Medicare Spending after 3 Years of the Medicare Shared Savings Program.
Medicare Spending after 3 Years of the Medicare Shared Savings Program.
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在Medicare共享储蓄计划3年后，Medicare支出。
DOI：
10.1056/nejmsa1803388
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发表时间：
2018-09-20
期刊：
影响因子：
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通讯作者：
Chernew ME
中科院分区：
文献类型：
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作者：
McWilliams JM;Hatfield LA;Landon BE;Hamed P;Chernew ME
作为一个负责任的护理组织（ACO）参与自愿医疗保险共享储蓄计划（MSSP）的医疗保健提供者有动机降低医疗保险患者的支出，同时在一系列质量指标上实现高绩效。很少有人知道在何种程度上实现了早期节省的ACO在该计划中已经增长，并复制了ACO进入该计划在以后几年。作为医生团体的ACO比医院综合ACO有更强的动机来降低支出。使用2009年至2015年的按服务收费医疗保险索赔，我们进行了差异中的差异分析，以比较进入MSSP之前和之后ACO患者的医疗保险支出变化，以及未参加MSSP的提供者（对照组）服务的当地患者的支出变化。我们估计了差异变化（即，与入组前相比变化的组间差异），分别针对2012年、2013年或2014年进入MSSP的医院整合ACO和医生组ACO。MSSP参与与医生组ACO的差异支出减少相关。这些减少随着参与该计划的时间延长而增加，并且显著大于医院整合的ACOs的减少。到2015年，每位患者医疗保险支出的平均差异变化为-474美元（入组前平均值的-4.9%，P<0.001）对于2012年入组的医生组ACO，-342美元2013年入学的学生平均收入为-3.5%（入学前平均收入的-3.5%，P<0.001），2014年入学的学生平均收入为-156美元（入学前平均收入的-1.6%，P = 0.009）。医院合并ACO的相应差异变化分别为-169美元（P = 0.005）、-18美元（P = 0.78）和88美元（P = 0.14），显著低于医生组ACO（P<0.001）。2015年，医生组ACO的支出减少为医疗保险节省了2.564亿美元，而医院综合ACO的支出减少被奖金抵消。MSSP实施3年后，医生团体参与共享储蓄合同与研究期间医疗保险的储蓄增长相关，而医院整合的ACO在同一时期没有产生储蓄（平均）。（由国家老龄化研究所资助。
Health care providers who participate as an accountable care organization (ACO) in the voluntary Medicare Shared Savings Program (MSSP) have incentives to lower spending for Medicare patients while achieving high performance on a set of quality measures. Little is known about the extent to which early savings achieved by ACOs in the program have grown and been replicated by ACOs that entered the program in later years. ACOs that are physician groups have stronger incentives to lower spending than hospital-integrated ACOs. Using fee-for-service Medicare claims from 2009 through 2015, we performed difference-in-differences analyses to compare changes in Medicare spending for patients in ACOs before and after entry into the MSSP with concurrent changes in spending for local patients served by providers not participating in the MSSP (control group). We estimated differential changes (i.e., the between-group difference in the change from the pre-entry period) separately for hospital-integrated ACOs and physician-group ACOs that entered the MSSP in 2012, 2013, or 2014. MSSP participation was associated with differential spending reductions in physician-group ACOs. These reductions grew with longer participation in the program and were significantly greater than the reductions in hospital-integrated ACOs. By 2015, the mean differential change in per-patient Medicare spending was −$474 (−4.9% of the pre-entry mean, P<0.001) for physician-group ACOs that entered in 2012, −$342 (−3.5% of the pre-entry mean, P<0.001) for those that entered in 2013, and −$156 (−1.6% of the pre-entry mean, P = 0.009) for those that entered in 2014. The corresponding differential changes for hospital-integrated ACOs were −$169 (P = 0.005), −$18 (P = 0.78), and $88 (P = 0.14), which were significantly lower than for physician-group ACOs (P<0.001). Spending reductions in physician-group ACOs constituted a net savings to Medicare of $256.4 million in 2015, whereas spending reductions in hospital-integrated ACOs were offset by bonus payments. After 3 years of the MSSP, participation in shared-savings contracts by physician groups was associated with savings for Medicare that grew over the study period, whereas hospital-integrated ACOs did not produce savings (on average) during the same period. (Funded by the National Institute on Aging.)