Difference In Total Spending Research Articles

Factors Associated with Reduced Medicare Spending in the Accountable Care Organization (ACO) Investment Model

Research ObjectiveThe ACO Investment Model (AIM) was designed to encourage providers in rural or underserved areas to participate in the Medicare Shared Savings Program (SSP) by providing up‐front financial support for care transformation. In the second performance year, there were 41 ACOs that continued participation in AIM, with 423,434 beneficiaries assigned them. Our research objective was to determine whether the significant reductions in total Medicare spending we found in the first performance year were sustained in the second year, and whether specific ACO or market characteristics were associated with spending in both performance years.Study DesignWe utilized a difference‐in‐differences evaluation design to estimate differences in total spending between Medicare fee‐for‐service (FFS) beneficiaries attributed to AIM ACOs and comparison beneficiaries, before versus after the start of AIM. The comparison group included beneficiaries residing in each AIM ACO’s market who were eligible but not attributed to an ACO. Regression and weighting were used to adjust for demographic characteristics and health status. We stratified first and second performance year results based on ACO and market characteristics, including whether an ACO used a management company; partnered with a hospital; had fewer than 6,500 enrolled beneficiaries; was in the top quartile of rurality among AIM markets; had a discontinuous market; or had total Medicare spending at baseline that was above the median among all AIM markets.Population StudiedMedicare FFS beneficiaries attributed to ACOs in AIM, which targeted ACO formation in rural/underserved areas in 2016 and 2017.Principal FindingsAcross all 41 AIM ACOs, we estimated a significant reduction in total spending of $36.94 per beneficiary per month (PBPM) in the second performance year—a reduction of 3.5% and similar to findings from the first performance year. There were no significant differences in AIM impacts based on any of our six stratifications, but results across the two performance years suggest that greater reductions were achieved by ACOs working with a management company.ConclusionsACOs participating in AIM sustained reductions in total Medicare spending across the first two performance years and across diverse ACO and market characteristics.Implications for Policy or PracticeResults from the second performance year strengthen the evidence that ACOs can help reduce Medicare spending in rural or underserved areas. Among AIM markets, variations in market‐level baseline spending, market dispersion, and high rurality were not barriers to achieving spending reductions. ACOs locating in rural or underserved areas may benefit through partnership with a management company.Primary Funding SourceCenters for Medicare and Medicaid Services.

Utilization by Long-Term Nursing Home Residents Under Accountable Care Organizations

ObjectivesNursing home care is common and costly. Accountable care organization (ACO) payment models, which have incentives for care that is better coordinated and less reliant on acute settings, have the potential to improve care for this high-cost population. We examined the association between ACO attribution status and utilization and Medicare spending among long-term nursing home residents and hypothesized that attribution of nursing home residents to an ACO will be associated with lower total spending and acute care use. DesignObservational propensity-matched study. Setting and ParticipantsMedicare fee-for-service beneficiaries who were long-term nursing home residents residing in areas with ≥5% ACO penetration. MethodsACO attribution and covariates used in propensity matching were measured in 2013 and outcomes were measured in 2014, including hospitalization (total and ambulatory care sensitive conditions), outpatient emergency department visits, and Medicare spending. ResultsNearly one-quarter (23.3%) of nursing home residents who survived into 2014 (n = 522,085, 76.1% of 2013 residents) were attributed to an ACO in 2013 in areas with ≥5% ACO penetration. After propensity score matching, ACO-attributed residents had significantly (P < .001) lower hospitalization rates per 1000 (total: 402.9 vs 419.9; ambulatory care sensitive conditions: 64.4 vs 71.4) and fewer outpatient ED visits (29.9 vs 33.3 per 100) but no difference in total spending ($14,071 vs $14,293 per resident, P = .058). Between 2013 and 2014, a sizeable proportion of residents’ attribution status switched (14.6%), either into or out of an ACO. Conclusions and ImplicationsACO nursing home residents had fewer hospitalizations and ED visits, but did not have significantly lower total Medicare spending. Among residents, attribution was not stable year over year.

Making EGMs Accountable: Can an Informative and Dynamic Interface Help Players Self-regulate?

