ACOs Serving High Proportions Of Racial And Ethnic Minorities Lag In Quality Performance

Telehealth Infrastructure, Accountable Care Organization, and Medicare Payment for Patients with Alzheimer's Disease and Related Dementia Living in Socially Vulnerable Areas

Background: Structural social determinants of health have an accumulated negative impact on physical and mental health. Evidence is needed to understand whether emerging health information technology and innovative payment models can help address such structural social determinants for patients with complex health needs, such as Alzheimer's disease and related dementias (ADRD). Objective: This study aimed to test whether telehealth for care coordination and Accountable Care Organization (ACO) enrollment for residents in the most disadvantaged areas, particularly those with ADRD, was associated with reduced Medicare payment. Methods: The study used the merged data set of 2020 Centers for Medicare and Medicaid Services Medicare inpatient claims data, the Medicare Beneficiary Summary File, the Medicare Shared Savings Program ACO, the Center for Medicare and Medicaid Service's Social Vulnerability Index (SVI), and the American Hospital Annual Survey. Our study focused on community-dwelling Medicare fee-for-service beneficiaries aged 65 years and up. Cross-sectional analyses and generalized linear models (GLM) were implemented. Analyses were implemented from November 2023 to February 2024. Results: Medicare fee-for-service beneficiaries residing in SVI Q4 (i.e., the most vulnerable areas) reported significantly higher total Medicare costs and were least likely to be treated in hospitals that provided telehealth post-discharge services or have ACO affiliation. Meanwhile, the proportion of the population with ADRD was the highest in SVI Q4 compared with other SVI levels. The GLM regression results showed that hospital telehealth post-discharge infrastructure, patient ACO affiliation, SVI Q4, and ADRD were significantly associated with higher Medicare payments. However, coefficients of interaction terms among these factors were significantly negative. For example, the average interaction effect of telehealth post-discharge and ACO, SVI Q4, and ADRD on Medicare payment was -$1,766.2 (95% confidence interval: -$2,576.4 to -$976). Conclusions: Our results suggested that the combination of telehealth post-discharge and ACO financial incentives that promote care coordination is promising to reduce the Medicare cost burden among patients with ADRD living in socially vulnerable areas.

Measuring value in health care: lessons from accountable care organizations

Accountable care organizations (ACOs) were created to promote health care value by improving health outcomes while curbing health care expenditures. Although a decade has passed, the value of care delivered by ACOs is yet to be fully understood. We proposed a novel measure of health care value using data envelopment analysis and examined its association with ACO organizational characteristics and social determinants of health (SDOH). We observed that the value of care delivered by ACOs stagnated in recent years, which may be partially attributed to challenges in care continuity and coordination across providers. ACOs that were solely led by physicians and included more participating entities exhibited lower value, highlighting the role of coordination across ACO networks. Furthermore, SDOH factors, such as economic well-being, healthy food consumption, and access to health resources, were significant predictors of ACO value. Our findings suggest a "skinny in scale, broad in scope" approach for ACOs to improve the value of care. Health care policy should also incentivize ACOs to work with local communities and enhance care coordination of vulnerable patient populations across siloed and disparate care delivery systems.

Segregated Patterns of Hospital Care Delivery and Health Outcomes

Importance

Residential segregation has been shown to be a root cause of racial inequities in health outcomes, yet little is known about current patterns of racial segregation in where patients receive hospital care or whether hospital segregation is associated with health outcomes. Filling this knowledge gap is critical to implementing policies that improve racial equity in health care.

Objective

To characterize contemporary patterns of racial segregation in hospital care delivery, identify market-level correlates, and determine the association between hospital segregation and health outcomes.

Design, Setting, and Participants

This cross-sectional study of US hospital referral regions (HRRs) used 2018 Medicare claims, American Community Survey, and Agency for Healthcare Research and Quality Social Determinants of Health data. Hospitalization patterns for all non-Hispanic Black or non-Hispanic White Medicare fee-for-service beneficiaries with at least 1 inpatient hospitalization in an eligible hospital were evaluated for hospital segregation and associated health outcomes at the HRR level. The data analysis was performed between August 10, 2022, and September 6, 2023.

Exposures

Dissimilarity index and isolation index for HRRs.

Main Outcomes and Measures

Health outcomes were measured using Prevention Quality Indicator (PQI) acute and chronic composites per 100 000 Medicare beneficiaries, and total deaths related to heart disease and stroke per 100 000 residents were calculated for individuals aged 74 years or younger. Correlation coefficients were used to compare residential and hospital dissimilarity and residential and hospital isolation. Linear regression was used to examine the association between hospital segregation and health outcomes.

Results

This study included 280 HRRs containing data for 4386 short-term acute care and critical access hospitals. Black and White patients tended to receive care at different hospitals, with a mean (SD) dissimilarity index of 23 (11) and mean (SD) isolation index of 13 (13), indicating substantial variation in segregation across HRRs. Hospital segregation was correlated with residential segregation (correlation coefficients, 0.58 and 0.90 for dissimilarity and isolation, respectively). For Black patients, a 1-SD increase in the hospital isolation index was associated with 204 (95% CI, 154-254) more acute PQI hospitalizations per 100 000 Medicare beneficiaries (28% increase from the median), 684 (95% CI, 488-880) more chronic PQI hospitalizations per 100 000 Medicare beneficiaries (15% increase), and 6 (95% CI, 2-9) additional deaths per 100 000 residents (6% increase) compared with 68 (95% CI, 24-113; 6% increase), 202 (95% CI, 131-274; 8% increase), and 2 (95% CI, 0 to 4; 3% increase), respectively, for White patients.

Conclusions and Relevance

This cross-sectional study found that higher segregation of hospital care was associated with poorer health outcomes for both Black and White Medicare beneficiaries, with significantly greater negative health outcomes for Black populations, supporting racial segregation as a root cause of health disparities. Policymakers and clinical leaders could address this important public health issue through payment reform efforts and expansion of health insurance coverage, in addition to supporting upstream efforts to reduce racial segregation in hospital care and residential settings.

Maternal Health Equity in Medicaid Accountable Care Organizations: Early Lessons from the Massachusetts Experience

There are substantial inequities by race and ethnicity in maternal health care utilization and health outcomes across the perinatal period. As Medicaid covers 42% of births nationally and almost two-thirds of births to Black birthing people, state Medicaid financing and delivery system reforms have substantial scope to impact these inequities. Twenty-one states have implemented Medicaid Accountable Care Organizations (ACOs) at some point since 2015. Using public documents and interviews with ACO administrators, we examine the implications of Massachusetts Medicaid ACOs, implemented in March 2018, for maternal health equity. Although these Medicaid ACOs have the potential to impact maternal health equity, they face many challenges in doing so. We review future steps within Massachusetts Medicaid ACOs and Medicaid programs more generally to incorporate policies that may better address racial and ethnic inequities.

Variation in Risk-Standardized Acute Admission Rates Among Patients With Heart Failure in Accountable Care Organizations: Implications for Quality Measurement

Background Accountable care organizations (ACOs) aim to improve health care quality and reduce costs, including among patients with heart failure (HF). However, variation across ACOs in admission rates for patients with HF and associated factors are not well described. Methods and Results We identified Medicare fee-for-service beneficiaries with HF who were assigned to a Medicare Shared Savings Program ACO in 2017 and survived ≥30 days into 2018. We calculated risk-standardized acute admission rates across ACOs, assigned ACOs to 1 of 3 performance categories, and examined associations between ACO characteristics and performance categories. Among 1 232 222 beneficiaries with HF, 283 795 (mean age, 81 years; 54% women; 86% White; 78% urban) were assigned to 1 of 467 Medicare Shared Savings Program ACOs. Across ACOs, the median risk-standardized acute admission rate was 87 admissions per 100 people, ranging from 61 (minimum) to 109 (maximum) admissions per 100 beneficiaries. Compared to the overall average, 13% of ACOs performed better on risk-standardized acute admission rates, 72% were no different, and 14% performed worse. Most ACOs with better performance had fewer Black beneficiaries and were not hospital affiliated. Most ACOs that performed worse than average were large, located in the Northeast, had a hospital affiliation, and had a lower proportion of primary care providers. Conclusions Admissions are common among beneficiaries with HF in ACOs, and there is variation in risk-standardized acute admission rates across ACOs. ACO performance was associated with certain ACO characteristics. Future studies should attempt to elucidate the relationship between ACO structure and characteristics and admission risk.

Clinical Validity of the PROMIS Healthcare Engagement 8-Item Short Form

BACKGROUND

Healthcare engagement is a key measurement target for value-based healthcare, but a reliable and valid patient-reported measure has not yet been widely adopted.

