Changes in Postacute Care in the Medicare Shared Savings Program.
Changes in Postacute Care in the Medicare Shared Savings Program.
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DOI：
10.1001/jamainternmed.2016.9115
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发表时间：
2017-04-01
影响因子：
39
通讯作者：
Grabowski DC
中科院分区：
文献类型：
--
作者：
McWilliams JM;Gilstrap LG;Stevenson DG;Chernew ME;Huskamp HA;Grabowski DC
急性后护理被认为是浪费性支出的主要来源。责任护理组织(ACO)可以在多大程度上限制急性后支出，这对包括急性后护理在内的其他支付模式的重要性和设计具有影响。评估与提供者作为ACO参与联邦医疗保险共享储蓄计划(MSSP)相关的急性后支出和利用的变化，以及这些变化发生的途径。使用2009-2014年的按服务收费的医疗保险索赔，我们对加入MSSP之前和之后由ACO服务的受益人和由当地非ACO提供者服务的受益人(对照组)进行了差异比较。我们分别估计了2012年、2013年和2014年进入MSSP的ACO队列的差异变化。随机抽样20%的受益人，25,544,650人年，8,395,426人住院，1,595,352人在2009-2014年间住院。患者归因于MSSP中的ACO。根据患者特征调整后的急症后支出、出院情况、SNF住院时间、再入院时间、高评级SNF的使用以及死亡率。在2012年的ACO队列中，MSSP的参与与急症后支出的整体减少有关(2014年ACOs与对照组的差异变化：−为106美元/受益人或−9.0%；P=0.003)，这是由住院使用率、出院到设施而不是家庭(−0.6%或−2.7%；P=0.03)以及特殊护理人员停留时间(−0.60d/住院或−2.2%；P=0.002)的差异推动的。SNF使用量和住院时间的减少在很大程度上是由于医院内或SNF内部专门针对ACO患者护理的变化。MSSP的参与与2013年ACO队列2014年的SNF支出较小的显着削减有关，但与2013或2014年队列参与的第一年无关。对与医院有经济联系和没有经济联系的ACO的估计类似。MSSP的参与与30天再入院、使用高评级SNF或死亡率的显著变化无关。参加MSSP与急性后支出的大幅减少有关，而不会出现质量明显下降的情况。支出的减少与临床医生在医院和SNF内工作以影响ACO患者的护理更一致，而不是ACO在医院范围内的倡议或使用首选SNF。
Post-acute care is thought to be a major source of wasteful spending. The extent to which accountable care organizations (ACOs) can limit post-acute spending has implications for the importance and design of other payment models that include post-acute care. To assess changes in post-acute spending and utilization associated with provider participation as ACOs in the Medicare Shared Savings Program (MSSP) and the pathways by which they occurred. Using fee-for-service Medicare claims from 2009–2014, we conducted difference-in-difference comparisons of beneficiaries served by ACOs with beneficiaries served by local non-ACO providers (control group) before vs. after entry into the MSSP. We estimated differential changes separately for cohorts of ACOs entering the MSSP in 2012, 2013, and 2014. Random 20% sample of beneficiaries with 25,544,650 patient-years, 8,395,426 hospital admissions, and 1,595,352 SNF stays from 2009–2014. Patient attribution to an ACO in the MSSP. Post-acute spending, discharge to a facility, length of SNF stays, readmissions, use of highly-rated SNFs, and mortality, adjusted for patient characteristics. For the 2012 cohort of ACOs, MSSP participation was associated with an overall reduction in post-acute spending (differential change in 2014 for ACOs vs. control group: −$106/beneficiary or −9.0%; P=0.003) that was driven by differential reductions in inpatient utilization, discharges to facilities rather than home (−0.6 percentage points or −2.7%; P=0.03), and length of SNF stays (−0.60 days/stay or −2.2%; P=0.002). Reductions in SNF use and length of stay were due largely to within-hospital or within-SNF changes in care specifically for ACO patients. MSSP participation was associated with smaller significant reductions in SNF spending in 2014 for the 2013 ACO cohort but not in the 2013 or 2014 cohort’s first year of participation. Estimates were similar for ACOs with and without financial ties to hospitals. MSSP participation was not associated with significant changes in 30-day readmissions, use of highly-rated SNFs, or mortality. Participation in the MSSP has been associated with significant reductions in post-acute spending without ostensible deterioration in quality. Spending reductions were more consistent with clinicians working within hospitals and SNFs to influence care for ACO patients than with hospital-wide initiatives by ACOs or use of preferred SNFs.