Electronic gaming machines (EGMs) are recognised as one of the most harmful gambling forms, because they promote high-speed repetitive gambling and automatically reinvest winnings. These features, amongst others, make it difficult for EGM gamblers to keep track of their play. Tools to assist gamblers exist, but have limited effectiveness because they require user registration and manual activation, leading to low uptake. The present study aimed to evaluate the effect of a more informative interface (including removal of automatic reinvestment of winnings) and pop-up messages on gambling behaviour, and on player experience. A total of 213 Australian participants, recruited through social media, played a simulated online EGM. The experiment was a two (standard vs. informative interface) × two (pop-ups absent vs. present) between-subjects design. The informative interface: promoted keeping track of spins played; increased accurate estimation of amount spent (as did pop-up messages) and time played; and provided game usage figures which acted as cues to quit play. Once the initial deposit (but not winnings) was expended, informative interface users could opt to reinvest their winnings, although many opted to exit at that point. No difference in total spending or dissociation was observed between experimental groups. Informative interface users reported no reduction in enjoyment. Pop-up messages reduced enjoyment with the standard interface, but increased enjoyment when paired with an informative interface. These findings indicate that a more informative interface and pop-up messages may be useful in reducing the harmful nature of EGMs.

Race and Consumption: Black and White Disparities in Household Spending.

Differences in consumption patterns are usually treated as a matter of preferences. In this article, the authors examine consumption from a structural perspective and argue that black households face unique constraints restricting their ability to acquire important goods and services. Using data from the Consumer Expenditure Surveys, the authors examine racial differences in total spending and in spending on major categories of goods and services (food, transportation, utilities, housing, health care, and entertainment). The authors also capture heterogeneous effects of racial stratification across class by modeling racial consumption gaps across household income levels. The results show that black households tend to have lower levels of total spending than their white counterparts and that these disparities tend to persist across income levels. Overall, these analyses indicate that racial disparities in consumption exist independently of other economic disparities and may be a key unexamined factor in the reproduction of racial inequality.

Impact of Medicare Age Eligibility on Health Spending among U.S. and Foreign-Born Adults.

Examine differences in health care expenditures between foreign-born and U.S.-born adults in late mid-life, and how these differences change after age 65, when Medicare is near-universal. Medical Expenditures Panel Survey data (2000-2010) on adults ages 55-75years (n=46,132) to examine annual total and payer-specific expenditures. We use (1) propensity score matching to generate quasi-experimental samples with equivalent health needs and health care preferences, (2) generalized linear modeling to estimate group differences in expenditures, and (3) bootstrapping methods to obtain variance estimates for significance testing. Among adults ages 55-64, the foreign-born spend $3,314 (p<.001) less on health care, even when they have equivalent health needs and health care preferences. This difference is due mainly to lower spending through private insurance. After age 65, differences in total spending disappear but not differences in payer-specific spending. The foreign-born continue to spend significantly less through private insurance and begin to spend significantly more through Medicare and Medicaid. Foreign-born adults in late mid-life spend significantly less on health care than U.S.-born adults. After age 65, with near-universal Medicare coverage, differences in total spending disappear between the groups, although differences in spending by payer persist.

Pronounced Gender And Age Differences Are Evident In Personal Health Care Spending Per Person

This paper examines differences in national health care spending by gender and age. Our research found significant variations in per person spending by gender across age groups, health services, and types of payers. For example, in 2004 per capita health care spending for females was 32 percent more than for males. Per capita differences were most pronounced among the working-age population, largely because of spending for maternity care. Except for children, total spending for and by females was greater than that for and by males, for most services and payers. The gender difference in total spending was most pronounced in the elderly, as a result of the longer life expectancy of women.

Risk coping and starvation in rural China

We use a 3-year panel from two poor provinces in Southern China to examine the nature of risks to which rural households are exposed and their ability to insure calorie consumption and spending of total consumption against idiosyncratic shocks to their income. We find that idiosyncratic risks are indeed the main source of income variation in the sample, consumption is better insured than total spending. Unlike total spending where full insurance is rejected in most cases, calorie intake is completely insured for both land-rich and land-poor households in both provinces. Access to even modest amounts of land significantly enhances households’ ability to guard against total spending. Land-rich households are much better insured against total spending than land-poor households. The results are robust across model specifications although Generalized Method of Moments (GMM) estimations increase the magnitude of difference in total spending between the land-rich and the land-poor. Policies targeting poverty reduction and improving land use rights and land access to the poor could potentially improve the overall risk sharing ability of the rural poor.