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

摘要 哮喘是儿童时期最常见的慢性疾病，导致更容易预防。 住院和失学天数比任何其他儿童疾病都要多。低收入城市的儿童， 种族/少数民族人口更有可能患有哮喘，疾病控制不力， 并体验到可预防的发病率。多层次干预，解决复杂的 造成这些差距的相互关联的社会和环境因素得到的支持很少 在传统的按服务收费的支付模式中。相比之下，负责任的护理组织(ACO)是 旨在支持和维持解决健康的社会决定因素的干预措施 医疗护理。在高危人群中，有大量且不断增长的哮喘儿童 ACOs中的护理，但其对哮喘护理质量、结果和差异的影响尚不清楚。 这项研究将是第一次通过利用自然的 在马萨诸塞州(马萨诸塞州)进行的一项实验，该州儿童哮喘发病率高：2018年， 推出了17个新的医疗补助ACO，具有不同的组织特征(例如，规模；年龄结构)。我们会 使用详细的州级别索赔数据来：1)确定实施 ACOS与儿童哮喘质量指标、医疗补助儿童健康结局的变化 2)评估这些成果指标中社会经济和种族/族裔差距的变化 将参加医疗补助ACOs的儿童与匹配的商业保险儿童进行比较。然后我们转过身来 用混合方法了解ACO的组织特征对变革的影响 生成ACO的组织特征的详细描述并4)测试关联性 这些特征与儿童哮喘质量指标和预后之间的关系。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，以考虑可能影响结果的ACO实施以外的因素。 这项研究将发生在一个时刻，在健康和医疗保健方面的严重不平等 新冠肺炎疫情让美国大吃一惊。#年的社会经济和种族/族裔差距 尽管几十年来存在循证治疗，但儿童哮喘仍在继续 工作和数十亿美元用于改善哮喘治疗。医疗保健的结构性变化是 公平地提供循证哮喘护理所需的，这应该会减少甚至消除 这些长期存在的差距。ACO模式推动医疗支付和提供朝着一个方向发展 这可能会促进这一变化。这项研究将解决知识上的主要差距，即大型 在开发ACO模式方面所做的投资可能会让数百万儿童在 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.