• Miranda B Lam, Tynan H Friend, Parsa Erfani, E John Orav, Ashish K Jha, and Jose F Figueroa.
• Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA. Miranda_Lam@dfci.harvard.edu.
• J Gen Intern Med. 2022 Oct 1; 37 (13): 327532823275-3282.

BackgroundEnd-of-life (EOL) costs constitute a substantial portion of healthcare spending in the USA and have been increasing. ACOs may offer an opportunity to improve quality and curtail EOL spending.ObjectiveTo examine whether practices that became ACOs altered spending and utilization at the EOL.DesignRetrospective analysis of Medicare claims.PatientsWe assigned patients who died in 2012 and 2015 to an ACO or non-ACO practice. Practices that converted to ACOs in 2013 or 2014 were matched to non-ACOs in the same region. A total of 23,643 ACO patients were matched to 23,643 non-ACO patients.Main MeasuresUsing a difference-in-differences model, we examined changes in EOL spending and care utilization after ACO implementation.Key ResultsThe introduction of ACOs did not significantly impact overall spending for patients in the last 6 months of life (difference-in-difference (DID) = $192, 95%CI -$841 to $1125, P = 0.72). Changes in spending did not differ between ACO and non-ACO patients across spending categories (inpatient, outpatient, physician services, skilled nursing, home health, hospice). No differences were seen between ACO and non-ACO patients in rates of ED visits, inpatient admissions, ICU admission, mean healthy days at home, and mean hospice days at 180 and 30 days prior to death. However, non-ACO patients had a significantly greater increase in hospice utilization compared to ACO patients at 180 days (DID P-value = 0.02) and 30 days (DID P-value = 0.01) prior to death.ConclusionsWith the exception of hospice care utilization, spending and utilization were not different between ACOs and non-ACO patients at the EOL. Longer follow-up may be necessary to evaluate the impact of ACOs on EOL spending and care.© 2021. Society of General Internal Medicine.

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