2019 ACO Publications
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Delivery System Performance as Financial Risk Varies
Date: December 2019
Source: American Journal of Managed Care
Article Link
Banner Health, a large delivery system in Maricopa County, AZ, entered into both Medicare and commercial insurance contracts that varied the amount of financial risk assumed by the system. Before 2012, Banner held Medicare Advantage (MA) contracts, and in 2012, Banner started a Medicare Pioneer ACO. Banner also introduced a commercial ACO contract in 2012. The study compared risk-adjusted healthcare utilization and spending in the MA plan, the ACO, and a local traditional Medicare comparison group. Researchers also compared risk-adjusted utilization and spending in Banner’s commercial ACO with a comparison group drawn from the same employment groups that were not attributed to Banner providers. Researchers used claims and encounter data to measure utilization and spending and risk adjusted using hierarchical condition categories. The study found that within Medicare, MA enrollees had lower risk-adjusted utilization and total spending than either the Pioneer ACO beneficiaries or the local traditional Medicare comparison group. Participation in the Pioneer ACO program was associated with a greater reduction in hospitalization rates for ACO patients relative to local traditional Medicare patients served by non-ACO providers, but the effect on total medical spending was ambiguous. Risk-adjusted differences between the commercial ACO group and the fee-for-service comparison group were generally small. The authors concluded that the study results are consistent with the Center for Medicare & Medicaid Services’ efforts to shift reimbursement away from pure fee-for-service reimbursement.
Hospital Utilization and Expenditures Among a Nationally Representative Sample of Medicare Fee-For-Service Beneficiaries 2 Years After Receipt of an Annual Wellness Visit
Date: December 2019
Source: Preventive Medicine
Article Link
Medicare’s annual wellness visit (AWV) provides an opportunity to link beneficiaries to cancer screenings and immunizations. However, research has not examined its effectiveness. This study examined the effect of receiving an AWV on outcomes while accounting for the healthy user effect. Researchers used 2013-2017 Medicare claims data to compare hospital utilization and total expenditures among a 5% random sample of Medicare fee-for-service (FFS) beneficiaries with and without AWV use in 2014 (228,053 AWV users were propensity-score matched to 228,053 nonusers). Researchers examined differences in study outcomes 12 and 24 months after AWV use, controlling for baseline differences in beneficiary sociodemographics, health status, utilization, and ACO attribution. The proportion of Medicare FFS beneficiaries using an AWV increased from 13% in 2013 to 24% in 2017. Users of the AWV had a marginally significant reduction in Medicare spending 12 months (−$122, 95% CI −$256, $11, p = 0.073) and significant reductions (−$162, 95% CI, −$310, −$14, p = 0.032) 24 months after the visit, relative to non-users. However, it remains unclear what is driving these savings as there was no change in hospital-related utilization and results may still be biased due to inherent differences between users and non-users. The AWV provides an opportunity for providers to focus on prevention and geriatric needs not covered in typical office visits. Practices adopting AWVs have noted increased revenue, more stable patient populations, and stronger provider-patient relationships.
Early Accountable Care Organization Results in End-of-Life Spending Among Cancer Patients
Date: December 2019
Source: Journal of the National Cancer Institute
Article Link: https://academic.oup.com/jnci/article/111/12/1307/5374764
This study examined whether ACOs are associated with subsequent changes in end-of-life (EOL) spending or utilization among patients with cancer. Using national Medicare claims from 2011 to 2015, researchers identified patients who died in 2012 (pre-ACO, n = 12,248) and 2015 (post-ACO, n = 12,248), assigning each decedent to a practice. ACOs were matched to non-ACOs within the same geographic region. Researchers used a difference-in-difference model to examine changes in EOL spending and utilization associated with becoming an ACO in the Medicare Shared Savings Program for beneficiaries with cancer. The study found that the introduction of ACOs had no meaningful impact on overall EOL spending in cancer patients (change in overall spending in ACOs = -$1,687 vs -$1,434 in non-ACOs, difference = $253, 95% confidence interval = -$1,809 to $1,304, P= .75). The study also found no changes in total patient spending by cancer type examined or by spending categories, including cancer-specific categories of radiation, therapy, and hospice services. Finally, emergency department visits, inpatient hospitalization, intensive care unit admissions, radiation therapy, chemotherapy, and hospice use did not meaningfully differ between ACO and non-ACO patients.
Changes In Physician Consolidation With The Spread Of Accountable Care Organizations
Date: November 2019
Source: Health Affairs
Article Link: https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2018.05415?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed
While early evidence suggests that ACOs are associated with higher quality and lower costs, there have been simultaneous concerns that ACOs may incentivize consolidation of physician groups. This is particularly concerning as previous research has shown that consolidation is associated with lower quality and higher prices. Using a difference-in-differences strategy and data from the Medicare Shared Savings Program, which began in 2012, researchers examined whether physician practices consolidated after ACOs entered health care markets. The study found a 4.0-percentage-point increase in large practices (those with 50 or more physicians) in counties with the greatest ACO penetration, compared to counties with zero ACO penetration, and a 2.7-percentage-point decline in the percentage of small practices (10 or fewer physicians) from 2010 to 2015. The growth of large practices was concentrated in specialty and hospital-owned practices. These findings suggest that ACOs may contribute to the concentration of physician practices.
Five-year Impact of a Commercial Accountable Care Organization on Health Care Spending, Utilization, and Quality of Care
Date: November 2019
Source: Medical Care
Article Link: https://journals.lww.com/lww-medicalcare/Abstract/2019/11000/Five_year_Impact_of_a_Commercial_Accountable_Care.2.aspx
The study evaluated the long-term impact of a commercial ACO on health care spending, utilization, and quality outcomes among continuously enrolled members using a retrospective cohort study design and propensity-weighted difference-in-differences approach. The study compared two ACO cohorts and one non-ACO cohort within a commercial health maintenance organization—40,483 continuously enrolled members—during the commercial ACO implementation in 2010-2014. The ACO cohorts had (1) increased inpatient and outpatient total spending in the first 2 years of ACO operation but insignificant differential changes for the latter 3 years; (2) decreased outpatient spending in the latter 2 years through reduced primary care visits and lowered spending on specialists, testing, and imaging; (3) no differential changes in inpatient hospital spending, utilization, and quality measures for most of the 5 years; and (4) favorable results for several quality measures in preventive and diabetes care domains in at least one of the 5 years. In conclusion, the commercial ACO improved outpatient process quality measures modestly and slowed outpatient spending growth by the fourth year of operation but had a negligible impact on inpatient hospital cost, use, and quality measures.
