Moving Forward With Accountable Care Organizations: Some Answers, More Questions

Practice Site Heterogeneity within and between Medicaid Accountable Care Organizations

The existing literature has considered accountable care organizations (ACOs) as whole entities, neglecting potentially important variations in the characteristics and experiences of the individual practice sites that comprise them. In this observational cross-sectional study, our aim is to characterize the experience, capacity, and process heterogeneity at the practice site level within and between Medicaid ACOs, drawing on the Massachusetts Medicaid and Children's Health Insurance Program (MassHealth), which launched an ACO reform effort in 2018. We used a 2019 survey of a representative sample of administrators from practice sites participating in Medicaid ACOs in Massachusetts (n = 225). We quantified the clustering of responses by practice site within all 17 Medicaid ACOs in Massachusetts for measures of process change, previous experience with alternative payment models, and changes in the practices' ability to deliver high-quality care. Using multilevel logistic models, we calculated median odds ratios (MORs) and intraclass correlation coefficients (ICCs) to quantify the variation within and between ACOs for each measure. We found greater heterogeneity within the ACOs than between them for all measures, regardless of practice site and ACO characteristics (all ICCs ≤ 0.26). Our research indicates diverse experience with, and capacity for, implementing ACO initiatives across practice sites in Medicaid ACOs. Future research and program design should account for characteristics of practice sites within ACOs.

New Payment Models: The Medicare Access and CHIP Reauthorization Act of 2015, Merit-based Incentive Payment System, Advanced Alternative Payment Models, Bundling, Value-Based Care, Quadruple Aim, and Big Data: What Do They Mean for Otolaryngology?

New payment models have been introduced by the Centers for Medicare and Medicaid Services to move medicine away from volume-based care toward value-based care. Most models focus on changes for primary care, but specialists like otolaryngologists are wise to familiarize themselves with this changing payment landscape to take advantage of the opportunities and avoid the pitfalls associated with each model.

Turning Neural Prosthetics Into Viable Products

Academic researchers concentrate on the scientific and technological feasibility of novel treatments. Investors and commercial partners, however, understand that success depends even more on strategies for regulatory approval, reimbursement, marketing, intellectual property protection and risk management. These considerations are critical for technologically complex and highly invasive treatments that entail substantial costs and risks in small and heterogeneous patient populations. Most implanted neural prosthetic devices for novel applications will be in FDA Device Class III, for which guidance documents have been issued recently. Less invasive devices may be eligible for the recently simplified “de novo” submission routes. We discuss typical timelines and strategies for integrating the regulatory path with approval for reimbursement, securing intellectual property and funding the enterprise, particularly as they might apply to implantable brain-computer interfaces for sensorimotor disabilities that do not yet have a track record of approved products.

Comparative Effectiveness of a Complex Care Program for High-Cost/High-Need Patients: a Retrospective Cohort Study

BACKGROUND

High-cost/high-need (HCHN) adults and the healthcare systems that provide their care may benefit from a new patient-centered model of care involving a dedicated physician and nurse team who coordinate both clinical and social services for a small patient panel.

OBJECTIVE

Evaluate the impact of a Complex Care Program (CCP) on likelihood of patient survival and hospital admission in 180 days following empanelment to the CCP.

DESIGN

Retrospective cohort study using a quasi-experimental design with CCP patients propensity score matched to a concurrent control group of eligible but unempaneled patients.

SETTING

Kaiser Permanente Mid-Atlantic States (KPMAS) during 2017-2018.

PARTICIPANTS

Nine hundred twenty-nine CCP patients empaneled January 2017-June 2018, 929 matched control patients for the same period.

INTERVENTIONS

The KPMAS CCP is a new program consisting of 8 teams each staffed by a physician and nurse who coordinate care across a continuum of specialty care, tertiary care, and community services for a panel of 200 patients with advanced clinical disease and recent hospitalizations.

MAIN OUTCOMES

Time to death and time to first hospital admission in the 180 days following empanelment or eligibility.

RESULTS

Compared to matched control patients, CCP patients had prolonged time to death (hazard ratio [HR]: 0.577, 95% CI: 0.474, 0.704), and CCP decedents had longer survival (median days 69.5 vs. 53.0, p=0.03). CCP patients had similar time to hospital admission (HR: 1.081, 95% CI: 0.930, 1.258), with similar results when adjusting for competing risk of death (HR: 1.062, 95% CI: 0.914, 1.084).

