美国卫生和环境司Matthew J. Trombley课题组分析了问责医疗组织模式对服务不足地区的早期影响。2019年8月8日，国际知名学术期刊《新英格兰医学杂志》发表了这一结论。

医疗保险和医疗补助服务中心（CMS）开发了问责医疗组织（ACO）的投资模式（AIM），以鼓励医疗保险共享储蓄计划（MSSP）ACOs在农村和服务不足地区的增长。AIM通过预付共享储蓄的方式，为符合资格的MSSP ACOs提供财政支持。在执行的第一年评估AIM ACOs的支出和使用情况，将有助于了解在这些地区设置ACOs的可行性。

课题组研究人员分析了医疗保险索赔和登记数据，观察组为41个AIM ACOs的医疗费用受益人，对照组为身在ACOs市场但主要由非ACOs提供服务的医疗费用受益人。该研究团队采用差异研究设计，同时比较了AIM ACOs组和对照组受益人从基线期（2013年至2015年）到执行期（2016年）的变化。主要分析医疗保险A部分和B部分的总支出。

与对照组相比，参与AIM的医疗机构每人每月的医疗保险支出总额减少28.21美元，总计减少1.31亿美元。在同一时期，CMS预支付了7620万美元，并向ACOs额外支付了620万美元的共享储蓄，其中共享储蓄超过了预付款。该研究组统计这8240万美元的CMS支出，发现净节约了4860万美元，相当于每人每月节约10.46美元。住院人数的减少和急症后期护理机构的使用有助于减少总开支。

通过预投资，农村和服务不足地区的医疗机构参与ACO共享储蓄，与非ACO医疗机构相比，医疗保险支出更低。



附：英文原文

Title: Early Effects of an Accountable Care Organization Model for Underserved Areas

Author: Matthew J. Trombley, Betty Fout, Sasha Brodsky, J. Michael McWilliams, David J. Nyweide, Brant Morefield

Issue&Volume: Vol.381 No.6

Abstract:

BACKGROUND

The Centers for Medicare and Medicaid Services (CMS) developed the Accountable Care Organization (ACO) Investment Model (AIM) to encourage the growth of Medicare Shared Savings Program (MSSP) ACOs in rural and underserved areas. AIM provides financial support to eligible MSSP ACOs by means of prepayment of shared savings. Estimation of the performance of AIM ACOs on measures of spending and utilization in their first performance year would be useful for understanding the viability of ACOs located in these areas.

METHODS

We analyzed Medicare claims and enrollment data for a group of fee-for-service beneficiaries who had been attributed to 41 AIM ACOs and for a comparable group of beneficiaries who resided in the ACO markets but were served primarily by non-ACO providers. We used a difference-in-differences study design to compare changes in outcomes from the baseline period (2013 through 2015) to the performance period (2016) among beneficiaries attributed to AIM ACOs with concurrent changes among beneficiaries in the comparison group. The primary outcome of interest was total Medicare Part A and B spending.

RESULTS

Provider participation in AIM was associated with a differential reduction in total Medicare spending of $28.21 per beneficiary per month relative to the comparison group, which amounted to an aggregate decrease of $131.0 million. Over the same period, CMS made $76.2 million in prepayments and paid an additional $6.2 million in shared savings to ACOs in which shared savings exceeded the prepayments. After we accounted for this $82.4 million in CMS spending, the aggregate net reduction was $48.6 million, which corresponded to a net reduction of $10.46 per beneficiary per month. Decreases in the number of hospitalizations and use of institutional post-acute care contributed to the observed reduction in overall spending.

CONCLUSIONS

With up-front investments, participation in ACO shared savings contracts by providers serving rural and underserved areas was associated with lower Medicare spending than that among non-ACO providers.

DOI: 10.1056/NEJMsa1816660

Source: https://www.nejm.org/doi/full/10.1056/NEJMsa1816660