OBJECTIVE

To assess the validity of a newly developed patient-reported measure of healthcare engagement, the 8-item PROMIS Healthcare Engagement (PHE-8a).

DESIGN

Prospective cohort study of the association between healthcare engagement and quality of care over 1 year. We fit mixed effects models of quality indicators as a function of engagement scores, adjusting for age, race/ethnicity, rural residence, and risk scores.

PARTICIPANTS

National stratified random sample of 9552 Veterans receiving Veterans Health Administration care for chronic conditions (hypertension, diabetes) or mental health conditions (depression, post-traumatic stress disorder).

MAIN MEASURES

Patient experience: Consumer Assessment of Health Plans and Systems communication and self-management support composites; no-show rates for primary care and mental health appointments; use of patient portal My HealtheVet; and Healthcare Effectiveness Data and Information Set electronic quality measures: HbA1c poor control, controlling high blood pressure, and hyperlipidemia therapy adherence.

KEY RESULTS

Higher engagement scores were associated with better healthcare quality across all outcomes, with each 5-point increase (1/2 standard deviation) in engagement scores associated with statistically significant and clinically meaningful gains in quality. Across the continuum of low to high engagement scores, we observed a concomitant reduction in primary care no-show rates of 37% and 24% for mental health clinics; an increased likelihood of My HealtheVet use of 15.4%; and a decreased likelihood of poor diabetes control of 44%.

CONCLUSIONS

The PHE-8a is a brief, reliable, and valid patient-reported measure of healthcare engagement. These results confirm previously untested hypotheses that patient engagement can promote healthcare quality.

The Next Generation of Payment Reforms for Population Health - An Actionable Agenda for 2035 Informed by Past Gains and Ongoing Lessons

Policy Points The predominantly fee-for-service reimbursement architecture of the US health care system contributes to waste and excess spending. While the past decade of payment reforms has galvanized the adoption of alternative payment models and generated moderate savings, uptake of truly population-based payment systems continues to lag, and interventions to date have had limited impact on care quality, outcomes, and health equity. To realize the promise of payment reforms as instruments for delivery system transformation, future policies for health care financing must focus on accelerating the diffusion of value-based payment, leveraging payments to redress inequities, and incentivizing partnerships with cross-sector entities to invest in the upstream drivers of health.

A Decade of ACOs in Medicare: Have They Delivered on Their Promise?

Accountable care organizations (ACOs) were envisioned as a way to address both health care cost growth and uneven quality in US health care. They emerged in the early 2000s, with the 2010 Affordable Care Act (ACA) establishing a Medicare ACO program. In the decade since their launch, ACOs have grown into one of Medicare's flagship payment reform programs, with millions of beneficiaries receiving care from hundreds of ACOs. While great expectations surrounded ACOs' introduction into Medicare, their impacts to date have been modest. ACOs have achieved some savings and improvements in measured quality, but disagreement persists over the meaning of those results: Do ACOs represent important, incremental steps forward on the path toward a more efficient, high-quality health care system? Or do their modest achievements signal a failure of large-scale progress despite the substantial investments of resources? ACOs have proven to be politically resilient, largely sidestepping the controversies and partisan polarization that have led to the demise of other ACA provisions. But the same features that have enabled ACOs to evade backlash have constrained their impacts and effectiveness. After a decade, ACOs' long-term influence on Medicare and the US health care system remains uncertain.

Discrepancies in Outcomes by Race and Ethnicity in COVID-19 Patients Receiving Casirivimab and Imdevimab

OBJECTIVES

The Centers for Disease Control and Prevention has reported increased rates of coronavirus disease 2019 (COVID-19)-related hospitalizations and deaths in Black and Hispanic individuals. One contributing factor to this may be a difference in access to treatment. We thus sought to compare the outcomes of Black, non-Hispanic patients and Hispanic patients with White, non-Hispanic individuals using a group of patients with COVID-19 who received casirivimab/imdevimab.

METHODS

This was a secondary analysis of data from a previously published retrospective chart review of patients who received casirivimab/imdevimab for COVID-19 between December 9, 2020 and August 20, 2021, when they were treated at one of three facilities within a single hospital system. We compared the baseline characteristics (including age, sex, body mass index, duration of symptoms, and vaccination status) and outcomes of Black, non-Hispanic patients and Hispanic patients with those of White, non-Hispanic patients. Our primary outcome was the odds of a return visit to the emergency department (ED) within 28 days of treatment as assessed by multivariate logistic regression. We also assessed the rates of return visits to the ED for symptoms caused by COVID-19, hospitalizations, and hospitalizations from hypoxia.

RESULTS

In total, 1318 patients received casirivimab/imdevimab for COVID-19 at the three study facilities. Of these, 410 (31.1%) identified themselves as White and non-Hispanic, 88 (6.7%) as Black and non-Hispanic, and 736 (55.8%) as Hispanic. Vaccination rates at the time of treatment were as follows: Black, non-Hispanic 10.2%, Hispanic 13.6%, and White, non-Hispanic 21.5%. On multivariate analysis, the odds of return visits to the ED within 28 days were higher for Black, non-Hispanic patients and Hispanic patients as compared with White, non-Hispanic patients, with odds ratios of 2.8 (95% confidence interval [CI] 1.4-5.5, P = 0.003) and of 2.3 (95% CI 1.5-3.6, P = 0.0002), respectively. For hospitalizations caused by hypoxia within 28 days of treatment, the adjusted odds ratio for Black, non-Hispanic patients was 3.4 (95% CI 1.1-10.5, P = 0.03) as compared with White, non-Hispanic patients. There were no other statistically significant differences among groups in regard to subsequent hospitalizations within 28 days.

CONCLUSIONS

Black, non-Hispanic patients and Hispanic patients are more likely to make a return visit to the ED within 28 days after casirivimab/imdevimab treatment for COVID-19 as compared with White, non-Hispanic patients. This holds true even when adjusting for higher vaccination rates among White, non-Hispanic individuals.

Accountable Care Organizations and Health Disparities of Rural Latinos: A Longitudinal Analysis

The purpose of this study was 2-fold: (1) to analyze the change in diabetes-related hospitalization rates of rural Latino older adult patients as compared with their White counterparts and (2) to determine what factors, including rural health clinic (RHC) participation in accountable care organizations (ACOs), are related to reduced disparities in diabetes-related hospitalization rates. Data for Latino Medicare beneficiaries who were served by RHCs over an 8-year period were analyzed. First, a difference-of-means test was conducted to determine whether there was a change in disparity from the pre-ACO period (2008-2011) to the post-ACO period (2012-2015). A statistically significant decrease in disparity over time was found (t = -7.6899, df = 115, P < 0.001.) Second, multiple regression analyses of 3 separate models were conducted to determine whether ACO participation contributed to reducing disparities in diabetes-related hospitalization rates between Latinos and Whites. The analyses indicated moderate evidence that consistent ACO participation is associated with lower health disparities (t = -1.947, P = 0.0525). However, this association is not significant after balancing covariates, and no causal relationship can be established. Latinos compose one of the fastest growing groups in rural as well as urban areas of the United States. It is critical that ACOs, with their emphasis on care coordination, health care quality, and value, monitor their provision of services to Latinos, rural, and other vulnerable populations.

Exit Rates of Accountable Care Organizations That Serve High Proportions of Beneficiaries of Racial and Ethnic Minority Groups

Importance

The Medicare Shared Savings Program provides financial incentives for accountable care organizations (ACOs) to reduce costs of care. The structure of the shared savings program may not adequately adjust for challenges associated with caring for patients with high medical complexity and social needs, a population disproportionately made up of racial and ethnic minority groups. If so, ACOs serving racial and ethnic minority groups may be more likely to exit the program, raising concerns about the equitable distribution of potential benefits from health care delivery reform efforts.

Objective

To evaluate whether ACOs with a high proportion of beneficaries of racial and ethnic minority groups are more likely to exit the Medicare Shared Savings Program and identify characteristics associated with this disparity.

Design, Setting, and Participants

This retrospective observational cohort study used secondary data on Medicare Shared Savings Program ACOs from January 2012 through December 2018. Bivariate and multivariate cross-sectional regression analyses were used to understand whether ACO racial and ethnic composition was associated with program exit, and how ACOs with a high proportion of beneficaries of racial and ethnic minority groups differed in characteristics associated with program exit.

Exposures

Racial and ethnic composition of an ACO's beneficiaries.

Main Outcomes and Measures

Shared savings program exit before 2018.

