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King CA, Cook R, Korthuis PT, McCarty D, Morris CD, Englander H. Expanding Inpatient Addiction Consult Services Through Accountable Care Organizations for Medicaid Enrollees: A Modeling Study. J Addict Med 2022; 16:570-576. [PMID: 35135988 PMCID: PMC9357852 DOI: 10.1097/adm.0000000000000972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Addiction consult services (ACS) care for hospitalized patients with substance use disorder, including opioid use disorder (OUD). Medicaid Accountable Care Organizations (ACOs) could enhance access to ACS. This study extends data from Oregon's only ACS to Oregon's 15 regional Medicaid Coordinated Care Organizations (CCOs) to illustrate the potential value of enhanced in- and out-patient care for hospitalized patients with OUD. The study objectives were to estimate the effects of (1) expanding ACS care through CCOs in Oregon, and (2) increasing community treatment access within CCOs, on post-discharge OUD treatment engagement. METHODS We used a validated Markov model, populated with Oregon Medicaid data from April 2015 to December 2017, to estimate study objectives. RESULTS Oregon Medicaid patients hospitalized with OUD with care billed to a CCO (n = 5878) included 1298 (22.1%) patients engaged in post-discharge OUD treatment. Simulation of referral to an ACS increased post-discharge OUD treatment engagement to 47.0% (95% confidence interval [CI] 45.7%, 48.3%), or 2684 patients (95% CI 2610, 2758). Ten of fifteen (66.7%) CCOs had fewer than 20% of patients engage in post-discharge OUD care. Without ACS, increasing outpatient treatment such that 20% of patients engage increased the patients engaging in post-discharge OUD care from 12.9% or 296 patients in care at baseline to 20% (95% CI 18.1%, 21.4%) or 453 (95% CI 416, 491). DISCUSSION ACOs can improve care for patients hospitalized with OUD. Implementing ACS in ACO networks can potentially improve post-discharge OUD treatment engagement, but community treatment systems must be prepared to accept more patients as inpatient addiction care improves.
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Yan BW, Shashoua M, Figueroa JF. Changes in spending, utilization, and quality of care among Medicare accountable care organizations during the COVID-19 pandemic. PLoS One 2022; 17:e0272706. [PMID: 35960735 PMCID: PMC9374212 DOI: 10.1371/journal.pone.0272706] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 07/25/2022] [Indexed: 11/19/2022] Open
Abstract
The COVID pandemic disrupted health care spending and utilization, and the Medicare Shared Savings Program (MSSP), Medicare’s largest value-based payment model with 11.2 million assigned beneficiaries, was no exception. Despite COVID, the 513 accountable care organizations (ACO) in MSSP returned a program record $1.9 billion in net savings to Medicare in 2020. To understand the extent of COVID’s impact on MSSP cost and quality, we describe how ACO spending changed in 2020 and further analyze changes in measured quality and utilization. We found that non-COVID per capita spending in MSSP fell by 8.3 percent from $11,496 to $10,537 (95% confidence interval(CI),-1,223.8 to-695.4, p<0.001), driven by 14.6% and 7.5% reductions in per capita acute inpatient and outpatient spending, respectively. Utilization fell across inpatient, emergency, and outpatient settings. On quality metrics, preventive screening rates remained stable or improved, while control of diabetes and blood pressure worsened. Large reductions in non-COVID utilization helped ACOs succeed financially in 2020, but worsening chronic disease measures are concerning. The appropriateness of the benchmark methodology and exclusion of COVID-related spending, especially as the virus approaches endemicity, should be revisited to ensure bonus payments reflect advances in care delivery and health outcomes rather than COVID-related shifts in spending and utilization patterns.
