1
|
Bao C, Bardhan IR. Measuring value in health care: lessons from accountable care organizations. HEALTH AFFAIRS SCHOLAR 2024; 2:qxae028. [PMID: 38756920 PMCID: PMC10986292 DOI: 10.1093/haschl/qxae028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 02/25/2024] [Accepted: 02/28/2024] [Indexed: 05/18/2024]
Abstract
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.
Collapse
Affiliation(s)
- Chenzhang Bao
- Department of Management Science and Information Systems, Oklahoma State University, Tulsa, OK 74106, United States
| | - Indranil R Bardhan
- Department of Information, Risk, and Operations Management, Red McCombs School of Business, The University of Texas at Austin, Austin, TX 78712, United States
| |
Collapse
|
2
|
Newton H, Miller-Rosales C, Crawford M, Cai A, Brunette M, Meara E. Availability of Medication for Opioid Use Disorder Among Accountable Care Organizations: Evidence From a National Survey. Psychiatr Serv 2024; 75:182-185. [PMID: 37614155 PMCID: PMC10895446 DOI: 10.1176/appi.ps.20230087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/25/2023]
Abstract
OBJECTIVE This report aimed to assess how accountable care organizations (ACOs) addressed ongoing opioid use disorder treatment needs over time. METHODS Responses from the 2018 (N=308 organizations) and 2022 (N=276) National Survey of Accountable Care Organizations (response rate=55% in both years) were used to examine changes in availability of medication for opioid use disorder (MOUD) among ACOs with Medicare and Medicaid contracts. RESULTS The percentage of respondents offering at least one MOUD grew from 39% in 2018 to 52% in 2022 (p<0.01). MOUDs were more likely to be available in 2022 among ACOs with (vs. without) in-network substance use treatment facilities (80% vs. 33%, p<0.001). The percentage of 2022 respondents who reported offering MOUD was similar in states with high versus low opioid overdose mortality rates. CONCLUSIONS Despite growing availability of MOUD among ACOs, nearly half reported not offering any MOUD in 2022, and the availability of MOUD did not increase with treatment need.
Collapse
Affiliation(s)
- Helen Newton
- Department of Family Medicine, University of North Carolina School of Medicine, Chapel Hill (Newton); Department of Health Care Policy, Harvard Medical School, Boston (Miller-Rosales); Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth Geisel School of Medicine, Lebanon, New Hampshire (Crawford); Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston (Cai, Meara); Department of Psychiatry, Dartmouth Geisel School of Medicine, Hanover, New Hampshire (Brunette)
| | - Chris Miller-Rosales
- Department of Family Medicine, University of North Carolina School of Medicine, Chapel Hill (Newton); Department of Health Care Policy, Harvard Medical School, Boston (Miller-Rosales); Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth Geisel School of Medicine, Lebanon, New Hampshire (Crawford); Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston (Cai, Meara); Department of Psychiatry, Dartmouth Geisel School of Medicine, Hanover, New Hampshire (Brunette)
| | - Maia Crawford
- Department of Family Medicine, University of North Carolina School of Medicine, Chapel Hill (Newton); Department of Health Care Policy, Harvard Medical School, Boston (Miller-Rosales); Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth Geisel School of Medicine, Lebanon, New Hampshire (Crawford); Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston (Cai, Meara); Department of Psychiatry, Dartmouth Geisel School of Medicine, Hanover, New Hampshire (Brunette)
| | - Arno Cai
- Department of Family Medicine, University of North Carolina School of Medicine, Chapel Hill (Newton); Department of Health Care Policy, Harvard Medical School, Boston (Miller-Rosales); Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth Geisel School of Medicine, Lebanon, New Hampshire (Crawford); Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston (Cai, Meara); Department of Psychiatry, Dartmouth Geisel School of Medicine, Hanover, New Hampshire (Brunette)
| | - Mary Brunette
- Department of Family Medicine, University of North Carolina School of Medicine, Chapel Hill (Newton); Department of Health Care Policy, Harvard Medical School, Boston (Miller-Rosales); Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth Geisel School of Medicine, Lebanon, New Hampshire (Crawford); Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston (Cai, Meara); Department of Psychiatry, Dartmouth Geisel School of Medicine, Hanover, New Hampshire (Brunette)
| | - Ellen Meara
- Department of Family Medicine, University of North Carolina School of Medicine, Chapel Hill (Newton); Department of Health Care Policy, Harvard Medical School, Boston (Miller-Rosales); Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth Geisel School of Medicine, Lebanon, New Hampshire (Crawford); Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston (Cai, Meara); Department of Psychiatry, Dartmouth Geisel School of Medicine, Hanover, New Hampshire (Brunette)
| |
Collapse
|
3
|
Dyer Z, Alcusky M, Himmelstein J, Ash A, Kerrissey M. Practice Site Heterogeneity within and between Medicaid Accountable Care Organizations. Healthcare (Basel) 2024; 12:266. [PMID: 38275548 PMCID: PMC10815263 DOI: 10.3390/healthcare12020266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 01/06/2024] [Accepted: 01/13/2024] [Indexed: 01/27/2024] Open
Abstract
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.