Results

The study included 589 Medicare Shared Savings Program ACOs. The ACOs in the highest quartile of proportion of beneficaries of racial and ethnic minority groups were designated high-proportion ACOs (145 [25%]), and those in the lowest 3 quartiles were designated low-proportion ACOs (444 [75%]). In unadjusted analysis, a 10-percentage point increase in the proportion of beneficiaries of racial and ethnic minority groups was associated with a 1.12-fold increase in the odds of an ACO exit (95% CI, 1.00-1.25; P = .04). In adjusted analysis, there were significant associations among high-proportion ACOs between characteristics such as patient comorbidities, disability, and clinician composition and a higher likelihood of exit.

Conclusions and Relevance

The study results suggest that ACOs that served a higher proportion of beneficaries of racial and ethnic minority groups were more likely to exit the Medicare Shared Savings Program, partially because of serving patients with greater disease severity and complexity. These findings raise concerns about how current payment reform efforts may differentially affect racial and ethnic minority groups.

Racial disparities in hypertension management among multiple sclerosis patients

BACKGROUND

Hypertension adversely impacts the multiple sclerosis (MS) disease course and is more common among Black Americans. Disparities in care due to structural racism may lead to suboptimal hypertension detection and control in Black American MS patients.

OBJECTIVES

To determine if uncontrolled hypertension is more common in Black or White Americans with MS and whether race impacts the likelihood of receiving anti-hypertensive treatment.

METHODS

A retrospective cohort study was conducted using longitudinal data from American participants in the Multiple Sclerosis Partners Advancing Technology and Health Solutions (MS PATHS) multi-institutional registry. Data was collected from 7 sites in the United States between May 2015 and November 2020. Patients with uncontrolled hypertension, defined as ≥2 blood pressure measurements ≥140/90 mmHg, were identified in the dataset. Racial differences in uncontrolled hypertension and odds of anti-hypertensive treatment were evaluated using logistic regression. Predictors of anti-hypertensive treatment in those with uncontrolled hypertension were determined by race.

RESULTS

The analysis included 10,673 MS patients, of whom 1,442 (13.5%) were Black Americans. Despite a lower mean age (45.7 vs. 49.2 years), Black Americans had a 31% increased odds of uncontrolled hypertension compared to White Americans. After adjustment for relevant covariates, mean systolic blood pressure was 1.84 mmHg (95% confidence interval=1.07-2.61) higher in Black Americans than White Americans, and mean diastolic blood pressure was 1.28 mmHg (95% confidence interval=0.74-1.82) higher. Black Americans were also more likely to be on anti-hypertensive therapy (OR=1.68, 95% confidence interval=1.30-2.18) and were exposed to an adjusted average of 0.61 (95% confidence interval=0.45-0.78) more anti-hypertensive treatments than White Americans (p<0.001). Age, comorbid diabetes mellitus, and comorbid hyperlipidemia were positively associated with use of anti-hypertensive treatments in all patients with uncontrolled hypertension.

CONCLUSION

Black American MS patients have significantly increased odds of uncontrolled hypertension, but also higher odds of receiving anti-hypertensive treatment.

Association Between Organizational Quality and Out-of-Network Primary Care Among Accountable Care Organizations That Care for High vs Low Proportions of Patients of Racial and Ethnic Minority Groups

Question

How is the quality of care delivered by a Medicare accountable care organization (ACO) associated with the level of out-of-network primary care among organizations that care for high vs low proportions of patients of racial and ethnic minority groups?

Findings

In this retrospective cohort study of 3 955 951 beneficiary-years within 528 Medicare ACOs, the ACOs that cared for more patients of racial and ethnic minority groups had significantly higher rates of out-of-network primary care than those that cared for fewer patients of racial and ethnic minority groups. The level of out-of-network primary care was negatively associated with performance among ACOs with many patients of racial and ethnic minority groups across most quality metrics examined.

Meaning

The study findings suggest that organizational efforts to limit out-of-network primary care at ACOs caring for many patients of racial and ethnic minority groups could serve as a tangible, accessible corrective for reducing health care disparities among the populations that they serve.

Importance

Medicare accountable care organizations (ACOs) that disproportionately care for patients of racial and ethnic minority groups deliver lower quality care than those that do not, potentially owing to differences in out-of-network primary care among them.

Objective

To examine how organizational quality is associated with out-of-network primary care among ACOs that care for high vs low proportions of patients of racial and ethnic minority groups.

Design, Setting, and Participants

A retrospective cohort study was conducted between March 2019 and October 2021 using claims data (2013 to 2016) from a national sample of Medicare beneficiaries. Among beneficiaries who were assigned to 1 of 528 Medicare ACOs, a distinction was made between those treated by organizations that cared for high (vs low) proportions of patients of racial and ethnic minority groups. For each ACO, the amount of out-of-network primary care that it delivered annually was determined. Multivariable models were fit to evaluate how the quality of care that beneficiaries received varied by the proportion of care provided to patients of racial and ethnic minority groups by the ACO and its amount of out-of-network primary care.

Exposures

The degree of care provided to patients of racial and ethnic minority groups by the ACO and its amount of out-of-network primary care.

Main Outcomes and Measures

The ACO quality assessed with 5 preventive care services and 4 utilization metrics.

Results

Among 3 955 951 beneficiary-years (2 320 429 [58.7%] women; 71 218 [1.8%] Asian, 267 684 [6.8%] Black, 44 059 [1.1%] Hispanic, 4922 [0.1%] North American Native, and 3 468 987 [87.7%] White individuals and 56 157 [1.4%] of Other race and ethnicity), those assigned to ACOs serving many patients of racial and ethnic minority groups at the mean level of out-of-network primary care were less likely than those assigned to ACOs serving fewer patients of racial and ethnic minority groups to receive diabetic retinal examinations (predicted probability, 49.4% [95%CI, 49.0%-49.7%] vs 51.6% [95% CI, 51.5%-51.8%]), glycated hemoglobin testing (predicted probability, 58.5% [95% CI, 58.2%-58.5%] vs 60.4% [95% CI, 60.3%-60.6%]), or low-density lipoprotein cholesterol testing (predicted probability, 85.2% [95% CI, 85.0%-85.5%] vs 86.0% [95% CI, 85.9%-86.1%]). They were also more likely to experience all-cause 30-day readmissions (predicted probability, 16.4% [95% CI, 16.1%-16.7%] vs 15.7% [95% CI, 15.6%-15.8%]). However, as the level of out-of-network primary care decreased, these gaps closed substantially, such that beneficiaries at ACOs that served many and fewer patients of racial and ethnic minority groups in the lowest percentile of out-of-network primary care received care of comparable quality.

Conclusions and Relevance

This large cohort study found that quality performance among ACOs serving many patients of racial and ethnic minority groups was negatively associated with their level of out-of-network primary care.

Association of Area-Level Socioeconomic Deprivation With Hypoglycemic and Hyperglycemic Crises in US Adults With Diabetes

IMPORTANCE

Social determinants of health play a role in diabetes management and outcomes, including potentially life-threatening complications of severe hypoglycemia and diabetic ketoacidosis (DKA) or hyperglycemic hyperosmolar state (HHS). Although several person-level socioeconomic factors have been associated with these complications, the implications of area-level socioeconomic deprivation are unknown.

OBJECTIVE

To examine the association between area-level deprivation and the risks of experiencing emergency department visits or hospitalizations for hypoglycemic and hyperglycemic crises (ie, DKA or HHS).

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used deidentified administrative claims data for privately insured individuals and Medicare Advantage beneficiaries across the US. The analysis included adults with diabetes who met the claims criteria for diabetes between January 1, 2016, and December 31, 2017. Data analyses were performed from November 17, 2020, to November 11, 2021.

EXPOSURES

Area deprivation index (ADI) was derived for each county for 2016 and 2017 using 17 county-level indicators from the American Community Survey. ADI values were applied to patients who were living in each county based on their index dates and were categorized according to county-level ADI quintile (with quintile 1 having the least deprivation and quintile 5 having the most deprivation).

MAIN OUTCOMES AND MEASURES

The numbers of emergency department visits or hospitalizations related to the primary diagnoses of hypoglycemia and DKA or HHS (ascertained using validated diagnosis codes in the first or primary position of emergency department or hospital claims) between 2016 and 2019 were calculated for each ADI quintile using negative binomial regression models and adjusted for patient age, sex, health plan type, comorbidities, glucose-lowering medication type, and percentage of White residents in the county.