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Jacobs D, Rawal P, Fowler L, Seshamani M. Expanding Accountable Care's Reach among Medicare Beneficiaries. N Engl J Med 2022; 387:99-102. [PMID: 35476633 DOI: 10.1056/nejmp2202991] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Katragadda C, Fung C, Yousefi-Nooraie R, Cupertino P, Joseph J, Kim Y, Li Y. Medicare accountable care organizations: post-acute care use and post-surgical outcomes in urologic cancer surgery. Urology 2022; 167:102-108. [PMID: 35772480 DOI: 10.1016/j.urology.2022.06.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 05/17/2022] [Accepted: 06/15/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To evaluate association between Medicare accountable care organizations (ACOs) participation of hospitals on post-acute care (PAC) use and spending, and post-surgical outcomes in Medicare beneficiaries undergoing urologic cancer surgeries. Despite increasing prevalence of urologic cancer and surgical care contributing to a large proportion of total health care costs, and recent Medicare payment reforms such as accountable care organizations, the role of ACOs in urologic cancer care has been unexplored. METHODS We conducted a longitudinal analysis of 2011-2017 Medicare claims data to compare post-surgical outcomes between Medicare ACO and non-ACO patients before and after implementation of Medicare shared savings program (MSSP). Our outcomes of interest were Post-acute care (PAC) use (overall, institutional, and home health), Skilled Nursing Facility (SNF) length of stay and Medicare spending for SNF patients, 30-day and 90-day unplanned readmissions and complications after index procedure. RESULTS Study sample included a total of 334,514 Medicare patients undergoing bladder, prostate, kidney cancer surgeries at 524 Medicare ACO and 2066 non-ACO hospitals. For bladder cancer surgery, Medicare ACO participation was associated with significantly reduced overall post-acute care use, but not with changes in readmission or complication rate. For prostate cancer and kidney cancer surgery, we found no significant association between hospital participation in Medicare ACOs and PAC use or post-surgical outcomes. CONCLUSIONS Hospital participation in MSSP ACOs leads to lower post-acute care use without compromising patient outcomes for Medicare beneficiaries undergoing bladder cancer surgery. Future research is needed to understand longer-term impact of ACO participation on urologic cancer surgery outcomes.
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Cole MB, Nguyen KH, Byhoff E, Murray GF. Screening for Social Risk at Federally Qualified Health Centers: A National Study. Am J Prev Med 2022; 62:670-678. [PMID: 35459451 PMCID: PMC9035213 DOI: 10.1016/j.amepre.2021.11.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 11/12/2021] [Accepted: 11/16/2021] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Federally Qualified Health Centers serve 29.8 million low-income patients across the U.S., many of whom have unaddressed social risks. In 2019, for the first time, data on social risk screening capabilities were collected from every U.S. Federally Qualified Health Center. The objectives of this study were to describe the national rates of social risk screening capabilities across Federally Qualified Health Centers, identify organizational predictors of screening, and assess between-state heterogeneity. METHODS Using a 100% sample of U.S. Federally Qualified Health Centers (N=1,384, representing 29.8 million patients) from the 2019 Uniform Data System, the primary outcome was whether a Federally Qualified Health Center collected data on patients' social risk factors (yes/no). Summary statistics on the rates of social risk screening capabilities were generated in aggregate and by state. Linear probability models were then used to estimate the relationship between the probability of social risk screening and 7 key Federally Qualified Health Center characteristics (e.g., Federally Qualified Health Center size, Medicaid MCO contract, Medicaid accountable care organization presence). Data were analyzed in 2020‒2021. RESULTS Most (71%) Federally Qualified Health Centers collected social risk data, with a between-state variation. The most common screener was the Protocol for Responding to and Assessing Patients' Assets Risks and Experiences (43% of Federally Qualified Health Centers that screened), whereas 22% collected social risk data using a nonstandardized screener. After adjusting for other characteristics, Federally Qualified Health Centers with social risk screening capabilities served more total patients, were more likely to be located in a state with a Medicaid accountable care organization, and were less likely to have an MCO contract. CONCLUSIONS There has been widespread adoption of social risk screening tools across U.S. Federally Qualified Health Centers, but between-state disparities exist. Targeting social risk screening resources to smaller Federally Qualified Health Centers may increase the adoption of screening tools.