An Examination of Multilevel Factors Influencing Colorectal Cancer Screening in Primary Care Accountable Care Organization Settings: A Mixed-Methods Study
Date: November/December 2019
Source: Journal of Public Health Management and Practice
Article Link: https://journals.lww.com/jphmp/Abstract/2019/11000/An_Examination_of_Multilevel_Factors_Influencing.8.aspx
The study examined patient, provider, and delivery system-level factors associated with colorectal cancer screening in eight ACO clinics in Nebraska. Using a mixed-methods design that included review of data from electronic health records, a provider survey, and provider interviews, researchers analyzed patients’ demographic/social characteristics, health utilization behaviors, and perceptions toward colorectal cancer screening; provider demographics and practice patterns; and delivery system factors, such as a reminder system. At the patient level, being 65 years of age and older, being non-Hispanic white, having insurance, having an annual physical examination, and having chronic conditions were associated positively with screening, compared with counterparts. The top five patient-level barriers included discomfort/pain of the procedure (60.3%), finance/cost (57.4%), other priority health issues (39.7%), lack of awareness (36.8%), and health literacy (26.5%). At the provider level, being female, having medical doctor credentials, and having a daily patient load less than 15 were positively related to colorectal cancer screening. None of the delivery system factors were significant except the reminder system. Interview data provided in-depth information on how these factors help or hinder screening.
Assessing Adherence and Cost-benefit of Cancer Screening for Accountable Providers
Date: October 2019
Source: Baylor University Medical Center Proceedings
Article Link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6793958/
The study assessed adherence and costs-benefits of colorectal cancer (CRC) screenings from an accountable care organization/population health perspective through a retrospective review of 94 patients (50–75 years of age) in an integrated safety net system for whom fecal CRC screening was abnormal from 2014 to 2016. A cost-benefit model was constructed using Medicare payment rates and a sensitivity analysis. Most patients included in the study (64/94, 68%) received or were offered a colonoscopy. Of those receiving a colonoscopy, 24 of 45 (53%) had an abnormal finding. Total direct medical costs avoided by screening the patient panel was $32,926 but could have exceeded $63,237 had more patients received follow-up colonoscopies. A sensitivity analysis with 1,000 patients demonstrated total monetary benefits between $2.2 million and $8.16 million when follow-up and colonoscopy rates were allowed to vary. Although the resulting rates of follow-up were within the range reported in the literature, there is room for improvement, especially considering the monetary benefit that could be used on other diseases. Health systems and payers should work cooperatively to structure payment models to better incentivize CRC screenings.
How Does Being Part of a Pediatric Accountable Care Organization Impact Health Service Use for Children with Disabilities?
Date: October 2019
Source: Health Services Research
Article Link: https://onlinelibrary.wiley.com/doi/abs/10.1111/1475-6773.13199
The study examined of a Medicaid pediatric ACO on health service use by children who qualify for Medicaid by virtue of a disability under the “aged, blind, and disabled” (ABD) eligibility criteria. Researchers evaluated a 2013 Ohio policy change that effectively moved ABD Medicaid children into an ACO model of care using Ohio Medicaid claims data for 2011-2016. The study used a difference-in-difference design to examine changes in patterns of health care service use by ABD-enrolled children before and after enrolling in an ACO compared with ABD-enrolled children enrolled in non-ACO managed care plans. The study identified 17,356 children as the ACO intervention group and 47,026 ABD-enrolled children who resided outside of the ACO region as non-ACO controls. The study found that being part of the ACO increased adolescent preventive services and decreased use of ADHD medications compared to similar children in non-ACO capitated managed care plans. Relative home health service use decreased for children in the ACO. Overall results indicate that being part of an ACO may improve quality in certain areas, such as adolescent well-child visits, though there may be room for improvement in other areas considered important by patients and their families such as home health service.
Frailty Screening Using the Electronic Health Record Within a Medicare Accountable Care Organization
Date: October 4, 2019
Source: Journal of Gerontology: Biological Sciences
Article Link: https://academic.oup.com/biomedgerontology/article/74/11/1771/5298349
The accumulation of deficits model for frailty has been used to develop an electronic health record (EHR) frailty index (eFI) in Britain, but there have been limited applications of EHR-based approaches in the United States. Researchers constructed an adapted eFI for patients in a Medicare ACO (N = 12,798) using encounter, diagnosis code, laboratory, medication, and Medicare annual wellness visit (AWV) data from the HER and then the association of the eFI with mortality, health care utilization, and falls. The overall cohort was 55.7% female, 85.7% white, with a mean age of 74.9 years. In the prior 2 years, 32.1% had AWV data. The eFI could be calculated for 9,013 (70.4%) ACO patients. Of these, 46.5% were classified as prefrail and 40.1% frail. Accounting for age, comorbidity, and prior health care utilization, the eFI independently predicted all-cause mortality, inpatient hospitalizations, emergency department visits, and falls with injuries. Construction of an eFI from the EHR, within the context of a managed care population, is feasible and can help to identify vulnerable older adults. Future work is needed to integrate the eFI with claims-based approaches and test whether it can be used to effectively target interventions tailored to the health needs of frail patients.
Can Accountable Care Divert the Sources of Hospitalization?
