The Effects of Accountable Care Organizations on Disparities in Childhood Asthma Care and Outcomes

摘要 哮喘是儿童最常见的慢性疾病， 住院和失学的人数比任何其他儿童疾病都多。低收入、城市、 少数民族人群更容易患哮喘，疾病控制不佳， 并经历可预防的疾病。多层次的干预措施，解决复杂的 造成这些差异的相互关联的社会和环境因素没有得到充分的支持 在传统的按服务付费模式中。责任关怀组织（ACO） 旨在支持和维持解决健康的社会决定因素的干预措施， 医疗等越来越多的高危人群中的哮喘儿童接受 ACOs的治疗，但其对哮喘护理质量，结果和差异的影响尚不清楚。 这项研究将是第一个解决这一关键差距的知识，利用自然的优势， 在儿童哮喘发病率高的马萨诸塞州（MA）进行的实验：2018年， 马，推出了17个新的医疗补助ACO与不同的组织特征（例如，大小;年龄混合）。我们将 使用详细的州一级索赔数据，以：1）确定执行 ACO和儿童哮喘质量指标的变化，医疗保险儿童的健康结果 和2）评估这些结果指标中社会经济和种族/民族差异的变化 将参加医疗补助ACO的儿童与匹配的商业保险儿童进行比较。然后我们转向 通过以下方法了解ACO的组织特征对变革的影响：3）使用混合方法 生成ACO组织特征的详细特征; 4）测试关联 这些特征与儿童哮喘质量指标和结果之间的关系。我们将使用创新的 考虑社会风险因素和倾向匹配差异的风险调整方法- 差异分析，以说明ACO实施以外可能影响结果的因素。 这项研究将发生在这样一个时刻，即健康和医疗保健的深刻不平等， 美国都被新冠肺炎大流行照亮了社会经济和种族/族裔不平等 儿童哮喘持续存在，尽管存在基于证据的治疗， 工作和数十亿美元用于改善哮喘护理。医疗保健的结构性变化是 需要公平地提供基于证据的哮喘护理，这应该减少甚至消除 这些长期存在的差异。ACO模式将医疗保健支付和交付的方向 可以促进这种变化。这项研究将解决知识上的主要差距， 在开发ACO模式方面所做的投资可能会为数百万儿童带来回报， 由于哮喘的可预防后果，增加了长期健康不良的风险。

ABSTRACT Asthma is the most common chronic disease of childhood and causes more preventable hospitalizations and lost school days than any other childhood disease. Children in lower-income, urban, and racial/ethnic minority populations are more likely to have asthma, to have poorly controlled disease, and to experience preventable morbidity. Multi-level interventions that address the complex array of interrelated societal and environmental factors that contribute to these disparities are poorly supported in traditional fee-for-service payment models. In contrast, accountable care organizations (ACOs) are designed to support and sustain interventions that address social determinants of health as part of medical care. A substantial and growing number children with asthma in higher-risk populations receive care in ACOs, but their effect on asthma quality of care, outcomes and disparities is not known. This study will be the first to address this critical gap in knowledge by taking advantage of a natural experiment taking place in Massachusetts (MA), a state with high rates of childhood asthma: In 2018, MA, launched 17 new Medicaid ACOs with varied organizational features (e.g., size; age mix). We will use detailed state-level claims data to: 1) determine the association between implementation of the ACOs and changes in childhood asthma quality indicators, health outcome for Medicaid-insured children and 2) assess changes in socioeconomic and racial/ethnic disparities in these outcome measures comparing children enrolled in Medicaid ACOs to matched commercially-insured children. We then turn to understanding the influence of ACOs’ organizational features on change by: 3) using mixed-methods to generate detailed characterizations of the ACOs’ organizational features and 4) test the association between these features and childhood asthma quality indicators and outcomes. We will use innovative methods of risk adjustment that take social risk factors into account and propensity matched difference- in-difference analyses to account for factors other than ACO implementation that may affect outcomes. This study will take place at a moment when the profound inequities in health and healthcare in the U.S. are starkly illuminated by the COVID-19 pandemic. Socioeconomic and racial/ethnic disparities in childhood asthma persist despite the existence of evidence-based treatments resulting from decades of work and billions of dollars directed at improving asthma care. Structural changes in healthcare are needed for equitable delivery of evidence-based asthma care, which should reduce or even eliminate these long standing disparities. The ACO model moves healthcare payment and delivery in a direction that could facilitate this change. This study will address major gaps in knowledge as to whether the large investments being made in developing the ACO model may pay off for the millions of children at increased risk for long-term poor health due to preventable consequences of asthma.