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Mechanic RE, Perloff J, Stuck AR, Crowley C. Characteristics of home-based care provided by accountable care organizations. THE AMERICAN JOURNAL OF MANAGED CARE 2022; 28:e185-e188. [PMID: 35546592 DOI: 10.37765/ajmc.2022.89150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
OBJECTIVES To describe the use of home-based services in accountable care organizations (ACOs). STUDY DESIGN Cross-sectional analysis of 2019 ACO survey. METHODS We analyzed surveys completed by 151 ACOs describing the characteristics of home-based care programs serving high-need, high-cost patients. We linked survey results to publicly available information about ACO characteristics, governance, and risk model participation. RESULTS Twenty-five percent of respondent ACOs had formal home-based care programs, 25% offered occasional home visits, and 17% were actively developing new programs. Home-based primary care was the most common program type. Half of programs were established within the past 3 years. The programs utilized multidisciplinary care teams, but two-thirds had fewer than 500 visits annually. Funding sources included direct billing for services, health system subsidies, and ACO shared savings. A majority of respondents expressed interest in expanding services but were concerned about their ability to demonstrate a return on investment (ROI), which was reported as a major or moderate challenge by three-quarters of respondents. CONCLUSIONS ACOs deliver a diverse array of home-visit services including primary care, acute medical care, palliative care, care transitions, and interventions to address social determinants of health. Many services provided are not billable, and therefore ACO leaders are hesitant to fund expansions without strong evidence of ROI. Expanding Medicare ACO home-visit waivers to all risk-bearing ACOs and covering integrated telehealth services would improve the financial viability of these programs.
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Kim TH, Thompson J. Market and Organizational Factors Associated with Hospital Leadership of Accountable Care Organizations. Hosp Top 2022; 101:275-287. [PMID: 35400305 DOI: 10.1080/00185868.2022.2040403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND The number of Accountable Care Organizations (ACOs) in the U.S. has been rapidly increasing during the past decade. Despite the growth of Accountable Care Organizations (ACOs), little is known about the factors that are associated with hospital leadership of ACOs that contract with public and private payers. PURPOSE Using a resource dependency framework, this study examines the organizational characteristics and environmental factors that are associated with hospitals who are leading an ACO. METHODOLOGY We used the data from the American Hospital Association (AHA) Annual Survey of Hospitals for 2018, the Area Health Resources Files and the Medicare Cost Reports. A multiple logistic regression was used to test associations of the independent variables with the hospital leadership of ACOs. RESULTS We found that nearly one third of the hospitals studied were leading an ACO. System affiliated and not-for-profit hospitals were more likely to be the leaders. Hospitals that lead an ACO offer more clinical services and have better financial performance. Metropolitan core-based statistical areas and per capita income were significantly positively associated with leading an ACO. However, the proportion of population aged 65 and over and the percentage of Medicare advantage penetration were significantly negatively associated with leading an ACO. CONCLUSIONS Hospitals vary in leading an ACO, which may provide critical resources for them by creating an infrastructure that enables accountable care, extends their services into population health and value-based care programs increasingly promoted by public and commercial payers.
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Ramirez AG, Marsh KM, McMurry TL, Turrentine FE, Tracci MA, Jones RS. How Total Performance Scores of Medicare Value-Based Purchasing Program Hospitals Change Over Time. J Healthc Qual 2022; 44:78-87. [PMID: 34469925 DOI: 10.1097/jhq.0000000000000321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND PURPOSE The Medicare Value-Based Purchasing (VBP) program established performance-based financial incentives for hospitals. We hypothesized that total performance scores (TPS) would vary by hospital type. METHODS Value-Based Purchasing reports were collected from 2015 to 2017 and merged with the Centers for Medicare and Medicaid Services (CMS) Impact File data. A total of 3,005 hospitals were grouped into physician-owned surgical hospitals (POSH), accountable care organizations (ACO), Kaiser, Vizient, and General hospitals. Longitudinal linear mixed-effects models compared temporal differences of TPS and secondary composite outcome, process, patient satisfaction, safety, and cost efficiency measures between hospital types. RESULTS Total performance scores decreased across all hospital types (p < .001). Physician-owned surgical hospitals had the highest TPS (59.9), followed by Kaiser (49.2), ACO (36.7), General (34.8), and Vizient (30.7) (p < .001). Hospital types differed significantly in size, geography, mean case-mix index, Medicare patient discharges, percent Medicare days to inpatient days, Disproportionate Share Hospital payments, and uncompensated care per claim. Scores improved in 84% of POSH and 14.6% of Kaiser hospitals using score reallocations. CONCLUSION In comparison with General hospitals, the TPS was higher for POSH and Kaiser and lower for Vizient in part due to weighting reallocation and individual domain scores. IMPLICATIONS Centers for Medicare and Medicaid Services scoring system changes have not addressed the methodological biases favoring certain hospital types.