Collapse
Affiliation(s)
- Zachary Dyer
- Department of Population and Quantitative Health Sciences, UMass Chan Medical School, Worcester, MA 01655, USA
| | - Matthew Alcusky
- Department of Population and Quantitative Health Sciences, UMass Chan Medical School, Worcester, MA 01655, USA
| | - Jay Himmelstein
- Department of Population and Quantitative Health Sciences, UMass Chan Medical School, Worcester, MA 01655, USA
| | - Arlene Ash
- Department of Population and Quantitative Health Sciences, UMass Chan Medical School, Worcester, MA 01655, USA
| | - Michaela Kerrissey
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
| |
Collapse
|
4
|
Ying M, Forman JH, Murali S, Gauntlett LE, Krein SL, Hollenbeck BK, Hollingsworth JM. Factors affecting Accountable Care Organizations' decisions to remain in or exit the Medicare Shared Savings Program following Pathways to Success. HEALTH AFFAIRS SCHOLAR 2024; 2:qxad093. [PMID: 38313161 PMCID: PMC10830425 DOI: 10.1093/haschl/qxad093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 12/21/2023] [Accepted: 01/02/2024] [Indexed: 02/06/2024]
Abstract
The Medicare Shared Savings Program (MSSP) is an alternative payment model launched in 2012, creating Accountable Care Organizations (ACOs) to improve quality and lower costs for Traditional Medicare patients. Most MSSP participants were expected to shift from bearing no financial risk to a 2-sided risk model (ie, bonus if spending reduced below historical benchmarks, penalty if not), yet fewer than 20% did. Therefore, in 2019, the Centers for Medicare and Medicaid Services launched the Pathways to Success program, which required shifting to a 2-sided model within 12 months. For the first time, more ACOs exited than entered the MSSP. To understand these participation decisions, we conducted qualitative interviews with ACO leaders. Pathways caused ACOs to reassess their potential shared savings vs losses, particularly in light of benchmarking methodology changes; reconsider perceived nonrevenue benefits; and reassess participation in the MSSP vs other programs. As ACOs, particularly those assuming downside risk, have contained costs and enhanced care quality, policymakers should strive to improve MSSP enrollment rates in downside-risk models through strategies that allow ACOs to achieve shared savings and deliver accountable care.