Date: October 2019
Source: American Journal of Managed Care
Article Link: https://www.ajmc.com/journals/issue/2019/2019-vol25-n10/can-accountable-care-divert-the-sources-of-hospitalization
The study examined the impact of coordinated care organizations (CCOs), Oregon’s Medicaid ACOs, on hospitalization by admission source among female Medicaid beneficiaries of reproductive age. Researchers used a difference-in-differences (DID) approach, capitalizing on the fact that CCO enrollment was generally mandatory while some Medicaid patients were exempt. Using Oregon Medicaid eligibility files linked to hospital discharge data and birth certificates, researchers constructed person-month panel data on 86,012 women aged 15 to 44 years (N = 2,705,543 observations) who were continuously enrolled in Oregon Medicaid. Outcomes included total and preventable hospital admissions. CCOs led to reductions in preventable hospital admissions, especially unscheduled admissions, among female Medicaid beneficiaries aged 15 to 44 years.
Cardiologist Participation in Accountable Care Organizations and Changes in Spending and Quality for Medicare Patients With Cardiovascular Disease
Date: September 2019
Source: Circulation: Cardiovascular Quality and Outcomes
Article Link: https://www.ahajournals.org/doi/full/10.1161/CIRCOUTCOMES.118.005438?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub++0pubmed
This study examined whether specialist participation in Medicare ACOs was associated with changes in healthcare spending and clinical quality. Working with a 20% random sample of Medicare beneficiaries (2008 to 2015), researchers identified those with cardiovascular disease and then estimated linear regression models at the beneficiary-quarter level to evaluate changes in healthcare spending and clinical quality after the start of the Shared Savings Program in 2012. Researchers then examined whether changes in spending and quality across ACOs were conditional on cardiologist participation. The study included about 1.6 million beneficiaries per year. Although the number of ACOs increased over the study period (from 114 in 2012 to 392 in 2015), the proportion with any cardiologist participation remained stable (from 80% in 2012 to 83% in 2015). Compared with unaligned beneficiaries, those cared for by ACOs without cardiologist participation were associated with a spending reduction (per quarter) of −$75 (95% CI, −$105 to −$46; P<0.001). Care receipt in an ACO with cardiologist participation was associated with an additional difference in spending of −$56 (95% CI, −$87 to −$25; P<0.001), driven by lower spending for skilled nursing facilities, evaluation and management services, procedural care, and testing. While heart failure admission rates were similar among aligned and unaligned beneficiaries, ACO care was associated with fewer all-cause readmissions (P<0.001) and emergency department visits (P<0.001). Rates of these outcomes did not vary by cardiologist participation. The study concluded that annual spending for beneficiaries with cardiovascular disease was about $200 lower when cared for by ACOs with cardiologist participation (compared with those without), without measurable differences in clinical quality.
Impact of Pharmacist-led Heart Failure Tool Kits on Patient-reported Self-care Behaviors in a Primary Care-based Accountable Care Organization
Date: September 30, 2019
Source: Journal of the American Pharmacists Association
Article Link: https://www.japha.org/article/S1544-3191(19)30400-5/fulltext
The study evaluated the impact of a pharmacist-led heart failure (HF) intervention, using an educational toolkit, on patient-reported self-care maintenance, management, and confidence at 30 days in three ACO) primary care provider offices in South Florida from January to March 2018. Pharmacists spent about 2 days per week in clinic. Before the project, no formalized management program for HF patients existed in the clinics. An educational toolkit was designed, reviewed, and approved by the team of pharmacists and ACO providers before use in the clinics and included educational material outlining common causes of HF exacerbation, symptoms of HF, symptom management strategies, medication action plan, self-management instructions, medication adherence tips, and a weight-management log sheet. A prospective, pre-/post-test observational project was conducted at the three clinical sites for eligible patients. The Self-Care for Heart Failure Index (SCHFI, v.6.2) tool was used to evaluate self-care practices and adequacy of maintenance, management, and confidence at baseline as compared with 30 days. Twelve participants completed the initial interview and 30-day follow-up. SCHFI scores for self-maintenance and self-management significantly improved from baseline, while self-confidence scores showed an increase, but the change was not statistically significant. Pharmacists and educational toolkits in ACO primary care settings may improve self-maintenance, self-management, and self-confidence behaviors in patients with HF.
Inclusion of Nursing Homes and Long-Term Residents in Medicare ACOs
Date: September 27, 2019
Source: Medical Care
Article Link:https://journals.lww.com/lww-medicalcare/Abstract/publishahead/Inclusion_of_Nursing_Homes_and_Long_Term_Residents.98388.aspx
The study assessed the extent of nursing home participation in ACOs and the characteristics of residents and their nursing homes connected to ACOs in 2014. Among 660,780 nursing home residents, a quarter were attributed to ACOs. ACO residents had only small differences from non-ACO residents: age 85 years and older (47.1% vs. 45.3%), % black (10.5% vs. 12.7%), % dual eligible (74.3% vs. 75.8%), and emergency department visits (55.1 vs. 57.3 per 100). Of the 14,868 nursing homes with study residents, few were ACO providers (N=222, 1.6% of total residents) yet many had at least one ACO resident (N=8,077, 76.4% of total residents); one-fifth had at least 20 (N=2,839, 33.4% of total residents). ACO-provider homes were more likely than other homes to have a 5-star rating, be hospital-based, and have Medicare as the primary payer.
With a quarter of long-term nursing home residents attributed to an ACO, and one-fifth of nursing homes caring for a large number of ACO residents, outcomes and spending in this setting are important for ACOs to consider when designing patient care strategies.