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Gibbons JB, Chang CH, Banerjee M, Meddings J, Norton EC, Chen L, Bynum JPW. Small practice participation and performance in Medicare accountable care organizations. THE AMERICAN JOURNAL OF MANAGED CARE 2022; 28:117-123. [PMID: 35404547 DOI: 10.37765/ajmc.2022.88839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
OBJECTIVES Alternative payment models (APMs) encouraging provider collaboration may help small practices overcome the participation challenges that they face in APMs. We aimed to determine whether small practices in accountable care organizations (ACOs) reduced their beneficiaries' spending more than large practices in ACOs. STUDY DESIGN Retrospective cohort study of Medicare patients attributed to ACOs and non-ACOs. METHODS We conducted a modified difference-in-differences analysis that allowed us to compare large vs small practices before and after the Medicare Shared Savings Program (MSSP) ACO started, between 2010 and 2016. Our sample included Medicare fee-for-service beneficiaries with 12 months of Medicare Part A and Part B (unless death) who were attributed to small (≤ 15 providers) and large (> 15 providers) practices participating in ACOs and non-ACOs. The outcome was patient annual spending based on CMS' total per capita costs. RESULTS Patients attributed to small practices in ACOs had annual Medicare spending decreases of $269 (95% CI, $213-$325; P < .001) more than patients attributed to large practices in ACOs. Small ACO practices reduced spending more than large practices by $165 for physician services (95% CI, $140-$190; P < .001), $113 for hospital/acute care (95% CI, $65-162; P < .001), and $52 for other services (95% CI, $27-$77; P < .001). Small practices in ACOs spent $253 more on average at baseline than small practices in non-ACOs. ACOs with a higher proportion of small practices were more likely to receive shared savings payments. CONCLUSIONS Small practices in ACOs controlled costs more so than large practices. Small practice participation may generate higher savings for ACOs.
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Markovitz AA, Ryan AM, Peterson TA, Rozier MD, Ayanian JZ, Hollingsworth JM. ACO Awareness and Perceptions Among Specialists Versus Primary Care Physicians: a Survey of a Large Medicare Shared Savings Program. J Gen Intern Med 2022; 37:492-494. [PMID: 33501534 PMCID: PMC8811095 DOI: 10.1007/s11606-020-06556-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 12/22/2020] [Indexed: 02/03/2023]
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Perloff J, Sobul S. Use of electronic health record systems in accountable care organizations. THE AMERICAN JOURNAL OF MANAGED CARE 2022; 28:e31-e34. [PMID: 35049264 DOI: 10.37765/ajmc.2022.88818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
OBJECTIVES To assess the ability of accountable care organizations (ACOs) to use electronic health record (EHR) data for quality. STUDY DESIGN Cross-sectional study of ACOs participating in the Medicare Shared Savings Program (MSSP). METHODS A national survey of MSSP ACOs included questions on the number of EHR systems used across all providers in the ACO and barriers to reporting EHR-based quality measures. RESULTS Just 9% of ACOs use a single EHR system, whereas 77% use 6 or more EHR systems. The more EHR systems an ACO uses, the less likely it is to report having the infrastructure to aggregate EHR data and the more concerned it is about the short-term viability and accuracy of EHR-based quality measures. CONCLUSIONS ACOs have diverse structures that often result in the usage of multiple EHR systems. This has the potential to cause serious delays when CMS begins requiring ACOs to report their quality measures through their EHRs in 2022.