RESULTS

The study population included 1 116 361 individuals (563 943 women [50.5%]), with a mean (SD) age of 64.9 (13.2) years. Of these patients, 343 726 (30.8%) resided in counties with the least deprivation (quintile 1) and 121 810 (10.9%) lived in counties with the most deprivation (quintile 5). Adjusted rates of severe hypoglycemia increased from 13.54 (95% CI, 12.91-14.17) per 1000 person-years in quintile 1 counties to 19.13 (95% CI, 17.62-20.63) per 1000 person-years in quintile 5 counties, corresponding to an incidence rate ratio of 1.41 (95% CI, 1.29-1.54; P < .001). Adjusted rates of DKA or HHS increased from 7.49 (95% CI, 6.96-8.02) per 1000 person-years in quintile 1 counties to 8.37 (95% CI, 7.50-9.23) per 1000 person-years in quintile 5 counties, corresponding to an incidence rate ratio of 1.12 (95% CI, 1.00-1.25; P = .049).

CONCLUSIONS AND RELEVANCE

This study found that living in counties with a high area-level deprivation was associated with an increased risk of severe hypoglycemia and DKA or HHS. The concentration of these preventable events in areas of high deprivation signals the need for interventions that target the structural barriers to optimal diabetes management and health.

Diverse community leaders' perspectives about quality primary healthcare and healthcare measurement: Qualitative community-based participatory research

Background

Healthcare quality measurements in the United States illustrate disparities by racial/ethnic group, socio-economic class, and geographic location. Redressing healthcare inequities, including measurement of and reimbursement for healthcare quality, requires partnering with communities historically excluded from decision-making. Quality healthcare is measured according to insurers, professional organizations and government agencies, with little input from diverse communities. This community-based participatory research study aimed to amplify the voices of community leaders from seven diverse urban communities in Minneapolis-Saint Paul Minnesota, view quality healthcare and financial reimbursement based on quality metric scores.

Methods

A Community Engagement Team consisting of one community member from each of seven urban communities —Black/African American, Lesbian-Gay-Bisexual-Transgender-Queer-Two Spirit, Hmong, Latino/a/x, Native American, Somali, and White—and two community-based researchers conducted listening sessions with 20 community leaders about quality primary healthcare. Transcripts were inductively analyzed and major themes were identified.

Results

Listening sessions produced three major themes, with recommended actions for primary care clinics.

#1: Quality Clinics Utilize Structures and Processes that Support Healthcare Equity.

#2: Quality Clinics Offer Effective Relationships, Education, and Health Promotion.

#3: Funding Based on Current Quality Measures Perpetuates Health Inequities.

Conclusion

Community leaders identified ideal characteristics of quality primary healthcare, most of which are not currently measured. They expressed concern that linking clinic payment with quality metrics without considering social and structural determinants of health perpetuates social injustice in healthcare.

Organizational Characteristics Associated with High Performance in Medicare's Comprehensive End-Stage Renal Disease Care Initiative

BACKGROUND AND OBJECTIVES

Medicare plans to extend financial structures tested through the Comprehensive End-Stage Renal Disease Care (CEC) Initiative-an alternative payment model for maintenance dialysis providers-to promote high-value care for beneficiaries with kidney failure. The End-Stage Renal Disease Seamless Care Organizations (ESCOs) that formed under the CEC Initiative varied greatly in their ability to generate cost savings and improve patient health outcomes. This study examined whether organizational or community characteristics were associated with ESCOs' performance.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We used a retrospective pooled cross-sectional analysis of all 37 ESCOs participating in the CEC Initiative during 2015-2018 (n=87 ESCO-years). Key exposures included ESCO characteristics: number of dialysis facilities, number and types of physicians, and years of CEC Initiative experience. Outcomes of interest included were above versus below median gross financial savings (2.4%) and standardized mortality ratio (0.93). We analyzed unadjusted differences between high- and low-performing ESCOs and then used multivariable logistic regression to construct average marginal effect estimates for parameters of interest.

RESULTS

Above-median gross savings were obtained by 23 (52%) ESCOs with no program experience, 14 (32%) organizations with 1 year of experience, and seven (16%) organizations with 2 years of experience. The adjusted likelihoods of achieving above-median gross savings were 23 (95% confidence interval, 8 to 37) and 48 (95% confidence interval, 24 to 68) percentage points higher for ESCOs with 1 or 2 years of program experience, respectively (versus none). The adjusted likelihood of achieving above-median gross savings was 1.7 (95% confidence interval, -3 to -1) percentage points lower with each additional affiliated dialysis facility. Adjusted mortality rates were lower for ESCOs located in areas with higher socioeconomic status.

CONCLUSIONS

Smaller ESCOs, organizations with more experience in the CEC Initiative, and those located in more affluent areas performed better under the CEC Initiative.

FQHC Designation and Safety Net Patient Revenue Associated with Primary Care Practice Capabilities for Access and Quality

BACKGROUND

Concerns exist about the ability of safety net health care organizations to participate in US health care reform. Primary care practices are key to several efforts, but little is known about how capabilities of primary care practices serving a high share of disadvantaged patients compare to other practices.

OBJECTIVE

To assess capabilities around access to and quality of care among primary care practices serving a high share of Medicaid and uninsured patients compared to practices serving a low share of these patients.

DESIGN

We analyzed data from the National Survey of Healthcare Organizations and Systems (response rate 46.8%), conducted 2017-2018.

PARTICIPANTS

A total of 2190 medical practices with at least three adult primary care physicians.

MAIN MEASURES

Our key exposures are payer mix and federally qualified health center (FQHC) designation. We classified practices as safety net if they reported a combined total of at least 25% of annual revenue from uninsured or Medicaid patients; we then further classified safety net practices into those that identified as an FQHC and those that did not.

KEY RESULTS

FQHCs were more likely than other safety net practices and non-safety net practices to offer early or late appointments (79%, 55%, 62%; p=0.001) and weekend appointments (56%, 39%, 42%; p=0.03). FQHCs more often provided medication-assisted treatment for opioid use disorders (43%, 27%, 25%; p=0.004) and behavioral health services (82%, 50%, 36%; p<0.001). FQHCs were more likely to screen patients for social and financial needs. However, FQHCs and other safety net providers had more limited electronic health record (EHR) capabilities (61%, 71%, 80%; p<0.001).

CONCLUSION

FQHCs were more likely than other types of primary care practices (both safety net practices and other practices) to possess capabilities related to access and quality. However, safety net practices were less likely than non-safety net practices to possess health information technology capabilities.

Sociodemographic, Clinical, and Treatment-Related Factors Associated With Hyperglycemic Crises Among Adults With Type 1 or Type 2 Diabetes in the US From 2014 to 2020

IMPORTANCE

Hyperglycemic crises (ie, diabetic ketoacidosis [DKA] and hyperglycemic hyperosmolar state [HHS]) are life-threatening acute complications of diabetes. Efforts to prevent these events at the population level have been hindered by scarce granular data and difficulty in identifying individuals at highest risk.

OBJECTIVE

To assess sociodemographic, clinical, and treatment-related factors associated with hyperglycemic crises in adults with type 1 or type 2 diabetes in the US from 2014 to 2020.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study analyzed administrative claims and laboratory results for adults (aged ≥18 years) with type 1 or type 2 diabetes from the OptumLabs Data Warehouse from January 1, 2014, through December 31, 2020.

MAIN OUTCOMES AND MEASURES

Rates of emergency department or hospital visits with a primary diagnosis of DKA or HHS (adjusted for age, sex, race/ethnicity, and region, and for year when calculating annualized rates) were calculated separately for patients with type 1 diabetes and type 2 diabetes. The associations of sociodemographic factors (age, sex, race/ethnicity, region, and income), clinical factors (comorbidities), and treatment factors (glucose-lowering medications, hemoglobin A1c) with DKA or HHS in patients with type 1 or type 2 diabetes were assessed using negative binomial regression.