Association of Bundled Payments for Joint Replacement Surgery and Patient Outcomes With Simultaneous Hospital Participation in Accountable Care Organizations
Date: September 27, 2019
Source: JAMA Network Open
Article Link:https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2752104
Although participation in bundled payments has been associated with savings for lower-extremity joint replacement (LEJR) surgery, simultaneous participation in ACOs may be associated with different outcomes. The study examined whether simultaneous participation in a Medicare Shared Savings Program ACO affects the association between hospitals’ participation in LEJR episodes under the Bundled Payments for Care Improvement (BPCI) initiative and patient outcomes compared with participation in the BPCI initiative alone. This cohort study used 2011 to 2016 Medicare claims data and incorporated an instrumental variable with a difference-in-differences method among 483,008 fee-for-service Medicare beneficiaries undergoing LEJR surgery at 212 bundled payment participant hospitals, 105 hospitals participating in both BCPI and ACO programs, and 1,413 nonparticipant hospitals. In adjusted analysis, hospitals participating in both ACOs and BCPI had 1.5% more unplanned readmissions than BCPI participants. Compared with BCPI participants, hospitals participating in both ACOs and BCPI also had differentially greater decreases in hospital length of stay (adjusted difference-in-differences value, −5.3%; 95% CI, −7.1% to −3.5%; P < .001) and home health care use (adjusted difference-in-differences value, −3.4%; 95% CI, −4.5% to −2.3%; P < .001) and greater increases in post-discharge outpatient follow up (adjusted difference-in-differences value, 2.1%; 95% CI, 0.9%-3.3%; P < .001). Coparticipants and bundled payment participants did not have differential changes in episode spending (adjusted difference-in-differences value, 0.4%; 95% CI, −0.7% to 1.6%; P = .46), although both groups had lower spending compared with nonparticipants. The findings suggest that that coparticipants may adopt care redesign strategies that differ from hospitals with bundled payments only.
Prevalence of Screening for Food Insecurity, Housing Instability, Utility Needs, Transportation Needs, and Interpersonal Violence by US Physician Practices and Hospitals
Date: September 18, 2019
Source: JAMA Network Open
Article Link: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2751390
In this study of U.S. hospitals and physician practices, approximately 24 percent of hospitals and 16 percent of physician practices reported screening for food insecurity, housing instability, utility needs, transportation needs, and interpersonal violence. Federally qualified health centers and physician practices participating in bundled payments, primary care improvement models, and Medicaid accountable care organizations screened more than other practices, and academic medical centers screened more than other hospitals. The study analyzed responses by physician practices and hospitals to the 2017-2018 National Survey of Healthcare Organizations and Systems. Among 4,976 physician practices surveyed, 2,333 responded, for a response rate of 46.9 percent. Among hospitals, 757 of 1,628 (46.5%) responded. Screening for interpersonal violence was most common (practices: 56.4%; hospitals: 75.0%), and screening for utility needs was least common (practices: 23.1%; hospitals: 35.5%). Among practices, federally qualified health centers (yes: 29.7% vs. no: 9.4%), bundled payment participants (yes: 21.4% vs no: 10.7%), primary care improvement models (yes: 19.6% vs no: 9.6%), and Medicaid accountable care organizations (yes: 21.8% vs. no: 11.2%) had higher rates of screening for all needs. The findings suggest that few U.S. physician practices and hospitals screen patients for all five key social needs associated with health outcomes. The role of physicians and hospitals in meeting patients’ social needs is likely to increase as more take on accountability for cost under payment reform.
Randomized Controlled Trial of Centralized Vaccine Reminder/Recall to Improve Adult Vaccination Rates in an Accountable Care Organization Setting
Date: September 2019
Source: Preventive Medicine Reports
Article Link: https://www.sciencedirect.com/science/article/pii/S2211335519300725?via%3Dihub
This study assessed the effectiveness of using Colorado’s Immunization Information System (CIIS) to send vaccine reminder/recalls (R/Rs) centrally vs. usual care for adult vaccine delivery within an ACO and practice staff’s perception of centralized R/R. From September 2016 to April 2017, researchers conducted a randomized controlled trial among adults enrolled in a Medicaid ACO at six healthcare entities. Adults were divided into two groups: 15,153 aged 19–64 and 616 aged 65+. Adults aged 19–64 who needed influenza and/or Tdap vaccine and adults age 65+ who needed influenza, and/or Tdap, and/or a pneumococcal vaccine were randomized to receive up to 3 R/Rs by autodialed telephone and mail or usual care. Documentation of receipt of any needed vaccines in CIIS within 6 months was the primary outcome. The intervention was not associated with increased vaccination for either age group. Practice staff perceived the intervention to be beneficial and not burdensome. Perceived barriers included lack of availability of appointments and adults receiving only influenza vaccine when other vaccines were needed. In conclusion, centralized R/R was not effective at improving adult vaccination rates in a Medicaid ACO. Future studies should consider better harmonizing vaccine centralized R/Rs with vaccine delivery efforts within the practice setting.
Payment and Delivery in 2018: Participation in Medical Homes and Accountable Care Organizations on the Rise While Fee-for-Service Revenue Remains Stable
Date: August 2019
Source: American Medical Association
Article Link: https://www.ama-assn.org/system/files/2019-09/prp-care-delivery-payment-models-2018.pdf
Based on the American Medical Association’s (AMA) 2018 Practice Benchmark Surveys, 31.9% of physicians worked in a practice that belonged to a medical home, 38.2% to a Medicare ACO, 26.3% to a Medicaid ACO, and 39.0% to a commercial ACO. Participation in each of the four care delivery models increased significantly from 2016 by 5 to 7 percentage points. Overall, 53.8% of physicians reported participation in at least one ACO type in 2018, up from 44.0 percent in 2016.
Shared Savings Program ACO Network Comprehensiveness and Patient Panel Stability
Date: August 29,2019
Source: American Journal of Managed Care
Article Link: https://www.ajmc.com/journals/issue/2019/2019-vol25-n9/medicare-shared-savings-program-aco-network-comprehensiveness-and-patient-panel-stability
The current Medicare Shared Savings Program (MSSP) ACO attribution methodology is unpredictable for ACOs. The goal of this study was to determine if ACO network comprehensiveness was associated with stability of assigned Medicare beneficiaries from 2013 to 2014. Using 2013 and 2014 Medicare fee-for-service beneficiary and provider files, researchers developed a measure of network comprehensiveness based on 2013 provider contracts, determined beneficiary attribution, and generated market-level measures. Of the 1,317,858 observed beneficiaries, 84.38% were attributed to the same ACO in 2013 and 2014, and mean (SD) ACO network comprehensiveness was 0.30 (0.20). The study found that a 0.10 increase in network comprehensiveness score significantly increased the odds of beneficiaries remaining attributed to the same ACO by 4.5% (P = .001). Patient panel stability was significantly associated with improved diabetes (P = .01) and hypertension (P = .02) control, timely access to care (P = .001), and delivery of health education (P = .03) over the 2-year period. The comprehensiveness of an MSSP ACO’s contracted provider network was associated with stable patient assignment year to year, and such stability may aid in long-term management of certain chronic conditions.