Collapse
Affiliation(s)
- Meiling Ying
- Department of Foundations of Medicine, New York University Langone Health, New York, NY 11501, United States
| | - Jane H Forman
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI 48105, United States
| | - Sitara Murali
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI 48109, United States
| | - Lauren E Gauntlett
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI 48105, United States
| | - Sarah L Krein
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI 48105, United States
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI 48109, United States
| | - Brent K Hollenbeck
- Department of Urology, Massachusetts General Hospital, Boston, MA 02114, United States
| | - John M Hollingsworth
- Department of Urology, NorthShore University HealthSystem, Chicago, IL 60201, United States
| |
Collapse
|
5
|
Coyne J, Gutman R, Ferraro C, Muhlestein D. Financial Performance of Accountable Care Organizations: A 5-Year National Empirical Analysis. J Healthc Manag 2024; 69:74-86. [PMID: 38175536 DOI: 10.1097/jhm-d-22-00141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
GOALS Of 513 accountable care organizations (ACOs) participating in the Medicare Shared Savings Program (MSSP) in 2020, 67% generated a positive shared savings of approximately $2.3 billion. This research aimed to examine their financial performance trends and drivers over time. METHODS The unit of analysis was the ACO in each year of the study period from 2016 to 2020. The dependent variable was the ACOs' total shared savings earned annually per beneficiary. The independent variables included ACO age, risk model, clinician staffing type, and provider type (hybrid, hospital-led, or physician-led). Covariates were the average risk score among beneficiaries, payer type, and calendar year. The Centers for Medicare & Medicaid Services (CMS) public use files (PUFs) and a commercial healthcare data aggregator were the data sources. RESULTS ACOs' earned shared savings grew annually by 35%, while the proportions of ACOs with positive shared savings grew by 21%. For 1-year increase in ACO age, an additional $0.57 of shared savings per beneficiary was observed. ACOs with two-sided risk contracting were associated with an average marginal increase of $109 in shared savings per beneficiary compared to ACOs with one-sided risk contracting. Primary care physicians were associated with the greatest increase in earned shared savings per beneficiary. In contrast, nurse practitioners/physician assistants/clinical nurse specialists were associated with a reduction in earned shared savings. Under a one-sided risk model, hospital-led ACOs were associated with $18 higher average shared savings earning per beneficiary compared to hybrid ACOs, while physician-led ACOs were associated with lower average saved shared earnings per beneficiary at -$2 compared to hybrid ACOs. Provider-type results were not statistically significant at the 5% nominal level. No statistically significant differences were observed between provider types under a two-sided risk model. PRACTICAL APPLICATIONS For all ACO provider types, building broader primary care provider networks was correlated with positive financial results. Future research should examine whether ACOs are conducting specific preventive screenings for cancer or monitoring conditions such as diabetes, hypertension, heart disease, obesity, mental disorders, and joint disorders. Such studies may answer health policy and strategy questions about the effects of incentives for improved ACO performance in serving a healthier population.
Collapse
Affiliation(s)
- Joseph Coyne
- School of Public Health, Brown University, Providence, Rhode Island
| | | | | | | |
Collapse
|
6
|
Sandhu AT, Heidenreich PA, Borden W, Farmer SA, Ho PM, Hammond G, Johnson JC, Wadhera RK, Wasfy JH, Biga C, Takahashi E, Misra KD, Joynt Maddox KE. Value-Based Payment for Clinicians Treating Cardiovascular Disease: A Policy Statement From the American Heart Association. Circulation 2023; 148:543-563. [PMID: 37427456 DOI: 10.1161/cir.0000000000001143] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/11/2023]
Abstract
Clinician payment is transitioning from fee-for-service to value-based payment, with reimbursement tied to health care quality and cost. However, the overarching goals of value-based payment-to improve health care quality, lower costs, or both-have been largely unmet. This policy statement reviews the current state of value-based payment and provides recommended best practices for future design and implementation. The policy statement is divided into sections that detail different aspects of value-based payment: (1) key program design features (patient population, quality measurement, cost measurement, and risk adjustment), (2) the role of equity during design and evaluation, (3) adjustment of payment, and (4) program implementation and evaluation. Each section introduces the topic, describes important considerations, and lists examples from existing programs. Each section includes recommended best practices for future program design. The policy statement highlights 4 key themes for successful value-based payment. First, programs should carefully weigh the incentives between lowering cost and improving quality of care and ensure that there is adequate focus on quality of care. Second, the expansion of value-based payment should be a tool for improving equity, which is central to quality of care and should be a focal point of program design and evaluation. Third, value-based payment should continue to move away from fee for service toward more flexible funding that allows clinicians to focus resources on the interventions that best help patients. Last, successful programs should find ways to channel clinicians' intrinsic motivation to improve their performance and the care for their patients. These principles should guide the future development of clinician value-based payment models.