RESULTS

Among 20 156 adults with type 1 diabetes (mean [SD] age, 46.6 [16.5] years; 51.2% male; 72.6% White race/ethnicity) and 796 382 with type 2 diabetes (mean [SD] age, 65.6 [11.8] years; 50.3% female; 54.4% White race/ethnicity), adjusted rates of hyperglycemic crises were 52.69 per 1000 person-years (95% CI, 48.26-57.12 per 1000 person-years) for type 1 diabetes and 4.04 per 1000 person-years (95% CI, 3.88-4.21 per 1000 person-years) for type 2 diabetes. In both groups, factors associated with the greatest hyperglycemic crisis risk were low income (≥$200 000 vs <$40 000: type 1 diabetes incidence risk ratio [IRR], 0.61 [95% CI, 0.46-0.81]; type 2 diabetes IRR, 0.69 [95% CI, 0.56-0.86]), Black race/ethnicity (vs White race/ethnicity: type 1 diabetes IRR, 1.33 [95% CI, 1.01-1.74]; type 2 diabetes IRR, 1.18 [95% CI, 1.09-1.27]), high hemoglobin A1c level (≥10% vs 6.5%-6.9%: type 1 diabetes IRR, 7.81 [95% CI, 5.78-10.54]; type 2 diabetes IRR, 7.06 [95% CI, 6.26-7.96]), history of hyperglycemic crises (type 1 diabetes IRR, 7.88 [95% CI, 6.06-9.99]; type 2 diabetes IRR, 17.51 [95% CI, 15.07-20.34]), severe hypoglycemia (type 1 diabetes IRR, 2.77 [95% CI, 2.15-3.56]; type 2 diabetes IRR, 4.18 [95% CI, 3.58-4.87]), depression (type 1 diabetes IRR, 1.62 [95% CI, 1.37-1.92]; type 2 diabetes IRR, 1.46 [95% CI, 1.34-1.59]), neuropathy (type 1 diabetes IRR, 1.64 [95% CI, 1.39-1.93]; type 2 diabetes IRR, 1.25 [95% CI, 1.17-1.34]), and nephropathy (type 1 diabetes IRR, 1.22 [95% CI, 1.01-1.48]; type 2 diabetes IRR, 1.23 [95% CI, 1.14-1.33]). Age had a U-shaped association with hyperglycemic crisis risk in patients with type 1 diabetes (compared with patients aged 18-44 years: 45-64 years IRR, 0.72 [95% CI, 0.59-0.87]; 65-74 years IRR, 0.62 [95% CI, 0.47-0.80]; ≥75 years IRR, 0.96 [95% CI, 0.66-1.38]). In type 2 diabetes, risk of hyperglycemic crises decreased progressively with age (45-64 years IRR, 0.57 [95% CI, 0.51-0.63]; 65-74 years IRR, 0.44 [95% CI, .39-0.49]; ≥75 years IRR, 0.41 [95% CI, 0.36-0.47]). In patients with type 2 diabetes, higher risk was associated with sodium-glucose cotransporter 2 inhibitor therapy (IRR, 1.30; 95% CI, 1.14-1.49) and insulin dependency (compared with regimens with bolus insulin: regimens with basal insulin only, IRR, 0.69 [95% CI, 0.63-0.75]; and without any insulin, IRR, 0.36 [95% CI, 0.33-0.40]).

CONCLUSIONS AND RELEVANCE

In this cohort study, younger age, Black race/ethnicity, low income, and poor glycemic control were associated with an increased risk of hyperglycemic crises. The findings suggest that multidisciplinary interventions focusing on groups at high risk for hyperglycemic crises are needed to prevent these dangerous events.

Evaluating the Effect of Medicaid Expansion on Black/White Breast Cancer Mortality Disparities: A Difference-in-Difference Analysis

PURPOSE

Medicaid expansion was designed to increase access to health care. Evidence is mixed, but theory and empirical data suggest that lower cost of care through greater access to insurance increases health care utilization and possibly improves the health of poor and sick populations. However, this major health policy has yet to be thoroughly investigated for its effect on health disparities. The current study is motivated by one of today’s most stark inequalities: the disparity in breast cancer mortality rates between Black and White women.

METHODS

This analysis used a difference-in-difference fixed effects regression model to evaluate the impact of Medicaid expansion on the disparity between Black and White breast cancer mortality rates. State-level breast cancer mortality data were obtained from the Centers for Disease Control and Prevention. Each state’s Medicaid expansion status was provided by a Kaiser Family Foundation white paper. Two tests were conducted, one compared all expanding states with all nonexpanding states, and the second compared all expanding states with nonexpanding states that voted to expand—but did not by 2014. The difference-in-difference regression models considered the year 2014 a washout period and compared 2012 and 2013 (pretreatment) with 2015 and 2016 (posttreatment).

RESULTS

Medicaid expansion did not lower the disparity in breast cancer mortality. In contrast to expectations, the Black/White mortality ratio increased in states expanding Medicaid for all Medicaid-eligible age groups, with significant effects in younger age groups (P = .01 to .15).

CONCLUSION

These results suggest that states cannot solely rely on access to insurance to alleviate disparities in cancer or other chronic conditions. More exploration of the impacts of low-quality health systems is warranted.

Adoption of Health System Innovations: Evidence of Urban-Rural Disparities from the Ohio Primary Care Marketplace

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.

Clinicians With High Socially At-Risk Caseloads Received Reduced Merit-Based Incentive Payment System Scores

To understand how clinicians with high caseloads of socially at-risk patients fare under Medicare's new outpatient Merit-based Incentive Payment System (MIPS), we examined the first (2019) round of MIPS performance data for 510,020 clinicians. Compared with clinicians with the lowest socially at-risk caseloads, those with the highest had 13.4 points lower MIPS performance scores, were 99 percent more likely to receive a negative payment adjustment, and were 52 percent less likely to receive an exceptional performance bonus payment. The lower performance scores were partly explained by lower clinician reporting of and performance on technology-dependent measures, which may reflect a lack of practice-level technological capability. If the Complex Patient Bonus were in effect, the performance scores and likelihood of receiving an exceptional performance bonus (payment of clinicians with the highest socially at-risk caseloads) would have increased by 4.7 percent and 2.8 percent, respectively; however, the proportion receiving negative payment adjustments would have remained unchanged. The Complex Patient Bonus appears unlikely to mitigate the most regressive effects of MIPS.

Out-Of-Network Primary Care Is Associated With Higher Per Beneficiary Spending In Medicare ACOs

Despite expectations that Medicare accountable care organizations (ACOs) would curb health care spending, their effect has been modest. One possible explanation is that ACOs' inability to prohibit out-of-network care limits their control over spending. To examine this possibility, we examined the association between out-of-network care and per beneficiary spending using national Medicare data for 2012-15. While there was no association between out-of-network specialty care and ACO spending, each percentage-point increase in receipt of out-of-network primary care was associated with an increase of $10.79 in quarterly total ACO spending per beneficiary. When we broke down total spending by place of service, we found that out-of-network primary care was associated with higher spending in outpatient, skilled nursing facility, and emergency department settings, but not inpatient settings. Our findings suggest an opportunity for the Medicare program to realize substantial savings, if policy makers developed explicit incentives for beneficiaries to seek more of their primary care within network.

Disparities in Preventable Hospitalization Among Patients With Alzheimer Diseases

INTRODUCTION

System-level care coordination strategies can be the most effective to promote continuity of care among people with Alzheimer's disease; however, the evidence is lacking. The objective of this study is to determine whether accountable care organizations are associated with lower rates of potentially preventable hospitalizations for people with Alzheimer's disease and whether hospital accountable care organization affiliation is associated with reduced racial and ethnic disparities in preventable hospitalizations among patients with Alzheimer's disease.

METHODS

This study employed a cross-sectional study design and used 2015 Healthcare Cost and Utilization Project inpatient claims data from 11 states and the 2015 American Hospital Association Annual Survey. Logistic regression and the Blinder-Oaxaca decomposition method were used.

RESULTS

African American patients with Alzheimer's disease were less likely to be hospitalized at accountable care organization‒affiliated hospitals than White patients. Among patients with Alzheimer's disease who were hospitalized, hospital accountable care organization affiliation was associated with lower odds of potentially preventable hospitalizations (OR=0.86, p=0.02; OR=0.66, p<0.001 with propensity score matching) after controlling for patient characteristics, hospital characteristics, and state indicators. Hospital accountable care organization affiliation explained 3.01% (p<0.01) of the disparity in potentially preventable hospitalizations between White and African American patients but could not explain disparities between White and Latinx patients.

CONCLUSIONS

Evidence suggests that accountable care organizations may be able to improve care coordination for people with Alzheimer's disease and to reduce disparities between Whites and African Americans. Further research is needed to determine whether this benefit can be attributed to accountable care organization formation or whether providers that participate in accountable care organizations tend to provide higher-quality care.

Impact of the Medicare Shared Savings Program on utilization of mental health and substance use services by eligibility and race/ethnicity

OBJECTIVE

To assess the impact of the Medicare Shared Savings Program (MSSP) ACOs on mental health and substance use services utilization and racial/ethnic disparities in care for these conditions.

DATA SOURCES

Five percent random sample of Medicare claims from 2009 to 2016.

STUDY DESIGN

We compared Medicare beneficiaries in MSSP ACOs to non-MSSP beneficiaries, stratifying analyses by Medicare eligibility (disability vs age 65+). We estimated difference-in-difference models of MSSP ACOs on mental health and substance use visits (outpatient and inpatient), medication fills, and adequate care for depression adjusting for age, sex, race/ethnicity, region, and chronic medical and behavioral health conditions. To examine the differential impact of MSSP on our outcomes by race/ethnicity, we used a difference-in-difference-in-differences (DDD) design.

DATA COLLECTION/EXTRACTION METHODS

Not applicable.