LIMITATIONS

Non-randomized intervention; single healthcare system; patient eligibility limited to specific conditions.

CONCLUSION

The KPMAS CCP was associated with significantly reduced short-term mortality risk for eligible patients who volunteered to participate in this intervention.

Factors associated with hospital participation in Centers for Medicare and Medicaid Services' Accountable Care Organization programs

BACKGROUND

In 2012, the Centers for Medicare and Medicaid Services (CMS) initiated the Medicare Shared Savings Program (MSSP) and Pioneer Accountable Care Organization (ACO) programs. Organizations in the MSSP model shared cost savings they generated with CMS, and those in the Pioneer program shared both savings and losses. It is largely unknown what hospital and environmental characteristics are associated with the development of CMS ACOs with one- or two-sided risk models.

PURPOSE

The aim of this study was to assess the organizational and environmental characteristics associated with hospital participation in the MSSP and Pioneer ACOs.

METHODOLOGY

Hospitals participating in CMS ACO programs were identified using primary and secondary data. The ACO hospital sample was linked with the American Hospital Association, Health Information and Management System Society, and other data sets. Multinomial probit models were estimated that distinguished organizational and environmental factors associated with hospital participation in the MSSP and Pioneer ACOs.

RESULTS

Hospital participation in both CMS ACO programs was associated with prior experience with risk-based payments and care management programs, advanced health information technology, and location in higher-income and more competitive areas. Whereas various health system types were associated with hospital participation in the MSSP, centralized health systems, higher numbers of physicians in tightly integrated physician-organizational arrangements, and location in areas with greater supply of primary care physicians were associated with Pioneer ACOs. Favorable hospital characteristics were, in the aggregate, more important than favorable environmental factors for MSSP participation.

CONCLUSION

MSSP ACOs may look for broader organizational capabilities from participating hospitals that may be reflective of a wide range of providers participating in diverse markets. Pioneer ACOs may rely on specific hospital and environmental characteristics to achieve quality and spending targets set for two-sided contracts.

PRACTICE IMPLICATIONS

Hospital and ACO leaders can use our results to identify hospitals with certain characteristics favorable to their participation in either one- or two-sided ACOs.

The Effect of Medicare Accountable Care Organizations on Early and Late Payments for Cardiovascular Disease Episodes

BACKGROUND

Initial evaluations of the Pioneer and Shared Savings Programs have shown modest savings associated with care receipt in a Medicare accountable care organization (ACO). Whether these savings are affected by disease chronicity and the mechanisms through which they occur are unclear. In this context, we examined the association between Medicare ACO implementation and episode spending for 2 different cardiovascular conditions.

METHODS AND RESULTS

We analyzed a 20% sample of national Medicare data, identifying fee-for-service beneficiaries aged ≥65 years admitted for acute myocardial infarction (AMI) or congestive heart failure (CHF) between January 2010 and October 2014. We distinguished admissions to hospitals participating in a Medicare ACO from those to hospitals that were not. We calculated 365-day, price-standardized episode spending made on behalf of these beneficiaries, differentiating between early (index admission to 90 days postdischarge) and late payments (91-365 days postdischarge). Using an interrupted time series design, we fit longitudinal multivariable models to estimate the association between hospital ACO participation and episode spending. Our study included 153 476 beneficiaries admitted for AMI to 401 ACO participating hospitals and 2597 nonparticipating hospitals and 260 420 beneficiaries admitted for CHF to 412 ACO participating hospitals and 2796 nonparticipating hospitals. On multivariable analysis, admission to an ACO participating hospital was not associated with changes in early episode spending (AMI, $95 per beneficiary; 95% CI, -$481 to $671; CHF, $158; 95% CI, -$290 to $605). However, it was associated with significant reductions in late episode spending for both cohorts (AMI, -$680; 95% CI, -$1348 to -$11; CHF, -$889; 95% CI, -$1465 to -$313).

CONCLUSIONS

For beneficiaries with AMI or CHF, admission to ACO participating hospitals was not associated with changes in early episode spending, but it was associated with significant savings during the late episode. ACO effects on late episode spending may complement other value-based payment reforms that target the early episode.