Collapse
|
7
|
Jacobs M, Morris E, Haleem Z, Mandato N, Marlow NM, Revere L. Drivers of Individual and Regional Variation in CMS Hierarchical Condition Categories Among Florida Beneficiaries. Risk Manag Healthc Policy 2023; 16:1011-1022. [PMID: 37323190 PMCID: PMC10266376 DOI: 10.2147/rmhp.s401474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 05/31/2023] [Indexed: 06/17/2023] Open
Abstract
Objective To explore hierarchical condition categories (HCC) risk score variation among Florida Fee for Service (FFS) Medicare beneficiaries between 2016 and 2018. Data Sources This study analyzed HCC risk score variation using Medicare claims data for Florida beneficiaries enrolled in Parts A & B between 2016 and 2018. Study Design The CMS methodology analyzed HCC risk score variation using annual mean county- and beneficiary-level risk score changes. The association between variation and beneficiary characteristics, diagnoses, and geographic location was characterized using mixed-effects negative binomial regression models. Data Collection Not applicable. Principal Findings Counties in the Northeast [marginal effect (ME)=-0.003], Central (ME=-0.021), and Southwest (ME=-0.009) Florida have relatively lower mean risk scores. A higher number of lifetime (ME=0.246) and treatable (ME=0.288) conditions were associated with higher county-level risk scores, while more preventable conditions (ME=-0.249) were associated with lower risk scores. Counties with older beneficiaries (ME=0.015) and more Blacks (ME=0.070) have higher risk scores, while having female beneficiaries reduced risk scores (ME=-0.005). Individual risk scores did not vary by age (ME=0.000), but Blacks (ME=0.001) had higher rates of variation relative to Whites, while other races had comparatively lower variation (ME=-0.003). In addition, individuals diagnosed with more lifetime (ME=0.129), treatable (ME=0.235), and preventable (ME=0.001) conditions had higher risk score variation. Most condition-specific indicators showed small associations with risk score changes; however, metastatic cancer/acute leukemia, respirator dependence/tracheostomy, and pressure ulcers of the skin were significantly associated with both types of HCC risk score variation. Conclusion Results showed demographics, HCC condition classifications (ie, lifetime, preventable, and treatable), and some specific conditions were associated with higher variation in mean county-level and individual risk scores. Results suggest consistent coding and reductions in the prevalence of certain treatable or preventable conditions could reduce the county and individual HCC risk score year-to-year change.
Collapse
Affiliation(s)
- Molly Jacobs
- Department of Health Services Research Management and Policy, University of Florida, Gainesville, FL, USA
| | - Earl Morris
- Department of Pharmaceutical Outcomes and Policy, University of Florida, Gainesville, FL, USA
| | - Zuhair Haleem
- Department of Health Services Research Management and Policy, University of Florida, Gainesville, FL, USA
| | - Nicholas Mandato
- Department of Biology, University of Florida, Gainesville, FL, USA
| | - Nicole M Marlow
- Department of Health Services Research Management and Policy, University of Florida, Gainesville, FL, USA
| | - Lee Revere
- Department of Health Services Research Management and Policy, University of Florida, Gainesville, FL, USA
| |
Collapse
|
8
|
Lyu PF, Chernew ME, McWilliams JM. Benchmarking Changes And Selective Participation In The Medicare Shared Savings Program. Health Aff (Millwood) 2023; 42:622-631. [PMID: 37126741 PMCID: PMC10228701 DOI: 10.1377/hlthaff.2022.01061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
In 2017 the Medicare Shared Savings Program (MSSP) began incorporating regional spending into accountable care organization (ACO) benchmarks, thus favoring the participation of ACOs and practices with lower baseline spending than their region. To characterize providers' responses to these incentives, we isolated changes in spending due to changes in the mix of ACOs and practices participating in the MSSP. In contrast to earlier participation patterns, the composition of the MSSP after 2017 increasingly shifted to providers with lower preexisting levels of spending relative to their region, consistent with a selection response. Changes occurred through the entry of new ACOs with lower baseline spending, the exit of higher-spending ACOs, and the reconfiguration of participant lists favoring lower-spending practices within continuing ACOs. These participation patterns varied meaningfully by ACO type. Although compositional changes could not be definitively tied to benchmarking changes, the disproportionate participation of providers with lower baseline spending implies substantial costs and the need for ACO benchmarking reforms.