PRINCIPAL FINDINGS

MSSP ACOs were associated with small reductions in outpatient mental health (Coeff: -0.012, P < .001) and substance use (Coeff: -0.001, P < .01) visits in the disability population, and in adequate care for depression for both the disability- and age-eligible populations (Coeff: -0.028, P < .001; Coeff: -0.012, P < .001, respectively). MSSP ACO's were also associated with increases in psychotropic medications (Coeff: 0.007 and Coeff: 0.0213, for disability- and age-eligible populations, respectively, both P < .001) and reductions in inpatient mental health stays (Coeff:-0.004, P < .001, and Coeff:-0.0002, P < .01 for disability- and age-eligible populations, respectively) and substance use-related stays for disability-eligible populations (Coeff:-0.0005, P<.05). The MSSP effect on disparities varied depending on type of service.

CONCLUSIONS

We found small reductions in outpatient and inpatient stays and in rates of adequate care for depression associated with MSSP ACOs. As MSSP ACOs are placed at more financial risk for population-based treatment, it will be important to include more robust behavioral health quality measures in their contracts and to monitor disparities in care.

Accountable Care Hospitals and Preventable Emergency Department Visits for Rural Dementia Patients

BACKGROUND/OBJECTIVES

This study examined urban/rural differences in the frequency of preventable emergency department (ED) visits among patients with Alzheimer's disease and related dementias (ADRD), with a focus on the variation of accountable care organization (ACO) participation status for hospitals in urban and rural areas.

DESIGN

We performed a cross-sectional study using the 2015 State Emergency Department Databases, the American Hospital Association Annual Survey of Hospitals, and the Area Health Resource File. Individual-, county-, and hospital-level characteristics and state fixed effects were used for model specification.

SETTING

Patients with ADRD from seven states who visited the ED and had routine discharges.

PARTICIPANTS

Our sample consisted of 117,196 patients with ADRD.

MEASUREMENTS

The outcome was preventable ED visits classified using the New York University Emergency Department visit algorithm. We performed a multivariable logistic regression to estimate the variation of preventable ED visits by urban and rural areas.

RESULTS

Rural patients with ADRD had 1.13 higher adjusted odds (P = .007) of going to the ED for a preventable visit compared with their urban counterparts. In addition, ACO-affiliated hospitals had .91 lower adjusted odds (P = .005) of preventable ED visits for ADRD patients compared with hospitals not affiliated with an ACO. Whole-county Mental Health Care Health Professional Shortage Area (HPSA) (odds ratio = 1.14; P = .002) designation was also an indicator of higher preventable ED rates.

CONCLUSION

ACO delivery systems have the potential to decrease rural preventable ED visits among ADRD patients.

'Eyes In The Home': ACOs Use Home Visits To Improve Care Management, Identify Needs, And Reduce Hospital Use

Home visits are used for a variety of services and patient populations. We used national survey data from physician practices and accountable care organizations (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 were. Eighty percent of ACOs reported using home visits for some of their 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. Home visit implementation for some types of patients can be challenging because of barriers related to reimbursement, staffing, and resources.

Accountable Care Organizations and Preventable Hospitalizations Among Patients With Depression

INTRODUCTION

Accountable care organizations have been successful in improving quality of care, but little is known about who is benefiting from accountable care organizations and through what mechanism. This study examined variation of potentially preventable hospitalizations for chronic conditions with coexisting depression in adults by hospital accountable care organization affiliation and care coordination strategies by race/ethnicity.

METHODS

Data files of 11 states from 2015 State Inpatient Databases were used to identify potentially preventable hospitalizations for chronic conditions with coexisting depression by race/ethnicity; the 2015 American Hospital Association's Annual Survey was used to identify hospital accountable care organization affiliation; and American Hospital Association's Survey of Care Systems and Payment (collected from January to August 2016) was used to identify hospital Accountable care organizations affiliation and hospital-based care coordination strategies, such as telephonic outreach, and chronic care management. In 2019, multiple logistic regressions was used to test the probability of potentially preventable hospitalization by accountable care organization affiliation and race/ethnicity. The test was repeated on a subsample analysis of accountable care organization-affiliated hospitals by care coordination strategy.

RESULTS

Preventable hospitalizations were significantly lower among accountable care organization-affiliated hospitals than accountable care organization-unaffiliated hospitals. Lower preventable hospitalization rates were observed among white, African American, Native American, and Hispanic patients. Effective care coordination strategies varied by patients' race. Results also showed variation of the adoption of specific care coordination strategies among accountable care organization-affiliated hospitals. Analysis further indicated effective care coordination strategies varied by patients' race.

CONCLUSIONS

Accountable care organizations and specifically designed care coordination strategies can potentially improve preventable hospitalization rates and racial disparities among patients with depression. Findings support the integration of mental and physical health services and provide insights for Centers for Medicare and Medicaid Services risk adjustment efforts across race/ethnicity and socioeconomic status.

Proportion of Racial Minority Patients and Patients With Low Socioeconomic Status Cared for by Physician Groups After Joining Accountable Care Organizations

Importance

The incentive structure of accountable care organizations (ACOs) may lead to participating physician groups selecting fewer vulnerable patients.

Objective

To test for changes in the percentage of racial minority patients and patients with low socioeconomic status cared for by physician groups after joining the ACO.

Design, Setting, and Participants

This retrospective cohort consisted of a 15% random sample of Medicare fee-for-service beneficiaries attributed to physician groups from 2010 to 2016. Medicare Shared Savings Program (MSSP) participation was determined using ACO files. Analyses were conducted between January 1, 2019, and February 25, 2020.

Exposures

Using linear probability models, we conducted difference-in-differences analyses based on the year a physician group joined an ACO to estimate changes in vulnerable patients within ACO-participating groups compared with nonparticipating groups.

Main Outcomes and Measures

Whether the patient was black, was dually enrolled in Medicare and Medicaid, and poverty and unemployment rates of the patient's zip code.

Results

In a cohort of 76 717 physician groups caring for 7 307 130 patients, 16.1% of groups caring for 27.8% of patients participated in an MSSP ACO. Using 2010 characteristics, patients attributed to ACOs from 2012 to 2016, compared with those who were not, were less likely to be black (8.0% [n = 81 698] vs 9.3% [n = 270 924]) or dually enrolled in Medicare and Medicaid (12.8% [n = 130 957] vs 18.2% [n = 528 685]), and lived in zip codes with lower poverty rates (13.8% vs 15.5%); unemployment rates were similar (8.0% vs 8.5%). In the difference-in-differences analysis, there was no statistically significant change associated with ACO participation in the proportions of vulnerable patients attributed to ACO-participating groups compared with nonparticipating groups. After joining an ACO, ACO-participating groups had 0.0 percentage points change (95% CI, -0.1 to 0.1 percentage points; P = .59) for black patients, -0.1 percentage points (95% CI, -0.2 to 0.1 percentage points; P = .32) for patients dually enrolled in Medicare and Medicaid, 0.2 percentage points (95% CI, -3.5 to 4.0 percentage points; P = .91) in poverty rates, and -0.4 percentage points (95% CI, -2.0 to 1.2 percentage points; P = .62) in unemployment rates.

Conclusions and Relevance

In this cohort study, there were no changes in the proportions of vulnerable patients cared for by ACO-participating physician groups after joining an ACO compared with changes among nonparticipating groups.

Gynecologic oncology care in the world of accountable care organizations

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Accountable care organizations are increasing in healthcare systems.

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Accountable care organizations previously have focused on primary care.

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Subspecialty care and surgical fields are a new focus for ACOs and value-based care.

Accountable Care Organizations (ACOs) are an example of alternative payment models that are becoming increasingly common in our healthcare system. ACOs focus on increasing value through cost reduction and improved outcomes, and historically focus on Medicare patients within primary care practices. As ACOs grow, attention will likely turn to costly subspecialty care as an area for improvement and standardization. This brief communication addresses the potential benefits and consequences of ACOs on Gynecologic Oncologists and for patients with gynecologic malignancies.

Do Medicare Accountable Care Organizations Reduce Disparities After Spinal Fracture?

BACKGROUND

National changes in health care disparities within the setting of trauma care have not been examined within Accountable Care Organizations (ACOs) or non-ACOs. We sought to examine the impact of ACOs on post-treatment outcomes (in-hospital mortality, 90-day complications, and readmissions), as well as surgical intervention among whites and nonwhites treated for spinal fractures.

MATERIALS AND METHODS

We identified all beneficiaries treated for spinal fractures between 2009 and 2014 using national Medicare fee for service claims data. Claims were used to identify sociodemographic and clinical criteria, receipt of surgery and in-hospital mortality, 90-day complications, and readmissions. Multivariable logistic regression analysis accounting for all confounders was used to determine the effect of race/ethnicity on outcomes. Nonwhites were compared with whites treated in non-ACOs between 2009 and 2011 as the referent.