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Apathy NC, Holmgren AJ, Werner RM. Growth in health information exchange with ACO market penetration. THE AMERICAN JOURNAL OF MANAGED CARE 2022; 28:e7-e13. [PMID: 35049261 DOI: 10.37765/ajmc.2022.88815] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
OBJECTIVES First, to assess whether hospitals expand the network breadth of their health information exchange (HIE) partners after joining an accountable care organization (ACO). Second, to analyze whether this HIE network expansion effect varies across markets with differing levels of ACO penetration. STUDY DESIGN Difference-in-differences analyses of US nonfederal acute care hospitals, 2014-2017. METHODS We used data from the American Hospital Association Annual Survey and Information Technology Supplement to measure hospital ACO participation, HIE network breadth (defined as number of different partner types), and ACO market penetration at the hospital referral region level. We implemented a difference-in-differences model to estimate changes in hospitals' HIE network breadth with ACO participation in different years. We estimate these effects combined across all markets and stratified by markets with high and low ACO market penetration. RESULTS In combined analyses, HIE breadth increased by 0.35 partner types with ACO participation, a 30.7% increase (P < .001). In stratified analyses, this effect was larger for hospitals in high-ACO penetration markets (0.41 partner types, a 32.0% increase; P < .001) and smaller for hospitals in low-ACO penetration markets (0.25 partner types, a 24.8% increase; P < .05). We found dynamic effects of ACO adoption illustrating an immediate effect in high-ACO penetration markets and a 2-year delayed effect in low-ACO penetration markets. CONCLUSIONS Hospitals that joined ACOs increased their HIE breadth, but this effect was heterogenous across markets and across time. Our findings illustrate a "network effect," with large, immediate effects in HIE breadth following ACO participation in high-ACO penetration markets and smaller, delayed effects in low-ACO penetration markets.
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Hersey C, McWilliams JM, Fout B, Trombley MJ, Scarpati L. An analysis of Medicare accountable care organization expense reports. THE AMERICAN JOURNAL OF MANAGED CARE 2021; 27:569-572. [PMID: 34889580 DOI: 10.37765/ajmc.2021.88795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
OBJECTIVES To understand the investments that Medicare Shared Savings Program accountable care organizations (ACOs) in the ACO Investment Model (AIM) made to participate in the program and the costs that they incurred as a result of their efforts to lower spending and improve quality. STUDY DESIGN We conducted a systematic review and categorization of all available and approved quarterly expenses reported by AIM ACOs. METHODS We reviewed final approved quarterly expense reports submitted by ACOs detailing how they spent funds in the quarter. All distinct line-item descriptions were classified into a more informative and consistent set of categories. We then applied higher conceptual dimensions (type of care input and type of ACO strategy) to these newly categorized expenses to facilitate additional analysis of spending patterns. RESULTS AIM ACOs reported expenses of $264.8 million over the 3 performance years (2016-2018). The majority of the $264.8 million in expenditures was incurred for personnel (55.5%), followed by infrastructure (22.3%), management firm expenses (15.3%), and internal programs and systems (6.9%). The dominant identifiable ACO strategy was care coordination and management, accounting for 52.9% of related ACO expenses. CONCLUSIONS AIM ACOs invested most heavily in personnel, information technology, and care management, with less than half of the investments explicitly tied to a strategy for improving quality or reducing spending. Efforts to change clinician practice patterns, alter the way patients access the health care system, and institute other practice redesigns were not primary targets for investment.
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Berlin J. Going Local: Accountable Health Organizations Could Help Combat Social Disparities at the Local Level. Tex Med 2021; 117:34-35. [PMID: 34855978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
"We believe that standardizing those kind of processes will be easier for [those] providing care. Because one of the things we hear a lot is this lack of harmonization of processes and procedures, whether that's in care or measures or processes. That is a really important part of it."
