The Impact of ACOs on Disparities

美国最近的医疗保健支付政策侧重于提高医疗质量，同时限制成本。 一个突出的例子是成立问责护理组织（ACO）。ACO是一个网络， 医疗保健提供者，负责管理一组患者的健康， 连续的卫生保健环境和提供者，并在财务上负责提供高质量的 低成本的护理。ACO是最近医疗保健领域最重要和影响最深远的变化之一， 在过去四年中呈指数增长，到2016年覆盖超过2 800万人。早期证据显示 支持ACO可以在限制成本的同时提高质量的前提。然而，人们担心， ACO可能会扩大现有的医疗保健差距。一方面，社会弱势群体（如种族 少数民族和生活在贫困社区的患者）可以从ACO中获益匪浅， 他们在许多慢性健康状况方面的患病率较高，接受的护理质量较差， 健康状况更差。另一方面，ACO在满足 弱势群体的需求。首先，早期的ACO可能位于贫困率较低的地区。提供商 形成ACO往往是大的，财务状况良好的集团做法，系统地排除供应商， 为不成比例的弱势患者提供服务，导致弱势患者难以获得 ACO供应商其次，由于许多脆弱的病人是慢性病患者， 结果可能会恶化用于评估ACO的质量和成本指标，ACO医生可能会避免照顾 他们，导致弱势患者减少归因于ACO提供者。第三， 为弱势群体提供高质量的护理，因为这些复杂患者的需求多种多样， 导致患者结果的差异增加。目前尚不清楚ACO是否能有效地发挥作用， 易受伤害的患者，越来越多的人担心ACO的实施会加剧不平等。我们的目标 （1）检查医生参与ACOs与弱势患者比例的关系， （2）检查医生患者小组中弱势患者比例的变化， ACO参与;（3）检查ACO对质量差异的影响（包括预防性护理，慢性 疾病管理、不必要的急诊、住院和再入院）和护理费用（Medicare 支付）;（4）探索ACO对医生群体之间护理差异的影响的异质性 不同的实践特点。我们使用一个包含提供商详细信息的唯一数据集来执行此操作 参与Medicare ACO，与衡量护理质量的国家Medicare索赔数据合并， 注册者和非注册者的费用。本研究的结果将为该效应提供经验证据 并就如何改变目前的ACO政策以减少 以最大限度地发挥支付改革的积极作用。

Recent US health care payment policies have focused on improving quality of care while constraining costs. One prominent example is the formation of Accountable Care Organizations (ACOs). ACOs are networks of health care providers that take on responsibility for managing the health of a group of patients across the full continuum of health care settings and providers, and are held financially accountable for providing high-quality and low-cost care. ACOs are one of the most important and far-reaching recent changes to health care, with exponential growth over the past four years, covering over 28 million lives by 2016. Early evidence lends support to the premise that ACOs can improve quality while constraining costs. However, there is concern that ACOs could widen existing health care disparities. On one hand, socially vulnerable groups (such as racial and ethnic minorities and patients living in impoverished neighborhoods) have much to gain from ACOs, as they have a higher prevalence of many chronic health conditions, receive worse quality of care, and experience worse health outcomes. On the other hand, ACOs face a number of challenges in meeting the needs of vulnerable populations. First, early ACOs may be located in areas with lower poverty rates. Providers forming ACOs tend to be large, financially well-off group practices, systematically excluding providers who serve a disproportionate share of vulnerable patients, and resulting in poor access of vulnerable patients to ACO providers. Second, because many vulnerable patients are chronically ill, high-cost patients whose outcomes could worsen quality and cost metrics used to evaluate ACOs, ACO physicians may avoid caring for them, resulting in reduced attribution of vulnerable patients to ACO providers. Third, ACOs may be ill equipped to provide high-quality care to vulnerable groups because of the diverse needs of these complex patients, resulting in increased disparities in patient outcomes. It is unknown whether ACOs will effectively serve vulnerable patients and there is increasing concern that ACO implementation will worsen disparities. Our aims are to: (1) examine physician participation in ACOs in relation to the proportion of vulnerable patients in a region or practice; (2) examine changes in share of vulnerable patients in physicians' patient panels in relation to ACO participation; (3) examine the effect of ACOs on disparities in quality (including preventive care, chronic disease management, unnecessary ER visits, hospitalizations, and readmissions) and costs of care (Medicare payments); and (4) explore heterogeneity in the effects of ACOs on disparities in care across physician groups that differ in practice characteristics. We do so using a unique dataset with detailed information on provider participation in Medicare ACOs, merged with national Medicare claims data measuring quality of care and costs for both enrollees and non-enrollees. Results from this study will provide empirical evidence of the effect of ACOs on disparities in care and provide guidance on how to alter current ACO policy to reduce disparities in order to maximize the positive effects of reform payment.