RESULTS

We identified 245,704 patients who were treated for spinal fractures. Two percent of the cohort received care in an ACO, whereas 7% were nonwhite. We found that disparities in the use of surgical fixation for spinal fractures were present in non-ACOs over the period 2009-2014 but did not exist in the context of care provided through ACOs (odds ratio [OR] 0.75; 95% confidence interval [CI] 0.44, 1.28). A disparity in the development of complications existed for nonwhites in non-ACOs (OR 1.09; 95% CI 1.01, 1.17) that was not encountered among nonwhites receiving care in ACOs (OR 1.32; 95% CI 0.90, 1.95). An existing disparity in readmission rates for nonwhites in ACOs over 2009-2011 (OR 1.34; 95% CI 1.01, 1.80) was eliminated in the period 2012-2014 (OR 0.85; 95% CI 0.65, 1.09).

CONCLUSIONS

Our work reinforces the idea that ACOs could improve health care disparities among nonwhites. There is also the potential that as ACOs become more familiar with care integration and streamlined delivery of services, further improvements in disparities could be realized.

Sources and Impact of Time Pressure on Opioid Management in the Safety-Net

PURPOSE

This study sought to understand clinicians' and patients' experience managing chronic noncancer pain (CNCP) and opioids in safety-net primary care settings. This article explores the time requirements of safer opioid prescribing for medically and socially complex patients in the context of safety-net primary care.

METHODS

We qualitatively interviewed 23 primary care clinicians and 46 of their patients with concurrent CNCP and substance use disorder (past or current). We also conducted observations of clinical interactions between the clinicians and patients. We transcribed, coded, and analyzed interview and clinical observation recordings using grounded theory methodology.

RESULTS

Clinicians reported not having enough time to assess patients' CNCP, functional status, and risks for opioid misuse. Inadequate assessment of CNCP contributed to tension and conflicts during visits. Clinicians described pain conversations consuming a substantial portion of primary care visits despite patients' other serious health concerns. System-level constraints (eg, changing insurance policies, limited access to specialty and integrative care) added to the perceived time burden of CNCP management. Clinicians described repeated visits with little progress in patients' pain or functional status due to these barriers. Patients acknowledged clinical time constraints and reported devoting significant time to following new opioid management protocols for CNCP.

CONCLUSIONS

Time pressure was identified as a major barrier to safer opioid prescribing. Efforts, including changes to reimbursement structures, are needed to relieve time stress on primary care clinicians treating medically and socially complex patients with CNCP in safety-net settings.

Performance in the Medicare Shared Savings Program by Accountable Care Organizations Disproportionately Serving Dual and Disabled Populations

BACKGROUND

The growth of accountable care organizations (ACOs) and other alternative payment models has prompted concern about whether these models will disadvantage providers who serve vulnerable populations, particularly those living in poverty or with a disability.

OBJECTIVE

To examine performance by ACOs in the top quintile of their proportion of beneficiaries dually enrolled in Medicare and Medicaid (high-dual) and the top quintile of disabled beneficiaries (high-disabled).

RESEARCH DESIGN

This is a retrospective cohort study.

SUBJECTS

The 333 ACOs in the Medicare Shared Savings Program in 2014, followed through 2016.

MEASURES

Quality scores, savings per beneficiary, whether or not the ACO shared savings, and amount of shared savings.

RESULTS

High-dual and high-disabled ACOs had slightly lower quality and similar or higher baseline spending than other ACOs, but achieved greater savings per beneficiary than other ACOs ($212 vs. $51 for high-dual ACOs, P=0.04; $241 vs. $44 for high-disabled ACOs, P=0.012). Further, these ACOs were equally or more likely to earn shared savings; just over 30% of high-dual ACOs earned shared savings compared with 25% of non-high-dual ACOs (P=0.35) and 38% of high-disabled ACOs earned shared savings compared with 23% of non-high-disabled ACOs (P=0.013). In longitudinal analyses, we found a decrease in the differences in quality between high-social risk and other ACOs over time. Savings remained higher for high-dual and high-disabled ACOs relative to other ACOs over 2014-2016 though the gap narrowed over time.

CONCLUSIONS

High-dual and high-disabled ACOs had similar or higher spending than other ACOs at baseline, but achieved greater savings and were equally or more likely to earn shared savings, suggesting that alternative payment models can have positive financial outcomes for providers who serve vulnerable populations.

Changes in the Use of Lumbar Arthrodesis Procedures Within Accountable Care Organizations

STUDY DESIGN

A retrospective review of Medicare claims data (2009-2014).

OBJECTIVE

The aim of this study was to evaluate changes in the use of lumbar fusion procedures following the formation of Accountable Care Organizations (ACOs).

SUMMARY OF BACKGROUND DATA

Within surgical care afforded by ACOs, savings are thought to be realized by improved care coordination as well as reductions in the use of preference-sensitive procedures such as lumbar fusion.

METHODS

We queried fee-for-service claims for patients enrolled in Medicare Part A and B, identifying patients who received lumbar spine fusion, discectomy, or decompression procedures. We performed a difference-in-differences analysis comparing the use of lumbar fusion in ACOs and non-ACOs in the period before (2009-2011) and after (2012-2014) ACO formation. Propensity score adjustment was used to address differences in case-mix. Multivariable logistic regression was used to compare the likelihood of receiving a lumbar fusion in ACOs and non-ACOs in the period before and after ACO formation.

RESULTS

Within organizations that would form ACOs, the raw rate of lumbar fusion increased from 50% (n = 2183) in 2009 to 2011 to 54% (n = 2283) in 2012 to 2014. Among non-ACOs, the use of fusion increased from 52% (n = 110,160) to 59% (n = 109,917). Adjusted difference in differences in the use of lumbar fusion between ACOs and non-ACOs was -2.6 percentage points (P = 0.13). When limited to patients with spinal stenosis, ACOs significantly reduced the use of fusion (-5.8 percentage points; P = 0.03).

CONCLUSION

Our results indicate that ACOs may effectively curtail the use of lumbar fusion procedures, particularly among patients with spinal stenosis. As these interventions are often associated with higher complications and need for reoperation, such practices might accrue additional health care savings for Medicare beyond those realized during the index surgical period.

LEVEL OF EVIDENCE

3.

Promoting Health Equity through De-Implementation Research

Ensuring equitable access to quality health care historically has focused on gaps in care, where patients fail to receive the high-value care that will benefit them, something termed underuse. But providing high-quality health care sometimes requires reducing low-value care that delivers no benefit or where known harms outweigh expected benefits. These situations represent health care overuse. The process involved in reducing low-value care is known as de-implementation. In this article, we argue that de-implementation is critical for advancing equity for several reasons. First, medical overuse is associated with patient race, ethnicity, and socioeconomic status. In some cases, the result is even double jeopardy, where racial and ethnic minorities are at higher risk of both overuse and underuse. In these cases, more traditional efforts focused exclusively on underuse ignore half of the problem. Second, overuse of preventive care and screening is often greater for more socioeconomically advantaged patients. Within insured populations, this means more socioeconomically disadvantaged patients subsidize overuse. Finally, racial and ethnic minorities may have different experiences of overuse than Whites in the United States. This may make efforts to de-implement overuse particularly fraught. We therefore provide several actions for closing current research gaps, including: adding subgroup analyses in studies of medical overuse; specifying and measuring potential mechanisms related to equity (eg, double jeopardy vs thermostat models of overuse); and testing de-implementation strategies that may mitigate bias.

Variation of Follow-Up Rate After Psychiatric Hospitalization of Medicare Beneficiaries by Hospital Characteristics and Social Determinants of Health

OBJECTIVE

Early follow-up after inpatient psychiatric hospitalization is a key part of the care transition process and has been found to reduce the risk of readmission and emergency department utilization. Our objective was to determine the extent to which hospital performance on measures of 7- and 30-day mental health follow-up after hospitalization for Medicare beneficiaries varies by hospital characteristics and hospital neighborhood socioeconomic characteristics.

METHODS

We linked 2015 hospital-level follow-up rates from the Centers for Medicare and Medicaid Services' Hospital Compare website to hospital characteristics obtained from the American Hospital Association Annual Survey and characteristics of the community within a 5-mile radius of the hospital obtained from the American Community Survey. Our population included 1,275 inpatient psychiatric facilities in 2015 in the United States. State fixed effects multivariate linear regression was used.

RESULTS

Hospital 30-day follow-up rates ranged from 16.00% to 95.00%, with an average of 55.80%. After controlling for hospital- and community-level factors, and applying state-level fixed effects, we found that psychiatric specialty hospitals, public hospitals, and minority-serving hospitals were associated with lower rates of mental health follow-up.