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Teno JM, Mitchell S, Belanger E, Bunker J, Gozalo PL. Accountable Care Organizations (ACOs) Could Potentially Improve the Quality of Care in Those Afflicted With Dementia. J Pain Symptom Manage 2021; 62:e1-e2. [PMID: 33957253 PMCID: PMC8500342 DOI: 10.1016/j.jpainsymman.2021.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 04/08/2021] [Indexed: 11/15/2022]
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Tanenbaum JE, Votruba M, Einstadter D, Love TE, Cebul RD. Adoption of Health System Innovations: Evidence of Urban-Rural Disparities from the Ohio Primary Care Marketplace. J Gen Intern Med 2021; 36:1584-1590. [PMID: 33515196 PMCID: PMC8175515 DOI: 10.1007/s11606-020-06440-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 12/10/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Accountable care organizations (ACOs), patient-centered medical homes (PCMHs), and the meaningful use of electronic health records (EHRs) generated particular attention during the last decade. Translating these reforms into meaningful increases in population health depends on improving the quality and clinical integration of primary care providers (PCPs). However, if these innovations spread more quickly among PCPs in urban and wealthier areas, then they could potentially worsen existing geographic disparities in health outcomes. OBJECTIVE To determine the market penetration of Medicare Shared Savings Program (MSSP) ACOs, PCMHs, and the meaningful use of EHRs among PCPs across urban and rural counties in Ohio. DESIGN Retrospective, observational study of the percent of PCPs in a county who are affiliated with PCMH, ACO, and meaningful use (MU) of EHR. PARTICIPANTS PCPs in all of Ohio's 88 counties from 2011 to 2015. MAIN MEASURES Primary care market penetration of ACO, PCMH, and meaningful use of EHR KEY RESULTS: In 2015, the Ohio primary care market penetration of PCMH was 23.4%, ACO was 27.7%, MU stage 1 was 55.8%, and MU stage 2 was 26.6%. During the study period, PCMH and ACO market penetration increased faster in urban counties relative to rural counties, and market penetration of meaningful use of EHR increased faster in rural counties. CONCLUSIONS Market penetration of PCMH and ACOs increased faster in urban markets compared to rural markets. However, the adoption of EHRs increased faster in rural markets. The results are a cause for optimism as well as a call to action: although recent efforts to increase PCMH and ACO adoption were less effective among the rural population in Ohio, federal programs to accelerate adoption of EHRs were overwhelmingly successful in rural areas.
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Santavicca S, Duszak R, Nicola GN, Golding LP, Rosenkrantz AB, Wernz C, Hughes DR. Evolving Radiologist Participation in Medicare Shared Savings Program Accountable Care Organizations. J Am Coll Radiol 2021; 18:1332-1341. [PMID: 34022135 DOI: 10.1016/j.jacr.2021.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 04/21/2021] [Accepted: 04/28/2021] [Indexed: 11/19/2022]
Abstract
PURPOSE The aim of this study was to temporally characterize radiologist participation in Medicare Shared Savings Program (MSSP) accountable care organizations (ACOs). METHODS Using CMS Physician and Other Supplier Public Use Files, ACO provider-level Research Identifiable Files, and Shared Savings Program ACO Public-Use Files for 2013 through 2018, characteristics of radiologist ACO participation were assessed over time. RESULTS Between 2013 and 2018, the percentage of Medicare-participating radiologists affiliated with MSSP ACOs increased from 10.4% to 34.9%. During that time, the share of large ACOs (>20,000 beneficiaries) with participating radiologists averaged 87.0%, and the shares of medium ACOs (10,000-20,000) and small ACOs (<10,000) with participating radiologists rose from 62.5% to 66.0% and from 26.3% to 51.6%, respectively. The number of physicians in MSSP ACOs with radiologists was substantially larger than those without radiologists (mean range across years, 573-945 versus 107-179). Primary care physicians constituted a larger percentage of the physician population for ACOs without radiologists (average across years, 66.3% versus 38.5%), and ACOs with radiologists had a higher rate of specialist representation (56.0% versus 33.7%). Beneficiary age, race, and sex demographics were similar among radiologist-participating versus nonparticipating ACOs. CONCLUSIONS In recent years, radiologist participation in MSSP ACOs has increased substantially. ACOs with radiologist participation are large and more diverse in their physician specialty composition. Nonparticipating radiologists should prepare accordingly.
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Abstract
The purpose of this study was to examine how the Medicare Access and CHIP Reauthorization Act (MACRA) has improved health care delivery and to determine its impact on Accountable Care Organization (ACO) goals. ACOs have provided quality care through the reduction in readmission rates, coordinated care, and cost savings. With the passage of the MACRA, it has been estimated that it would further decrease Medicare spending on physician and hospital services. Also, ACOs have had a positive impact on improving health care delivery and have played a significant role in providing exceptional quality of care while also managing to increase the cost savings.