Collapse
Affiliation(s)
- Peter F Lyu
- Peter F. Lyu , RTI International, Research Triangle Park, North Carolina
| | | | - J Michael McWilliams
- J. Michael McWilliams, Harvard University and Brigham and Women's Hospital, Boston, Massachusetts
| |
Collapse
|
9
|
KADAKIA KUSHALT, OFFODILE ANAEZEC. The Next Generation of Payment Reforms for Population Health - An Actionable Agenda for 2035 Informed by Past Gains and Ongoing Lessons. Milbank Q 2023; 101:866-892. [PMID: 37096610 PMCID: PMC10126963 DOI: 10.1111/1468-0009.12632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 09/13/2022] [Accepted: 01/06/2023] [Indexed: 04/26/2023] Open
Abstract
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.
Collapse
Affiliation(s)
| | - ANAEZE C. OFFODILE
- University of Texas MD Anderson Cancer Center and Baker Institute for Public Policy, Rice University
| |
Collapse
|
10
|
Mun H, Cho K, Lee S, Choi Y, Oh SJ, Kim YS, Seo M, Park JY, Pak SB. Patient-Centered Integrated Model of Home Health Care Services in South Korea (PICS-K). Int J Integr Care 2023; 23:6. [PMID: 37065614 PMCID: PMC10103715 DOI: 10.5334/ijic.6576] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 03/27/2023] [Indexed: 04/18/2023] Open
Abstract
Introduction As South Korea is fast becoming an aging society, the need for integrated care of the elderly has increased. 'Community Integrated Care Initiatives' have been implemented by the Ministry of Health and Welfare. However, home healthcare is insufficient to meet this need. Description The National Health Insurance Service (NHIS) launched the initiative, 'Patient-Centered Integrated model of Home Health Care Services in South Korea (PICS-K)'. Its purpose is to coordinate home healthcare providers by establishing a home health care support center (HHSC) in public hospitals starting in 2021. The PICS-K has six main features: integration of primary care-hospital-personal care-social services through a consortium, HHSC in hospitals with primary care collaboration, increased accessibility, interdisciplinary team (IDT), patient-centeredness, and education. Discussion Integrating healthcare, personal care, and social services at multiple levels is necessary. Accordingly, platforms to share participant information and service records, and institutional payment system reforms are required. Conclusion In public hospitals, the HHSC supported primary care, which provides home healthcare. The model combined community healthcare and social services to accomplish the aging-in-place of the homebound population by focusing on their needs. This model will be applicable to other regions in Korea.
Collapse
Affiliation(s)
- Hanbit Mun
- Department of Family Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Kyunghee Cho
- Department of Family Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Sanghyun Lee
- Department of Family Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Youngeun Choi
- Department of Family Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Seung-Jin Oh
- Division of Cardiology, Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Young-Sung Kim
- Department of Family Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Migyeung Seo
- Department of Chronic Disease Management, National Health Insurance Service, Wonju, Korea
| | - Ji-Young Park
- Department of Chronic Disease Management, National Health Insurance Service, Wonju, Korea
| | - Serng Bai Pak
- Department of Family Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| |
Collapse
|
11
|
Spivack SB, Murray GF, Lewis VA. A Decade of ACOs in Medicare: Have They Delivered on Their Promise? JOURNAL OF HEALTH POLITICS, POLICY AND LAW 2023; 48:63-92. [PMID: 36112955 DOI: 10.1215/03616878-10171090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
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.
