Changes in Low-Value Services in Year 1 of the Medicare Pioneer Accountable Care Organization Program.
Changes in Low-Value Services in Year 1 of the Medicare Pioneer Accountable Care Organization Program.
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DOI：
10.1001/jamainternmed.2015.4525
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发表时间：
2015-11
影响因子：
39
通讯作者：
McWilliams JM
中科院分区：
文献类型：
--
作者：
Schwartz AL;Chernew ME;Landon BE;McWilliams JM
浪费的做法在美国医疗保健系统中很普遍。目前尚不清楚旨在提高医疗保健效率的支付模式，如医疗保险责任医疗组织（ACO）计划，是否会阻碍提供低价值服务。评估Medicare Pioneer ACO计划的第一年是否与低价值服务的使用减少有关。在差异分析中，我们比较了进入先锋计划的提供者群体（ACO组）和其他提供者（对照组）的医疗保险按服务收费受益人之间使用低价值服务的情况（2009-2011年）与（2012年）先锋ACO合同开始后。我们调整了受益人的社会人口统计学和临床特征以及地理位置的比较。我们根据服务特征（临床类别、价格和对患者偏好的敏感性）对估计值进行了分解，并比较了基线使用低价值服务的ACO亚组之间的估计值。在提供最小临床效益的情况下使用31项服务并在其上支出。在合约前期间，助理法律顾问办公室和对照组使用低价值服务的趋势相似。ACO合同的第一年与ACO组每100名受益人0.8个低价值服务的差异减少有关（95% CI：-1.2，-0.4; P<0.001），相当于服务量减少1.9%（95%CI：-2.9%，-0.9%），低价值服务支出减少4.5%（95%CI：-7.5%，-1.4%; P=0.004）。对于对患者偏好不太敏感的服务和对患者偏好更敏感的服务以及高价服务和低价服务，差异减少是相似的。低价值服务使用水平高于市场平均基线水平的ACO经历了更大的服务减少（每100名受益人中有-1.2项服务，95% CI：-1.7，-0.7; P<0.001）（每100名受益人获得-0.2次服务，95%置信区间：-0.6，0.2; P=0.41;亚组间差异检验P=0.003）。在第一年，先锋ACO计划与低价值服务的适度减少有关，提供更多低价值护理的组织减少更多。类似ACO的风险合同可能能够阻止使用低价值服务，即使没有指定目标服务。
Wasteful practices are widespread in the US health care system. It is unclear if payment models intended to improve health care efficiency, such as the Medicare accountable care organization (ACO) programs, discourage the provision of low-value services. To assess whether the first year of the Medicare Pioneer ACO program was associated with a reduction in use of low-value services. In a difference-in-differences analysis, we compared use of low-value services between Medicare fee-for-service beneficiaries attributed to provider groups that entered the Pioneer program (ACO group) and beneficiaries attributed to other providers (control group) before (2009–2011) vs. after (2012) Pioneer ACO contracts began. We adjusted comparisons for beneficiaries’ sociodemographic and clinical characteristics and for geography. We decomposed estimates according to service characteristics (clinical category, price, and sensitivity to patient preferences) and compared estimates between subgroups of ACOs with higher vs. lower baseline use of low-value services. Use of, and spending on, 31 services in instances that provide minimal clinical benefit. During the pre-contract period, trends in use of low-value services were similar for the ACO and control groups. The first year of ACO contracts was associated with a differential reduction of 0.8 low-value services per 100 beneficiaries for the ACO group (95% CI: −1.2, −0.4; P<0.001), corresponding to a 1.9% reduction in service quantity (95% CI: −2.9%, −0.9%) and a 4.5% differential reduction in spending on low-value services (95% CI: −7.5%, −1.4%; P=0.004). Differential reductions were similar for services less vs. more sensitive to patient preferences and for higher- vs. lower-priced services. ACOs with higher than their markets average baseline levels of low-value service use experienced greater service reductions (−1.2 services per 100 beneficiaries, 95% CI: −1.7, −0.7; P<0.001) than ACOs with below average use (−0.2 services per 100 beneficiaries, 95% CI: −0.6, 0.2; P=0.41; P=0.003 for test of difference between subgroups). During its first year, the Pioneer ACO program was associated with modest reductions in low-value services, with greater reductions for organizations providing more low-value care. ACO-like risk contracts may be able to discourage use of low-value services even without specifying services to target.