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Charns MP. Limitations to National Policy and Financial Incentives: The Role of Organizational Dynamics. Med Care 2021; 59:193-194. [PMID: 33560764 DOI: 10.1097/mlr.0000000000001516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ouayogodé MH, Meara E, Ho K, Snyder CM, Colla CH. Estimates of ACO savings in the presence of provider and beneficiary selection. HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION 2021; 9:100460. [PMID: 33412439 DOI: 10.1016/j.hjdsi.2020.100460] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 07/24/2020] [Accepted: 08/03/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Medicare's accountable care organizations (ACOs)-designed to improve quality and lower spending-were associated with growing savings in previous studies. However, savings estimates may be biased by beneficiary sorting among providers based on healthcare needs and by providers opting into the program based on anticipated gains. METHODS Using Medicare administrative claims (2009-2014), we compared annual spending changes after provider organizations joined ACOs to changes in non-ACOs (controls). To address provider selection, using novel data to identify non-ACO organizations, we restricted controls to comparably large provider organizations. To address beneficiary selection, we (a) estimated within-organization (including non-ACO comparison organizations) spending changes, (b) estimated within-beneficiary spending changes, (c) incorporated beneficiaries without qualifying healthcare expenses, and (d) used a fixed beneficiary ACO assignment using the pre-ACO period. RESULTS Each year, 19% of Medicare beneficiaries switched provider organizations. Spending was higher for switchers than stayers ($3163, p < .001) and grew more the next year ($2004; p < .001). Starting from a baseline regression modeled on previous ACO evaluations, estimated savings varied widely as we sequentially introduced methods to address selection. Combining methods, however, generated more stable estimated ACO savings of $46 (p = .022), averaged across cohorts. CONCLUSIONS When implementing a comprehensive suite of methods to adjust for provider and beneficiary selection, we estimated ACO savings that grew over time. Our estimates are in line with, but smaller than, previous estimates in the literature. Implementing piecemeal adjustments produced misleading results. IMPLICATIONS Our results confirm the importance of selection for savings estimates and for provider organizations managing costs and quality. Attribution rules that consider multiple years may help mitigate the impact of beneficiary churn for providers and payers. Implementing payment reform by randomizing early participants, or implementing fully across selected markets, may better serve efforts to evaluate and improve payment models. LEVEL OF EVIDENCE Level 3.
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Awan AA, Erickson KF. ACOs and Bending the Cost Curve for Health Care Spending for People with Kidney Failure. Clin J Am Soc Nephrol 2020; 15:1699-1701. [PMID: 33234542 PMCID: PMC7769026 DOI: 10.2215/cjn.16521020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Domino ME, Norton EC, Yoon J, Cuddeback GS, Morrissey JP. Putting Providers At-Risk through Capitation or Shared Savings: How Strong are Incentives for Upcoding and Treatment Changes? THE JOURNAL OF MENTAL HEALTH POLICY AND ECONOMICS 2020; 23:81-91. [PMID: 32853157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 06/17/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Alternative payment models, including Accountable Care Organizations and fully capitated models, change incentives for treatment over fee-for-service models and are widely used in a variety of settings. The level of payment may affect the assignment to a payment category, but to date the upcoding literature has been motivated largely incorporating financial penalties for upcoding rather than by a theoretical model that incorporates the downstream effects of upcoding on service provision requirements. AIMS OF THE STUDY In this paper, we contribute to the literature on upcoding by developing a new theoretical model that is applicable to capitated, case-rate and shared savings payment systems. This model incorporates the downstream effects of upcoding on service provision requirements rather than just the avoidance of penalties. This difference is important especially for shared-savings models with quality benchmarks. METHODS We test implications of our theoretical model on changes in severity determination and service use associated with changes in case-rate payments in a publicly-funded mental health care system. We model provider-assigned severity categories as a function of risk-adjusted capitated payments using conditional logit regressions and counts of service days per month using negative binomial models. RESULTS We find that severity determination is only weakly associated with the payment rate, with relatively small upcoding effects, but that level of use shows a greater degree of association. DISCUSSION These results are consistent with our theoretical predictions where the marginal utility of savings or profit is small, as would be expected from public sector agencies. Upcoding did seem to occur, but at very small levels and may have been mitigated after the county and providers had some experience with the new system. The association between the payment levels and the number of service days in a month, however, was significant in the first period, and potentially at a clinically important level. Limitations include data from a single county/multiple provider system and potential unmeasured confounding during the post-implementation period. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE Providers in our data were not at risk for inpatient services but decreases in use of outpatient services associated with rate decreases may lead to further increases in inpatient use and therefore expenditures over time. IMPLICATIONS FOR HEALTH POLICIES Health program directors and policy makers need to be acutely aware of the interplay between provider payments and patient care and eventual health and mental health outcomes. IMPLICATIONS FOR FURTHER RESEARCH Further research could examine the implications of the theoretical model of upcoding in other payment systems, estimate the power of the tiered-risk systems, and examine their influence on clinical outcomes.