Overlap between Medicare’s Voluntary Bundled Payment and Accountable Care Organization Programs
Date: August 21, 2019
Source: Journal of Hospital Medicine
Article Link: https://www.journalofhospitalmedicine.com/jhospmed/article/206284/hospital-medicine/overlap-between-medicares-voluntary-bundled-payment-and
Using Medicare data, researchers defined overlap between Medicare Shared Savings Program ACOs and the Bundled Payments for Care Improvement (BPCI) model. Between 2013 and 2016, overlap as a share of ACO patients increased from 2.7% to 10% across BPCI episodes at CPCI participant hospitals, while overlap as a share of all bundled payment patients increased from 19% to 27%. Overlap from the perspectives of both ACO and bundled payments varied by specific episode. In the first description of overlap between ACOs and bundled payments, 1 in every 10 MSSP patients received care under BPCI by the end of the study period, while more than 1 in 4 patients receiving care under BPCI were also attributed to an MSSP ACO. Policymakers should consider strategies to address the clinical and policy implications of increasing payment model overlap.
How Do Accountable Care Organizations Deliver Preventive Care Services? A Mixed-Methods Study
Date: August 20, 2019
Source: Journal of General Internal Medicine
Article Link: https://link.springer.com/article/10.1007%2Fs11606-019-05271-5
The study objective was to understand how Medicare ACOs provide preventive care services to attributed patients. ACO executives completed survey data on 283 Medicare ACOs. These data were supplemented with 39 interviews conducted across 18 Medicare ACOs with executive-level leaders and associated clinical and managerial staff. Survey measures included ACO performance, organizational characteristics, collaboration experience, and capabilities in care management and quality improvement. Telephone interviews explored the mechanisms used and motivations of ACOs to deliver preventive care services. Medicare ACOs that reported being comprehensively engaged in the planning and management of patient care, including reminders for preventive care services, had more beneficiaries and a history of collaboration experience but were not more likely to receive shared savings or achieve high-quality scores compared to other surveyed ACOs. Interviews revealed that offering annual wellness visits and having a system-wide approach to closing preventive care gaps are key mechanisms used by high-performing ACOs to address patients’ preventive care needs. Few programs or initiatives were identified that specifically target clinically complex patients. Aside from meeting patient needs, motivations for ACOs included increasing patient attribution and meeting performance targets. ACOs are increasingly motivated to deliver preventive care services. Understanding the mechanisms and motivations used by high-performing ACOs may help both providers and payers to increase the use of preventive care.
Early Effects of an Accountable Care Organization Model for Underserved Areas
Date: August, 8, 2019
Source: New England Journal of Medicine
Article Link: https://www.nejm.org/doi/full/10.1056/NEJMsa1816660
The ACO Investment Model (AIM) was developed by the Centers for Medicare & Medicaid Services (CMS) to encourage growth of Medicare Shared Savings Program ACOs in rural and underserved areas by providing financial support to eligible ACOs through prepayment of shared savings. Researchers analyzed Medicare claims and enrollment data for a group of fee-for-service beneficiaries 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. The study used a difference-in-differences 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. Provider participation in AIM was associated with a differential reduction in total Medicare Part A and B spending of $28.21 per beneficiary per month relative to the comparison group, amounting to $131 million aggregate decrease. Over the same period, CMS made $76.2 million in prepayments and paid an additional $6.2 million in shared savings to ACOs where shared savings exceeded prepayments. After accounting for this $82.4 million in shared savings, the aggregate net reduction was $48.6 million, or 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. 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.
Engaging Primary Care Providers to Reduce Unwanted Clinical Variation and Support ACO Cost and Quality Goals: A Unique Provider-Payer Collaboration
Date: August 2, 2019
Source: Population Health Management
Article Link: https://www.liebertpub.com/doi/10.1089/pop.2018.0111
The study examined efforts to reduce unneeded variation among practicing primary care clinicians participating in an ACO and to raise quality and reduce costs. This real-world, quasi-controlled experiment compared ACO target improvements between three participating geographic regions and members within the ProHealth ACO against nonparticipating regions and members. Researchers used a novel care standardization initiative to engage participating providers. This was a 2-year longitudinal study with six rounds of serially measured provider care decisions and customized individual and group improvement feedback. Participating providers cared for online patient simulations as they would actual patients, and their care decisions were scored against evidence-based guidelines. This approach generated significant increases in evidence-based quality scores (+27%) and reductions in unneeded testing (-55%) in the patient simulations. Improvements in the online simulated patients correlated with improvements in patient-level ACO quality measures, which showed gains above and beyond the quasi-control group. Reductions calculated for spending on unneeded tests and specialist referrals exceeded $4.8 million.
ACOs’ Strategies for Transitioning to Value-Based Care: Lessons From the Medicare Shared Savings Program
Date: July 19, 2019
Source: HHS Office of the Inspector General
Article Link: https://oig.hhs.gov/oei/reports/oei-02-15-00451.asp
The study examined 20 high-performing ACOs that had reduced Medicare spending while providing high-quality care. OIG conducted structured onsite or telephone interviews with key officials from each ACO and analyzed supplemental documentation provided by ACOs. The study found that ACOs have developed a number of strategies to reduce Medicare spending and improve quality of care, including increasing cost awareness in ACO physicians, engaging beneficiaries to improve their own health, and managing beneficiaries with costly or complex care needs to improve their health outcomes. Other successful strategies involved reducing avoidable hospitalizations, controlling costs and improving quality in skilled nursing and home healthcare, addressing behavioral health needs and social determinants of health, and using technology to increase information sharing among providers. ACOs also reported challenges in each of these areas and describe ways they overcame them. Based on the findings, OIG recommended that the Centers for Medicare & Medicaid Services take the following actions to support efforts to reduce unnecessary spending and improve quality of care for patients: (1) review the impact of programmatic changes on ACOs’ ability to promote value-based care; (2) expand efforts to share information about strategies that reduce spending and improve quality among ACOs and more widely with the public; (3) adopt outcome-based measures and better align measures across programs; (4) assess and share information about ACOs’ use of the skilled nursing facility 3-day rule waiver and apply these results when making changes to the Shared Savings Program or other programs; (5) identify and share information about strategies that integrate physical and behavioral health services and address social determinants of health; (6) identify and share information about strategies that encourage patients to share behavioral health data; and (7) prioritize ACO referrals of potential fraud, waste, and abuse.
