Association Between Organizational Quality and Out-of-Network Primary Care Among Accountable Care Organizations That Care for High vs Low Proportions of Patients of Racial and Ethnic Minority Groups.
Association Between Organizational Quality and Out-of-Network Primary Care Among Accountable Care Organizations That Care for High vs Low Proportions of Patients of Racial and Ethnic Minority Groups.
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DOI：
10.1001/jamahealthforum.2022.0575
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发表时间：
2022-04
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医疗保险责任护理组织（ACO）提供的护理质量如何与照顾高比例与低比例种族和少数民族患者的组织中的网络外初级保健水平相关？在这项回顾性队列研究中，对528家医疗保险ACO进行了3 955 951年的研究，照顾更多种族和少数民族患者的ACO的网络外初级保健率显著高于那些照顾较少种族和少数民族患者的ACO。网络外初级保健水平与ACO的表现呈负相关，在大多数质量指标检查中，许多患者是种族和少数民族群体。研究结果表明，组织努力限制ACO照顾许多种族和少数民族患者的网络外初级保健可以作为减少他们所服务的人群之间医疗保健差异的有形，可访问的纠正措施。医疗保险责任医疗组织（ACO）不成比例地照顾种族和少数民族群体的患者，提供比那些不提供更低质量的护理，可能是由于网络外初级保健的差异。研究组织质量如何与ACO中的网络外初级保健相关，这些ACO负责照顾高比例和低比例的种族和少数族裔群体患者。在2019年3月至2021年10月期间进行了一项回顾性队列研究，使用了来自全国医疗保险受益人样本的索赔数据（2013年至2016年）。在被分配到528个Medicare ACO中的1个的受益人中，对那些由照顾高比例（与低比例）种族和少数族裔群体患者的组织治疗的受益人进行了区分。对于每个ACO，确定了它每年提供的网络外初级保健的数量。多变量模型适合于评估受益人获得的护理质量如何因ACO向种族和少数民族群体患者提供的护理比例及其网络外初级保健数量而异。ACO向少数种族和族裔群体患者提供的护理程度及其网络外初级护理的数量。ACO的质量评估有5个预防保健服务和4个利用指标。在3955951个春秋中（2 320 429名[58.7%]妇女; 71 218 [1.8%]亚裔，267 684 [6.8%]黑人，44 059 [1.1%]西班牙裔，4922 [0.1%]北美原住民，白色人3 468 987人[87.7%]，其他人种56 157人[1.4%]），那些分配到ACO服务许多种族和少数民族群体的患者的平均水平，网络初级保健不太可能比那些分配到ACO服务较少的种族和少数民族群体的患者接受糖尿病视网膜检查（预测概率，49.4% [95%CI，49.0%-49.7%] vs 51.6% [95%CI，51.5%-51.8%]），糖化血红蛋白检测（预测概率，58.5% [95% CI，58.2%-58.5%] vs 60.4% [95% CI，60.3%-60.6%]），或低密度脂蛋白胆固醇检测（预测概率，85.2% [95% CI，85.0%-85.5%] vs 86.0% [95% CI，85.9%-86.1%]）。他们也更有可能经历全因30天再入院（预测概率，16.4% [95% CI，16.1%-16.7%] vs 15.7% [95% CI，15.6%-15.8%]）。然而，随着网络外初级保健水平的下降，这些差距大大缩小，这样，在ACO的受益人，服务于许多和更少的病人的种族和少数民族群体在网络外初级保健的最低百分位获得相当的质量的照顾。这项大型队列研究发现，为许多种族和少数民族患者提供服务的ACO的质量表现与他们的网络外初级保健水平呈负相关。这项队列研究探讨了负责任的医疗机构，照顾高与低比例的种族和少数民族群体的患者之间的组织质量与网络外的初级保健的关联。
How is the quality of care delivered by a Medicare accountable care organization (ACO) associated with the level of out-of-network primary care among organizations that care for high vs low proportions of patients of racial and ethnic minority groups? In this retrospective cohort study of 3 955 951 beneficiary-years within 528 Medicare ACOs, the ACOs that cared for more patients of racial and ethnic minority groups had significantly higher rates of out-of-network primary care than those that cared for fewer patients of racial and ethnic minority groups. The level of out-of-network primary care was negatively associated with performance among ACOs with many patients of racial and ethnic minority groups across most quality metrics examined. The study findings suggest that organizational efforts to limit out-of-network primary care at ACOs caring for many patients of racial and ethnic minority groups could serve as a tangible, accessible corrective for reducing health care disparities among the populations that they serve. Medicare accountable care organizations (ACOs) that disproportionately care for patients of racial and ethnic minority groups deliver lower quality care than those that do not, potentially owing to differences in out-of-network primary care among them. To examine how organizational quality is associated with out-of-network primary care among ACOs that care for high vs low proportions of patients of racial and ethnic minority groups. A retrospective cohort study was conducted between March 2019 and October 2021 using claims data (2013 to 2016) from a national sample of Medicare beneficiaries. Among beneficiaries who were assigned to 1 of 528 Medicare ACOs, a distinction was made between those treated by organizations that cared for high (vs low) proportions of patients of racial and ethnic minority groups. For each ACO, the amount of out-of-network primary care that it delivered annually was determined. Multivariable models were fit to evaluate how the quality of care that beneficiaries received varied by the proportion of care provided to patients of racial and ethnic minority groups by the ACO and its amount of out-of-network primary care. The degree of care provided to patients of racial and ethnic minority groups by the ACO and its amount of out-of-network primary care. The ACO quality assessed with 5 preventive care services and 4 utilization metrics. Among 3 955 951 beneficiary-years (2 320 429 [58.7%] women; 71 218 [1.8%] Asian, 267 684 [6.8%] Black, 44 059 [1.1%] Hispanic, 4922 [0.1%] North American Native, and 3 468 987 [87.7%] White individuals and 56 157 [1.4%] of Other race and ethnicity), those assigned to ACOs serving many patients of racial and ethnic minority groups at the mean level of out-of-network primary care were less likely than those assigned to ACOs serving fewer patients of racial and ethnic minority groups to receive diabetic retinal examinations (predicted probability, 49.4% [95%CI, 49.0%-49.7%] vs 51.6% [95% CI, 51.5%-51.8%]), glycated hemoglobin testing (predicted probability, 58.5% [95% CI, 58.2%-58.5%] vs 60.4% [95% CI, 60.3%-60.6%]), or low-density lipoprotein cholesterol testing (predicted probability, 85.2% [95% CI, 85.0%-85.5%] vs 86.0% [95% CI, 85.9%-86.1%]). They were also more likely to experience all-cause 30-day readmissions (predicted probability, 16.4% [95% CI, 16.1%-16.7%] vs 15.7% [95% CI, 15.6%-15.8%]). However, as the level of out-of-network primary care decreased, these gaps closed substantially, such that beneficiaries at ACOs that served many and fewer patients of racial and ethnic minority groups in the lowest percentile of out-of-network primary care received care of comparable quality. This large cohort study found that quality performance among ACOs serving many patients of racial and ethnic minority groups was negatively associated with their level of out-of-network primary care. This cohort study examines the association of organizational quality with out-of-network primary care among accountable care organizations that care for high vs low proportions of patients of racial and ethnic minority groups.