Collapse
|
12
|
Zhu X, Huang H, MacKinney AC, Ullrich F, Mueller K. Medicare accountable care organization characteristics associated with participation in 2-sided risk. J Rural Health 2023; 39:302-308. [PMID: 35526082 DOI: 10.1111/jrh.12672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
PURPOSE To examine the associations of accountable care organization (ACO) characteristics with the likelihood of participation in 2-sided risk tracks in the Medicare Shared Savings Program (SSP). METHODS CMS ACO Public Use Files and Provider-Level Research Identifiable Files were used to trace Medicare ACOs' participation in the SSP between 2012 and 2020 and measure ACO characteristics, including size, rurality of the service area, affiliation with supporting organizations, program experience, and performance. Logistic regression and survival analysis were used to test the associations between ACO characteristics and the probability of ACOs initially participating in or subsequently switching to 2-sided risk tracks. FINDINGS Among the 624 Medicare SSP ACOs that started between 2012 and 2017, 26 participated in 2-sided risk tracks in their initial contracts and 95 switched to 2-sided risk tracks subsequently. ACO characteristics were not significantly associated with the probability of participating in 2-sided risk tracks in initial contracts. ACO size, affiliation with supporting organizations, and performance were positively associated with the likelihood of switching to 2-sided risk. Rural ACOs were less likely to switch to 2-sided risk than their urban counterparts. CONCLUSIONS Small and rural ACOs are less prepared to transition into 2-sided risk swiftly.
Collapse
Affiliation(s)
- Xi Zhu
- Department of Health Policy and Management, Fielding School of Public Health, University of California Los Angeles, Los Angeles, California, USA.,Department of Health Management and Policy, College of Public Health, University of Iowa, Iowa City, Iowa, USA
| | - Huang Huang
- Department of Health Management and Policy, College of Public Health, University of Iowa, Iowa City, Iowa, USA
| | - A Clinton MacKinney
- Department of Health Management and Policy, College of Public Health, University of Iowa, Iowa City, Iowa, USA
| | - Fred Ullrich
- Department of Health Management and Policy, College of Public Health, University of Iowa, Iowa City, Iowa, USA
| | - Keith Mueller
- Department of Health Management and Policy, College of Public Health, University of Iowa, Iowa City, Iowa, USA
| |
Collapse
|
13
|
Lin SC, Maddox KEJ, Ryan AM, Moloci N, Shay A, Hollingsworth JM. Exit Rates of Accountable Care Organizations That Serve High Proportions of Beneficiaries of Racial and Ethnic Minority Groups. JAMA HEALTH FORUM 2022; 3:e223398. [PMID: 36218951 PMCID: PMC9526083 DOI: 10.1001/jamahealthforum.2022.3398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Sunny C. Lin
- Division of General Medical Sciences, Department of Medicine, Washington University School of Medicine in St. Louis, St Louis, Missouri,Institute for Informatics, Washington University in St. Louis, St Louis, Missouri,Institute for Public Health, Washington University in St. Louis, St Louis, Missouri
| | - Karen E. Joynt Maddox
- Institute for Public Health, Washington University in St. Louis, St Louis, Missouri,Cardiovascular Division, Department of Medicine, Washington University School of Medicine in St. Louis, St Louis, Missouri
| | - Andrew M. Ryan
- Health Management and Policy, University of Michigan School of Public Health, Ann Arbor
| | - Nicholas Moloci
- Department of Health Policy and Management, University of North Carolina, Chapel Hill
| | - Addison Shay
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor
| | | |
Collapse
|
14
|
Baker N, Singer P. Accountable care organization reform: past challenges and future opportunities for public health. Public Health 2022; 205:99-101. [DOI: 10.1016/j.puhe.2022.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 01/13/2022] [Indexed: 11/28/2022]
|
15
|
Yajuan S, Nicholas M, Sitara M, Sarah K, Andy R, John M H. Use of Preventive Care Services and Hospitalization Among Medicare Beneficiaries in Accountable Care Organizations That Exited the Shared Savings Program. JAMA HEALTH FORUM 2022; 3. [PMID: 35048082 PMCID: PMC8765717 DOI: 10.1001/jamahealthforum.2021.4452] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Question How is the exit of an accountable care organization (ACO) from the Medicare Shared Savings Program (SSP) associated with clinical quality delivered to beneficiaries, and does the association change over time after exit? Findings In this cohort study of more than 1.7 million Medicare beneficiaries, SSP exit was associated with considerably lower rates of preventive service use, though not associated with rates of hospital utilization. These associations differed depending on how far