Association Between Care Management and Outcomes Among Patients With Complex Needs in Medicare Accountable Care Organizations
Date: July 12, 2019
Source: JAMA Network Open
Article Link: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2737898
In this cross-sectional study, survey information on care management and coordination processes from 244 Medicare Shared Savings Program ACOs in the 2017-2018 National Survey of ACOs (of 351 Medicare ACO respondents; response rate, 69%) was linked to 2016 Medicare administrative claims data. Medicare beneficiaries 66 years or older who were defined as having complex needs because of frailty or two or more chronic conditions associated with high costs and clinical need were included. The study divided responding ACOs into three groups (tertiles) based on the comprehensiveness of their self-reported care management and care coordination activities. Among 1,402,582 Medicare beneficiaries with complex conditions, the mean (SD) age was 78 (8.0) years and 55.1%were female. Compared with beneficiaries assigned to ACOs in the bottom tertile of care management and coordination activities, those assigned to ACOs in the top tertile had identical median prevention quality indicator admissions and 30-day all-cause readmissions (0 per beneficiary across all tertiles), hospitalization and emergency department visits (1.0 per beneficiary in bottom and top tertiles), evaluation and management visits in ambulatory settings (14.0 per beneficiary in both tertiles), longer median inpatient days (11.0 vs. 10.0), higher median annual spending ($14,350 vs $14,229), lower median health care contact days (28.0 vs 29.0), and lower continuity-of-care index (0.12 vs 0.13). Accounting for within-patient correlation, quality, utilization, and spending outcomes among patients with complex needs attributed to ACOs were not statistically different comparing the top vs bottom tertile of care management and coordination activities. The most important limitation of the study is its cross-sectional nature, which does not allow for causal interpretation. Because the study used claims-based methods, residual, unmeasured differences between the comparison groups are possible. If ACOs with high levels of care management had sicker patients not captured by the claims-based measures, illness would have not been adequately adjusted for and an underlying association between care management and coordination and outcomes would not have been observed. While the study is not definitive and includes several limitations, estimates on various outcomes were indistinguishable from zero, the authors conclude, indicating a call to invest in these areas with caution and to track local results in careful evaluations.
Association Between Specialist Office Visits and Health Expenditures in Accountable Care Organizations
Date: July 10, 2019
Source: JAMA Open Network
Article Link: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2737841?widget=personalizedcontent&previousarticle=0
This cross-sectional study examined the association between physician office visits conducted by specialists and health care spending in ACOs, finding that ACOs where 40% to 45% of patient visits were provided by specialists had statistically significantly lower per-beneficiary person-year spending compared with ACOs where less than 35% or at least 60% of physician visits were conducted by specialists. Researchers obtained data on 620 distinct ACOs from the Medicare Shared Savings Program ACO Public-Use Files from April 1, 2012, to September 30, 2017. The study adjusted for ACO-beneficiary health status, Medicare enrollment groups, ACO size, and proportion of participating specialists. The share of specialist office visits was categorized into seven groups: less than 35%, 35% to less than 40%, 40% to less than 45% (reference group), 45% to less than 50%, 50% to less than 55%, 55% to less than 60%, and 60% or greater. ACOs with a specialist encounter proportion of 40% to less than 45% had $1,129 (95% CI, $445-$1,814) lower per-beneficiary person-year spending than ACOs in the lowest specialist encounter proportion group and had $752 (95% CI, $115-$1,389) lower per-beneficiary person-year spending compared with ACOs in the highest specialist encounter proportion group. Decreases in emergency department visits, hospital discharges, and skilled nursing facility discharges were observed with increasing specialist encounter proportion. Conversely, increases in magnetic resonance imaging volume discharges were observed with increasing specialist encounter proportion. These findings suggest that an ACO’s ability to reduce spending may require sufficient involvement in care processes from specialists, who seem to complement the intrinsic primary care approach in ACOs.
Health Information Technology and Accountable Care Organizations: A Systematic Review and Future Directions
Date: July 8, 2019
Source: eGEMs: The Journal for Electronic Health Data and Methods
Article Link: https://egems.academyhealth.org//article/10.5334/egems.261/
Researchers conducted a systematic review and identified 32 studies describing the intersection of health IT and ACOs, mainly in the form of electronic health records and health information exchange. The synthesis identified three major subgroups of health IT and ACO studies: (1) studies focused on participation among hospitals and provider groups with health IT as a factor influencing participation; (2) studies examining adoption of health IT as an outcome, with ACO participation among provider groups and hospitals as a factor in those capabilities or use of health IT; and (3) studies examining patient or process outcomes with ACOs and health IT as factors. Although most studies found a positive association between health IT and ACO participation, studies examining the performance of ACOs in terms of their health IT capabilities showed more mixed results. The study concludes that advancing the evidence base of the effects of health IT within the context of ACOs is increasingly relevant to the ongoing discussion surrounding delivery reform.
Performance in the Medicare Shared Savings Program After Accounting for Nonrandom Exit: An Instrumental Variable Analysis
Date: July 2, 2019
Source: Annals of Internal Medicine
Article Link: https://annals.org/aim/article-abstract/2736098/performance-medicare-shared-savings-program-after-accounting-nonrandom-exit-instrumental
The study examined the effects of Medicare Shared Savings Program (MSSP) ACOs on spending and quality while accounting for clinicians’ nonrandom exit from ACOs.