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Grisel J, Fuller G. Hearing Health Care Belongs to Primary Care. Tex Med 2020; 116:4-5. [PMID: 32866278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Like many areas of health care, hearing loss is best managed when hearing professionals collaborate closely with physicians. Primary care physicians (PCPs) are uniquely suited to manage hearing loss because 1) patients trust their PCP; 2) PCPs have insight into the overall health and well-being of their patients; and 3) the PCP workforce is large enough to make a meaningful impact. Accountable care organizations, clinically integrated networks, and patient-centered medical homes are perfectly suited to be a positive force in the hearing health of their patients.
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Luo N, Hammill BG, DeVore AD, Xu H, Fonarow GC, Albert NM, Matsouaka RA, Hernandez AF, Yancy C, Mentz RJ. Outcomes and cost among Medicare beneficiaries hospitalized for heart failure assigned to accountable care organizations. Am Heart J 2020; 226:13-23. [PMID: 32502880 DOI: 10.1016/j.ahj.2020.04.028] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Accepted: 04/30/2020] [Indexed: 12/01/2022]
Abstract
Little is known about the impact of accountable care organizations (ACO) on hospitalized heart failure (HF) patients, a high-cost and high-risk population. OBJECTIVE We linked Medicare fee-for-service claims from 2013 to 2015 with data from American Heart Association Get With The Guidelines-HF registry to compare HF care, post-discharge outcomes, and total annual Medicare spending by ACO status at discharge. METHODS Using adjusted Cox models and accounting for competing risks of death, we compared all-cause mortality and readmission at 1 year by ACO status with reporting of hazard ratios (HR) and 99% confidence intervals (CI). RESULTS The study included 45,259 HF patients from 300 hospitals, with 21.1% assigned to an ACO. Patient characteristics were similar between the two groups with a few exceptions. The ACO patients lived in geographic areas with higher median income ($54400 [IQR $48600-65900] vs $52300 [$45900-61200], P < .0001). Compliance with four HF-specific quality measures was modestly higher in the ACO group (80% vs 76%, P < .0001). In adjusted analysis, ACO status was associated with similar all-cause readmission (HR: 1.03; 99% CI: 0.99, 1.07) but lower risk of 1-year mortality (HR: 0.85; 99% CI: 0.85, 0.90) compared with non-ACO status. Median Medicare spending in the calendar year of hospitalization was similar (ACO $42,737 [IQR $23,011-72,667] vs non-ACO $42,586 [$22,896-72,518], P = 0.06). CONCLUSIONS Among Medicare patients hospitalized for HF, participation in an ACO was associated with similar rates of all-cause readmission and no associated cost reductions compared with non-ACO status. There was a lower risk of 1-year mortality associated with ACO participation, which warrants further evaluation.
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Huang N, Raji M, Lin YL, Chou LN, Kuo YF. Nurse Practitioner Involvement in Medicare Accountable Care Organizations: Association With Quality of Care. Am J Med Qual 2020; 36:171-179. [PMID: 32715726 DOI: 10.1177/1062860620935199] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The objective was to examine trend and care quality outcomes associated with nurse practitioner (NP) involvement in Accountable Care Organizations (ACOs) via a cross-sectional study of 521 Medicare Shared Savings Program ACOs during 2014 to 2016. Data include ACO provider/beneficiary files, Medicare claims, and ACO performance data with a focus on Medicare beneficiaries with diabetes, chronic obstructive pulmonary disease, or heart failure. ACO care quality measures were stratified by NP involvement and adjusted for patient, provider, and ACO factors. NP involvement was highest in larger ACOs, states that allow NPs full scope of practice, and rural areas. Greater involvement was associated with fewer readmissions and higher scores on measures of preventive care but not chronic disease and medication management. Greater NP involvement in ACOs was associated with improvement in some care quality measures. With NPs' increasing involvement in ACOs, more research is needed to understand the NP role in processes and outcomes of care.
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