removed an ACO was from SSP participation, where the reductions in clinical quality were most prominent in the first 2 years after exit. Meaning Observations of declines in clinical quality after ACO exit from the SSP are important given recent changes to the SSP that could accelerate program exit. Importance Thirty percent of Medicare accountable care organizations (ACOs) in the Shared Savings Program (SSP) have exited within 5 years of joining. Absent the potential for shared savings, exiting ACOs may choose to divest from costly resources needed to support population health, worsening clinical quality for beneficiaries aligned to these organizations. Objective To examine the associations of SSP exit with clinical quality delivered to Medicare beneficiaries. Design, Setting, and Participants This retrospective cohort study was conducted between 2019 and 2020 using national Medicare claims data from a 20% random sample of beneficiaries. A total of 1 713 237 beneficiaries were aligned with an SSP ACO at some point between 2012 and 2016. Distinction was made between those for whom the ACO to which they were aligned exited the SSP and those whose ACO stayed in the program. By comparing exiting ACOs with those that stayed in the SSP, changes in the quality of care that a beneficiary received before and after the aligned ACO exited the SSP were evaluated. Whether findings associated with exit varied with respect to the number of years after exit was also examined. Exposures Exiting the SSP and the number of years after exit. Main Outcomes and Measures Receipt of annual preventive care services and hospital utilization. Results Among the cohort of 1 713 237 beneficiaries (mean [SD] age at enrollment, 75.20 [7.96] years), 998 511 (58.3%) were female, 126 123 (7.4%) were Black, and 1 482 823 (86.6%) were White. Exiting the SSP was associated with statistically significantly lower rates of annual glycated hemoglobin A1c testing (odds ratio [OR], 0.74; 95% CI, 0.68-0.81), low-density lipoprotein cholesterol testing (OR, 0.86; 95% CI, 0.76-0.97), and all diabetes complication screening (OR, 0.90; 95% CI, 0.81-0.97) for beneficiaries with diabetes. The exit was not associated with rates of hospital utilization in terms of emergency department visits and 30-day readmission after SSP exit. The associations with exit depended on the length of time since contracts ended. For example, the baseline rate of annual glycated hemoglobin A1c testing was 89.8% (95% CI, 89.5%-90.1%) but fell to 86.9% (95% CI, 85.9%-88.0%) and 86.8% (95% CI, 85.0%-88.5%) in years 1 and 2 after exit, respectively, but then rose to 91.9% (95% CI, 85.3%-98.5%) in year 3. Conclusions and Relevance In this cohort study of Medicare beneficiaries, SSP exit was associated with modest declines in clinical quality. These findings are timely given recent SSP changes that could accelerate program exit.
Collapse
Affiliation(s)
- Si Yajuan
- Survey Research Center, Institute for Social Research, University of Michigan, Ann Arbor, MI
| | | | - Murali Sitara
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - Krein Sarah
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Ryan Andy
- Department of Health Management and Policy, University of Michigan, Ann Arbor, MI
| | - Hollingsworth John M
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| |
Collapse
|
16
|
Trombley MJ, McWilliams JM, Fout B, Morefield B. ACO Investment Model Produced Savings, But The Majority Of Participants Exited When Faced With Downside Risk. Health Aff (Millwood) 2022; 41:138-146. [PMID: 34982636 DOI: 10.1377/hlthaff.2020.01819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Medicare's Accountable Care Organization (ACO) Investment Model (AIM) provided up-front funding to forty-one small, rurally located ACOs to encourage their participation in the Medicare Shared Savings Program. We estimate net savings to Medicare of $381.5 million over three years, driven by utilization reductions in inpatient and other institutional care and by the absence of shared risk for potential increases in Medicare spending incurred by participants. These savings suggest that population-based payment models can enable providers to better meet the needs of rural populations through greater flexibility in care delivery. However, nearly two-thirds of AIM ACOs exited the Medicare Shared Savings Program when faced with the requirement to assume downside financial risk, starting in year four of participation. As the Centers for Medicare and Medicaid Services builds on AIM and rural hospital global payment models, our findings suggest that new payment models can support more efficient use of resources to meet the health care needs of rural populations. However, the findings also caution against the vigorous pursuit of savings as a primary goal of payment models in traditionally underserved communities.