Similar to prior MSSP analyses, this study compared MSSP ACO participants versus control beneficiaries using adjusted longitudinal models that accounted for secular trends, market factors, and beneficiary characteristics. To further account for selection effects, the share of nearby clinicians in the MSSP was used as an instrumental variable. Hip fracture served as a falsification outcome. The authors also tested for compositional changes among MSSP participants. Researchers looked at fee-for-service Medicare from 2008 through 2014 using a 20% sample of beneficiary claims, or 97,204,192 beneficiary-quarters, to measure total spending, four quality indicators, and hospitalization for hip fracture. In adjusted longitudinal models, the MSSP was associated with spending reductions (change, −$118 [95% CI, −$151 to −$85] per beneficiary-quarter) and improvements in all four quality indicators. In instrumental variable models, the MSSP was not associated with spending (change, $5 [CI, −$51 to $62] per beneficiary-quarter) or quality. In falsification tests, the MSSP was associated with hip fracture in the adjusted model (−0.24 hospitalizations for hip fracture [CI, −0.32 to −0.16 hospitalizations] per 1,000 beneficiary-quarters) but not in the instrumental variable model (0.05 hospitalizations [CI, −0.10 to 0.20 hospitalizations] per 1000 beneficiary-quarters). Compositional changes were driven by high-cost clinicians exiting ACOs: High-cost clinicians (99th percentile) had a 30.4% chance of exiting the MSSP, compared with a 13.8% chance among median-cost clinicians (50th percentile). While noting that a limitation of the study was reliance on an observational design and administrative data, researchers concluded that the MSSP was not associated with improvements in spending or quality after adjustment for clinicians’ nonrandom exit.
ACO Contracts With Downside Financial Risk Growing, But Still In The Minority
Date: July 1, 2019
Source: Health Affairs
Article Link: https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2018.05386?journalCode=hlthaff
Success of the ACO model may require stronger financial incentives, such as including downside risk in contracts. Using the National Survey of ACOs, researchers explored ACO structure and contracts in 2012-18. Though the number of ACO contracts and the proportion of ACOs with multiple contracts have grown, the proportion bearing downside risk has increased only modestly. As of 2018, only one-third of ACOs had a payment contract with downside risk. Compared to ACOs without downside risk, other ACOs are bigger, more likely to be vertically and horizontally integrated, and more likely to have been exposed to other types of payment reform and have more ACO contracts across payer types (Medicare, Medicaid, and commercial). Understanding the importance of downside risk in increasing the impact of the ACO model, the hesitancy of ACOs, and the levers that could be used to strengthen both the breadth and the depth of incentives while maintaining participation in the voluntary program is key to moving the ACO model forward.
Linking Practice Adoption of Patient Engagement Strategies and Relational Coordination to Patient‐Reported Outcomes in Accountable Care Organizations
Date: June 17, 2019
Source: The Millbank Quarterly
Article Link: https://onlinelibrary.wiley.com/doi/abs/10.1111/1468-0009.12400
ACO adult primary care practices are adopting a range of patient engagement strategies, but little is known about how these strategies are related to patient‐reported outcomes (PROs) and how relational coordination among team members aids implementation. Researchers used a mixed‐methods cohort study design integrating administrative and clinical data with two data collection waves (2014‐2015 and 2016‐2017) of clinician and staff surveys (n = 764), surveys of adult patients with diabetes and/or cardiovascular disease (CVD) (n = 1,276), and key informant interviews of clinicians, staff, and administrators (n =103). Multivariable linear regression estimated the relationship of practice adoption of patient engagement strategies, relational coordination, and PROs of physical, social, and emotional function. The mediating role of patient activation was examined using cross‐lagged panel models. Key informant interviews assessed how relational coordination influences the implementation of patient engagement strategies. here were no differential improvements in PROs among patients of practices with high vs. low adoption of patient engagement strategies or among patients of practices with high vs. low relational coordination. The Patient Activation Measure (PAM) is strongly related to better physical, emotional, and social PROs over time. Relational coordination facilitated the implementation of patient engagement strategies, but key informants indicated that resources and systems to systematically track treatment preferences and goals beyond clinical indicators were needed to support effective implementation. Adult patients with diabetes and/or CVD of ACO‐affiliated practices with high adoption of patient engagement strategies do not have improved PROs of physical, emotional, and social function over a one‐year time frame. Implementing patient engagement strategies increases task interdependence among primary care team members, which needs to be carefully managed. ACOs may need to make greater investment in collecting, monitoring, and analyzing PRO data to ensure that practice adoption and implementation of patient engagement strategies leads to improved physical, emotional, and social function among patients.
‘Eyes In The Home’: ACOs Use Home Visits To Improve Care Management, Identify Needs, And Reduce Hospital Use
Date: June 3, 2019
Source: Health Affairs
Article Link: https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2019.00003
The study used national survey data from physician practices and ACOs, paired with qualitative interviews, to learn about home visiting programs. ACO practices were more likely to report using care transitions home visits than non-ACO practices. Eighty percent of ACOs reported using home visits for some patients, with larger ACOs more commonly using home visits. Interviewed ACOs reported using home visits as part of care management and care transitions programs as well as to evaluate patients’ home environments and identify needs. ACOs most often used nonphysician staff to conduct home visits. Despite the value perceived in home visits, ACOs experienced challenges, such as reimbursement, staffing capacity, and an inability to address identified social needs. The finding that larger and system-based ACOs were more likely to implement resource-intensive home visits creates concerns about the ability of smaller, independent practices and organizations to use home visits as a tool to engage patients and discover barriers to improved care. These organizations may need further financial or logistical support to implement home visits.