CONCLUSION

Hospitals have considerable opportunity to improve the quality of their transitional care processes and increase the percentage of Medicare patients receiving timely mental health follow-up after discharge. Policymakers should consider strengthening the incentives for hospital performance on these quality measures while working to improve the behavioral health infrastructure of minority communities.

Practices Caring For The Underserved Are Less Likely To Adopt Medicare's Annual Wellness Visit

In 2011 Medicare introduced the annual wellness visit to help address the health risks of aging adults. The visit also offers primary care practices an opportunity to generate revenue, and may allow practices in accountable care organizations to attract healthier patients while stabilizing patient-practitioner assignments. However, uptake of the visit has been uneven. Using national Medicare data for the period 2008-15, we assessed practices' ability and motivation to adopt the visit. In 2015, 51.2 percent of practices provided no annual wellness visits (nonadopters), while 23.1 percent provided visits to at least a quarter of their eligible beneficiaries (adopters). Adopters replaced problem-based visits with annual wellness visits and saw increases in primary care revenue. Compared to nonadopters, adopters had more stable patient assignment and a slightly healthier patient mix. At the same time, visit rates were lower among practices caring for underserved populations (for example, racial minorities and those dually enrolled in Medicaid), potentially worsening disparities. Policy makers should consider ways to encourage uptake of the visit or other mechanisms to promote preventive care in underserved populations and the practices that serve them.

Alterations in 90-day morbidity, mortality, and readmission rates following spine surgery in Medicare Accountable Care Organizations (2009-2014)

BACKGROUND CONTEXT

The impact of Accountable Care Organizations (ACOs) on healthcare quality and outcomes, including morbidity, mortality, and readmissions, has not been substantially investigated, especially following spine surgery.

PURPOSE

To evaluate the impact of ACO formation on postoperative outcomes in the 90-day period following spine surgery.

STUDY DESIGN

Retrospective review of national Medicare claims data (2009-2014).

PATIENT SAMPLE

Patients who underwent one of four lumbar spine surgical procedures in an ACO or non-ACO.

OUTCOME MEASURES

The development of in-hospital mortality, complications or hospital readmission within 90 days of the surgical procedure.

METHODS

The primary outcome measures included postsurgical complications and readmissions at 90 days following surgery. In-hospital mortality and 30-day outcomes were considered secondarily. The primary predictor variable consisted of ACO enrollment designation. Multivariable logistic regression analysis was utilized to adjust for confounders and determine the independent effect of ACO enrollment on postsurgical outcomes. The multivariable model included a propensity score adjustment that accounted for factors associated with the preferential enrollment of patients in ACOs, namely, sociodemographic characteristics, medical co-morbidities, hospital teaching status, bed size, and location.

RESULTS

In all, there were 344,813 patients identified for inclusion in this analysis with 97% (n = 332,890) treated in non-ACOs and 3% (n = 11,923) in an ACO. Although modest changes were apparent across both ACOs and non-ACOs over the time-period studied, improvements were slightly more dramatic in non-ACOs leading to statistically significant differences in both 90-day complications and readmissions. Specifically, in the period 2012-2014, ACOs demonstrated an 18% increase in the odds of 90-day complications and a 14% elevation in the odds of 90-day readmissions when compared to non-ACOs. There was no difference in hospital mortality between ACOs and non-ACOs.

CONCLUSIONS

Our study of Medicare data from 2009 to 2014 failed to demonstrate superior reductions in postoperative morbidity, mortality, and readmissions for beneficiaries treated in ACOs as compared to non-ACOs. These results indicate that meaningful changes in postoperative outcomes should not be anticipated based on organizational participation in ACOs at present.

Primary care clinicians' perspectives about quality measurements in safety-net clinics and non-safety-net clinics

BACKGROUND

Quality metrics, pay for performance (P4P), and value-based payments are prominent aspects of the current and future American healthcare system. However, linking clinic payment to clinic quality measures may financially disadvantage safety-net clinics and their patient population because safety-net clinics often have worse quality metric scores than non-safety net clinics. The Minnesota Safety Net Coalition's Quality Measurement Enhancement Project sought to collect data from primary care providers' (PCPs) experiences, which could assist Minnesota policymakers and state agencies as they create a new P4P system. Our research study aims are to identify PCPs' perspectives about 1) quality metrics at safety net clinics and non-safety net clinics, 2) how clinic quality measures affect patients and patient care, and 3) how payment for quality measures may influence healthcare.

METHODS

Qualitative interviews with 14 PCPs (4 individual interviews and 3 focus groups) who had worked at both safety net and non-safety net primary care clinics in Minneapolis-St Paul Minnesota USA metropolitan area. Qualitative analyses identified major themes.

RESULTS

Three themes with sub-themes emerged. Theme #1: Minnesota's current clinic quality scores are influenced more by patients and clinic systems than by clinicians. Theme #2: Collecting data for a set of specific quality measures is not the same as measuring quality healthcare. Subtheme #2.1: Current quality measures are not aligned with how patients and clinicians define quality healthcare. Theme #3: Current quality measures are a product of and embedded in social and structural inequities in the American health care system. Subtheme #3.1: The current inequitable healthcare system should not be reinforced with financial payments. Subtheme #3.2: Health equity requires new metrics and a new healthcare system. Overall, PCPs felt that the current inequitable quality metrics should be replaced by different metrics along with major changes to the healthcare system that could produce greater health equity.

CONCLUSION

Aligning payment with the current quality metrics could perpetuate and exacerbate social inequities and health disparities. Policymakers should consider PCPs' perspectives and create a quality-payment framework that does not disadvantage patients who are affected by social and structural inequities as well as the clinics and providers who serve them.

Comparison of Populations Served in Hospital Service Areas With and Without Comprehensive Primary Care Plus Medical Homes

IMPORTANCE

Little is known about the types of primary care practices that have chosen to participate in the Comprehensive Primary Care Plus (CPC+) program or about how participation could affect disparities.

OBJECTIVE

To describe practices that joined the CPC+ model and compare hospital service areas with and without CPC+ practices.

DESIGN, SETTING, AND PARTICIPANTS

This comparative cross-sectional study identified 2647 CPC+ practices in round 1 (from January 1, 2017; round 1 is ongoing through 2021). Using IMS Health Care Organization Services data, ownership and characteristics of health systems and practices were extracted. Practices participating in the CPC+ program were compared with practices with similar proportions of primary care physicians (>85%) within the 14 regions designated as eligible to participate by the Centers for Medicare & Medicaid Services. Within eligible regions, hospital service areas with (n = 434) and without (n = 322) 1 or more CPC+ practice were compared. Characteristics compared included area-level population demographics (from the US Census Bureau), health system characteristics (from the IMS Health Care Organization Services), and use of health services by Medicare fee-for-service enrollees (Dartmouth Atlas).

MAIN OUTCOMES AND MEASURES

Area-level characteristics of all eligible CPC+ regions, areas without a CPC+ practice, and areas with 1 or more CPC+ practices.

RESULTS

Of 756 eligible service areas, 322 had no CPC+ practices and 434 had at least 1 CPC+ practice. Of 2647 CPC+ practices, 579 (21.9%) had 1 physician and 1791 (67.7%) had 2 to 10 physicians. In areas without CPC+ practices, the population had a lower median income ($43 197 [interquartile range, $42 170-$44 224] vs $57 206 [interquartile range, $55 470-$58 941]), higher mean share of households living in poverty (17.8% [95% CI, 17.2%-18.4%] vs 14.4% [95% CI, 13.9%-15.0%]), higher mean educational attainment of high school or less (52.7% [95% CI, 51.7%-53.6%] vs 43.1% [95% CI, 42.1%-44.2%]), higher mean proportion of disabled residents (17.7% [95% CI, 17.3%-18.2%] vs 14.2% [13.8%-14.6%]), higher mean participation in Medicare (21.9% [95% CI, 21.3%-22.4%] vs 18.8% [95% CI, 18.3%-19.1%]) and Medicaid (22.2% [95% CI, 21.5%-22.9%]) vs 18.5% [95% CI, 17.8%-19.2%]), and higher mean proportion of uninsured residents (12.4% [95% CI, 11.9%-12.9%] vs 10.3% [95% CI, 9.9%-10.7%]) (P < .001 for all) compared with areas that had a CPC+ practice.

CONCLUSIONS AND RELEVANCE

According to this study, although a diverse set of practices joined the CPC+ program, practices in areas characterized by patient populations with greater advantage were more likely to join, which may affect access to advanced primary care medical home models such as CPC+, by vulnerable populations.