Collapse
Affiliation(s)
| | - J Michael McWilliams
- J. Michael McWilliams, Harvard Medical School and Brigham and Women's Hospital, Boston, Massachusetts
| | - Betty Fout
- Betty Fout, Abt Associates Inc., Rockville, Maryland
| | | |
Collapse
|
17
|
McClellan M, Rajkumar R, Couch M, Holder D, Pham M, Long P, Medows R, Navathe A, Sandy L, Shrank W, Smith M. Health Care Payers COVID-19 Impact Assessment: Lessons Learned and Compelling Needs. NAM Perspect 2021; 2021:202105a. [PMID: 34532685 PMCID: PMC8406497 DOI: 10.31478/202105a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
| | | | | | | | | | | | - Rhonda Medows
- Providence St. Joseph Health and Ayin Health Solutions
| | | | | | | | | |
Collapse
|
18
|
Abstract
EXECUTIVE SUMMARY Accountable care organizations (ACOs) need confidence in their return on investment to implement changes in care delivery that prioritize seriously ill and high-cost Medicare beneficiaries. The objective of this study was to characterize spending on seriously ill beneficiaries in ACOs with Medicare Shared Savings Program (MSSP) contracts and the association of spending with ACO shared savings. The population included Medicare fee-for-service beneficiaries identified with serious illness (N = 2,109,573) using the Medicare Master Beneficiary Summary File for 100% of ACO-attributed beneficiaries linked to MSSP beneficiary files (2014-2016). Lower spending for seriously ill Medicare beneficiaries and risk-bearing contracts in ACOs were associated with achieving ACO shared savings in the MSSP. For most ACOs, the seriously ill contribute approximately half of the spending and constitute 8%-13% of the attributed population. Patient and geographic (county) factors explained $2,329 of the observed difference in per beneficiary per year spending on seriously ill beneficiaries between high- and low-spending ACOs. The remaining $12,536 may indicate variation as a result of potentially modifiable factors. Consequently, if 10% of attributed beneficiaries were seriously ill, an ACO that moved from the worst to the best quartile of per capita serious illness spending could realize a reduction of $1,200 per beneficiary per year for the ACO population overall. Though the prevalence and case mix of seriously ill populations vary across ACOs, this association suggests that care provided for seriously ill patients is an important consideration for ACOs to achieve MSSP shared savings.
Collapse
|
19
|
Barath D, Amaize A, Chen J. Accountable Care Organizations and Preventable Hospitalizations Among Patients With Depression. Am J Prev Med 2020; 59:e1-e10. [PMID: 32334954 PMCID: PMC7458155 DOI: 10.1016/j.amepre.2020.01.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 01/30/2020] [Accepted: 01/31/2020] [Indexed: 11/24/2022]
Abstract
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.
Collapse
Affiliation(s)
- Deanna Barath
- Department of Health Policy and Management, University of Maryland, College Park, Maryland.
| | - Aitalohi Amaize
- Department of Health Policy and Management, University of Maryland, College Park, Maryland
| | - Jie Chen
- Department of Health Policy and Management, University of Maryland, College Park, Maryland
| |
Collapse
|
20
|
Joynt Maddox K, Bleser WK, Crook HL, Nelson AJ, Hamilton Lopez M, Saunders RS, McClellan MB, Brown N. Advancing Value-Based Models for Heart Failure: A Call to Action From the Value in Healthcare Initiative's Value-Based Models Learning Collaborative. