有差异变化的证据。使用逆概率加权的敏感性分析得出了类似的结果。
利用关于生命末期痴呆症受益人的全国代表性数据，这项准实验研究没有发现证据表明医疗保险按服务收费受益人进入ACO与非ACO受益人相比，生命末期护理流程、结果或支出发生了变化。可能需要ACO之外的替代支付模式来为生命末期的痴呆症受益人协调高质量护理与更低支出。
