Assessing the Effects of Accountable Care Organizations on Surgical Spending and Quality

项目总结 手术费用占全国医疗费用的30%，而且增长速度快于#年的支出 其他关键的医疗保健行业。许多人希望患者保护和医疗保险中包括的支付改革 《平价医疗法案》将有助于遏制这种支出增长。在这些改革中，最主要的是 建立负责任的护理组织(ACO)。通过鼓励更深入的卫生系统整合和 更好的财务管理，支持者认为ACOs将加强护理协调并减少 使用不必要的服务，最终提高质量和降低医疗支出。然而，网络 ACOs对外科治疗的影响尚不清楚。一方面，ACOS激励可能会激励临床医生 考虑更便宜的手术替代方案，以追求更低的人口支出。另一方面，共享 储蓄协议可能会产生意想不到的后果。例如，初级保健提供者(PCP)具有 ACO合同可能过于强调外科医生的成本，而忽略了他们的质量，在进行转介时 决定。此外，经济压力可能会导致外科医生依赖ACO PCP获得源源不断的 患者，拒绝接受昂贵但有价值的护理。此外，重要的背景因素可能会影响ACO 效果。例如，ACO通常不包括外科医生执业和门诊手术中心， 在那里提供越来越多的外科护理。如果这些手术提供者与 接受集体问责的PCP群体，ACO对他们的影响可能会减弱。在这方面， 我们建议进行一项研究，以更好地了解ACO对外科护理的影响。我们的提案有 遵循三个具体目标。以确定ACO对手术费用和质量的影响。 使用国家联邦医疗保险人口，我们将确定符合联邦医疗保险ACO的合格受益人，并 那些不是的。然后，我们将比较这些受益者的手术和总体支出 在ACO形成后。对于接受手术的受益人，我们还将评估他们的围手术期 结果和总剧集付款。目的2：评价ACO的临床异质性 外科护理服务。我们将从目标1中确定符合以下六种条件之一的医疗保险受益人子集 手术被认为是一种治疗方法。然后，我们将评估手术费用的差异 这些受益者在ACO手术前后的高、中、低价值外科手术 队形。目的3：评估政策实施中的异质性如何影响外科护理的提供。 使用来自全国责任护理组织调查的关联数据和网络分析工具， 我们将评估财务风险和组织结构(包括外科医生参与)如何控制ACO 有效性。我们的研究结果将与医疗保健研究机构直接相关。 质量的研究优先领域#3，因为他们将向医疗保险和医疗保险中心的决策者提供信息 医疗补助服务关于新的报销机制对医疗支出的影响。

PROJECT SUMMARY Surgical spending accounts for 30% of national health spending and is growing more rapidly than spending in other key healthcare sectors. Many hope that payment reforms included in the Patient Protection and Affordable Care Act will help curtail such spending growth. Chief among these reforms were provisions for establishing accountable care organizations (ACOs). By encouraging deeper health system integration and greater financial stewardship, proponents believe that ACOs will enhance care coordination and reduce the use of unnecessary services, ultimately improving quality and lowering health spending. However, the net effects of ACOs on surgical care remain unclear. On the one hand, ACOs incentives may motivate clinicians to consider cheaper alternatives to surgery in pursuit of lower population expenditures. On the other hand, shared saving agreements could have unintended consequences. For example primary care providers (PCPs) with ACO contracts may place too much emphasis on surgeons' costs, ignoring their quality, when making referral decisions. Moreover, economic pressures may lead surgeons, who rely on ACO PCPs for a steady stream of patients, to withhold costly but valuable care. In addition, important contextual factors may moderate ACO effects. For instance, ACOs frequently do not encompass surgeon practices and ambulatory surgery centers, where a growing share of surgical care is delivered. If these surgical providers are weakly connected to the PCP groups accepting collective accountability, ACOs' influence on them may be attenuated. In this context, we propose a study to better understand the impact that ACOs have on surgical care. Our proposal has the following three Specific Aims. To determine the impact that ACOs have on surgical spending and quality. Using the national Medicare population, we will identify eligible beneficiaries aligned with a Medicare ACO and those that are not. We will then compare surgical and overall expenditures among these beneficiaries before and after ACO formation. For beneficiaries who undergo surgery, we will also assess their perioperative outcomes and total episode payments. Aim 2: To evaluate for clinical heterogeneity in ACO effects on surgical care delivery. We will identify subsets of Medicare beneficiaries from Aim 1 with one of six conditions for which surgery is considered a treatment. We will then evaluate for differences in surgical spending on higher, intermediate, and lower value surgical procedures among these beneficiaries before and after ACO formation. Aim 3: To assess how heterogeneity in policy implementation affects surgical care delivery. Using linked data from the National Survey of Accountable Care Organizations and network analytical tools, we will assess how financial risk and organizational structure (including surgeon participation) moderate ACO effectiveness. Findings from our study will be directly relevant to the Agency for Healthcare Research & Quality's Research Priority Area #3, as they will inform decision makers at the Centers for Medicare & Medicaid Services about the effects of new reimbursement mechanisms on health spending.