ACO Serious Illness Care: Survey and Case Studies Depict Current Challenges And Future Opportunities
Date: June 3, 2019
Source: Health Affairs
Article Link: https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2019.00013?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dpubmed
Care for people living with serious illness is suboptimal for many reasons, including underpayment for key services, such as care coordination and social supports, in fee-for-service reimbursement. ACOs have potential to improve serious illness care because of their widespread dissemination, strong financial incentives for care coordination in downside-risk models, and flexibility in shared savings spending. Based on 2018 Annual ACO Survey results—20% response rate (N=203 ACOs)—the study found that 94% of responding ACOs at least partially identify their seriously ill beneficiaries, yet only 8% to 21% have widely implemented serious illness initiatives such as advance care planning or home-based palliative care. Researchers selected six diverse ACOs with successful programs for case studies and interviewed 53 leaders and front-line personnel. Cross-cutting themes include the need for up-front investment beyond shared savings to build serious illness infrastructure and workforce; supporting the business case for organizational buy-in; how ACO contract specifications affect savings for serious illness populations; and using data and health information technology to manage populations. The article also discusses the implications of the recent Medicare ACO regulatory overhaul and other policies related to serious illness quality measures, risk adjustment, attribution methods, supporting rural ACOs, and enhancing timely data access.
Medicare Cost at End of Life
Date: March 18, 2019
Source: The Journal of Hospice and Palliative Medicine
Article Link: https://journals.sagepub.com/doi/full/10.1177/1049909119836204
As the Medicare program struggles to control expenditures, there is increased focus on opportunities to manage patient populations more efficiently and at a lower cost. Patients at the end of life (EOL) represent a disproportionate share of Medicare’s costs, implying that these patients are an appropriate population for management by risk-taking Medicare entities such as Medicare Advantage plans and ACOs, whose mission is to reduce cost as well as improve the quality of care. Because risk-taking entities need to reduce costs to share savings, they seek opportunities for more intense patient engagement and management. The study summarizes main findings of previously published research articles on EOL expenditures and utilization patterns; proposes a methodology for estimating the proportion of Medicare spending accounted for by patients at EOL that takes into account spending during the final year of life, not just at the time of death; investigates recent Medicare EOL expenditures using the most recent Medicare Limited Data Set data for calendar year 2015 to 2016 and models the opportunity for Medicare Advantage plans and Medicare Shared-savings Program ACOs to reduce cost of care for members in their final year of life while maintaining or improving care quality.
Medicare Shared Savings ACOs and Hospice Care for Ischemic Stroke Patients
Date: March 5, 2019
Source: Journal of the American Geriatrics Society
Article Link: https://onlinelibrary.wiley.com/doi/abs/10.1111/jgs.15852
Palliative care services have the potential to improve the quality of end‐of‐life care and reduce cost. Services such as the Medicare hospice benefit, however, are often underutilized among stroke patients with a poor prognosis. Researchers tested the hypothesis that the Medicare Shared Savings Program (MSSP) is associated with increased hospice enrollment and inpatient comfort measures among ischemic stroke patients with a high-mortality risk. The study used a difference‐in‐differences design to compare outcomes before and after hospital participation in the MSSP for patients discharged from MSSP ACO hospitals (N = 273) vs non‐MSSP hospitals (N = 1,490). The study linked records from a national registry, Get with the Guidelines (GWTG)‐Stroke, to Medicare hospice claims (2010‐2015) for fee-for‐service Medicare beneficiaries aged 65 and older hospitalized for incident ischemic stroke at a GWTG‐Stroke hospital from January 2010 to December 2014 (N = 324,959). Among patients with high-mortality risk, ACO alignment was associated with a 16% increase in odds of hospice enrollment (adjusted odds ratio [OR] = 1.16; 95% confidence interval [CI] = 1.06‐1.26), increasing the probability of hospice enrollment from 20% to 22%. In the low-mortality-risk group, discharge from an MSSP vs non‐MSSP hospital was associated with a decrease in the predicted probability of inpatient comfort measures or discharge to hospice from 9% to 8% (OR = .82; CI = .74‐.91), and ACO alignment was associated with reduced odds of a short stay (<7 days) (OR = .86; CI = .77‐.96). Among ischemic stroke patients with severe stroke or indicators of high-mortality risk, MSSP was associated with increased hospice enrollment. MSSP contract incentives may motivate improved end‐of‐life care among the subgroups most likely to benefit.
Efficiency-Based Comparisons of One-Sided and Two-Sided Medicare Accountable Care Organizations (ACOs) and Their Potential Cost Savings
Abstract: Medicare ACOs represent the nation’s largest initiative of Medicare alternative payment models toward value and health outcomes. Various ACO models have been experimented at differential risk structures, and the CMS has issued a final rule to accelerate the ACOs to assume greater downside financial risks. In response, this research conducts a comprehensive efficiency analysis of Medicare ACOs incorporating quality measures, investigates whether superiority exists among the various ACO models and determines their potential cost reductions. The results indicate that in minimizing expenditures given quality services, or maximizing quality services given health expenditures, one-sided ACOs are more efficient than two-sided ACOs, so it might not be advisable to mandate the transition of ACOs from one-sided to two-sided, as far as efficiency is concerned. This research also shows that the ACOs should be able to reduce expenditures significantly through efficiency improvement. Maintaining the same level of enrollment, utilization, and quality, without switching to two-sided ACO tracks, Track 1 ACOs are expected to reduce expenditures by 4.1% using the median efficiency target, and 1.5% using the 25th percentile efficiency target (compared to actual expenditures). Another finding is that the benchmark expenditures for one in four Medicare ACOs are below the efficient expenditures using the median efficiency target, and one in three using the 25th percentile efficiency target. The benchmark expenditures are probably too low for these ACOs, and should be adjusted upward.
Source Date: January 28, 2019
How Accountable Care Organizations Use Population Segmentation to Care for High-Need, High-Cost Patients
Authors: Ann S. O’Malley, Eugene C. Rich, Rumin Sarwar, Eli Schultz, W. Cannon Warren, Tanya Shah, and Melinda K. Abrams
Abstract: ACOs use a range of approaches to segment their HNHC patients. Although there was no consistent set of subgroups for HNHC patients across ACOs, there were some common ones. Respondents noted that when primary care clinicians were engaged in refining segmentation approaches, there was an increase in both the clinical relevance of the results as well as the willingness of frontline providers to use them. Population segmentation results informed ACOs’ understanding of program needs, for example, by helping them better understand what skill sets and staff were needed to deliver enhanced care management. Findings on how mature ACOs are segmenting their HNHC population can improve the future development of more systematic approaches.
Source: The Commonwealth Fund
Source Date: January 3, 2019