Characteristics of Markets and Patients Served by ESRD Seamless Care Organizations

Under the Comprehensive End-stage Renal Disease (ESRD) Care (CEC) Model, dialysis facilities and nephrologists form ESRD Seamless Care Organizations (ESCOs) to deliver high value care. This study compared the characteristics of patients and markets served and unserved by CEC and assessed its generalizability. ESCOs operated in 65 of 384 markets. ESCO markets were larger than non-ESCO markets, had fewer White patients, higher household income, and higher Medicare spending per patient. Patients in ESCOs were similar to eligible nonaligned patients in age and sex but differed in race/ethnicity and were more often treated in an urban area; comorbidity prevalence differed modestly. CEC is available to a meaningful share of the dialysis population and relatively few dialysis patients resided in a market where no provider could meet the participation threshold, so market size may not be the primary barrier for potential new participants in CEC or future kidney care models.

Lessons for achieving health equity comparing Aotearoa/New Zealand and the United States

Aotearoa/New Zealand (Aotearoa/NZ) and the United States (U.S.) suffer inequities in health outcomes by race/ethnicity and socioeconomic status. This paper compares both countries' approaches to health equity to inform policy efforts. We developed a conceptual model that highlights how government and private policies influence health equity by impacting the healthcare system (access to care, structure and quality of care, payment of care), and integration of healthcare system with social services. These policies are shaped by each country's culture, history, and values. Aotearoa/NZ and U.S. share strong aspirational goals for health equity in their national health strategy documents. Unfortunately, implemented policies are frequently not explicit in how they address health inequities, and often do not align with evidence-based approaches known to improve equity. To authentically commit to achieving health equity, nations should: 1) Explicitly design quality of care and payment policies to achieve equity, holding the healthcare system accountable through public monitoring and evaluation, and supporting with adequate resources; 2) Address all determinants of health for individuals and communities with coordinated approaches, integrated funding streams, and shared accountability metrics across health and social sectors; 3) Share power authentically with racial/ethnic minorities and promote indigenous peoples' self-determination; 4) Have free, frank, and fearless discussions about impacts of structural racism, colonialism, and white privilege, ensuring that policies and programs explicitly address root causes.

The Value-Based Payment Modifier: Program Outcomes and Implications for Disparities

BACKGROUND

When risk adjustment is inadequate and incentives are weak, pay-for-performance programs, such as the Value-Based Payment Modifier (Value Modifier [VM]) implemented by the Centers for Medicare & Medicaid Services, may contribute to health care disparities without improving performance on average.

OBJECTIVE

To estimate the association between VM exposure and performance on quality and spending measures and to assess the effects of adjusting for additional patient characteristics on performance differences between practices serving higher-risk and those serving lower-risk patients.

DESIGN

Exploiting the phase-in of the VM on the basis of practice size, regression discontinuity analysis and 2014 Medicare claims were used to estimate differences in practice performance associated with exposure of practices with 100 or more clinicians to full VM incentives (bonuses and penalties) and exposure of practices with 10 or more clinicians to partial incentives (bonuses only). Analyses were repeated with 2015 claims to estimate performance differences associated with a second year of exposure above the threshold of 100 or more clinicians. Performance differences were assessed between practices serving higher- and those serving lower-risk patients after standard Medicare adjustments versus adjustment for additional patient characteristics.

SETTING

Fee-for-service Medicare.

PATIENTS

Random 20% sample of beneficiaries.

MEASUREMENTS

Hospitalization for ambulatory care-sensitive conditions, all-cause 30-day readmissions, Medicare spending, and mortality.

RESULTS

No statistically significant discontinuities were found at the threshold of 10 or more or 100 or more clinicians in the relationship between practice size and performance on quality or spending measures in either year. Adjustment for additional patient characteristics narrowed performance differences by 9.2% to 67.9% between practices in the highest and those in the lowest quartile of Medicaid patients and Hierarchical Condition Category scores.

LIMITATION

Observational design and administrative data.

CONCLUSION

The VM was not associated with differences in performance on program measures. Performance differences between practices serving higher- and those serving lower-risk patients were affected considerably by additional adjustments, suggesting a potential for Medicare's pay-for-performance programs to exacerbate health care disparities.

PRIMARY FUNDING SOURCE

The Laura and John Arnold Foundation and National Institute on Aging.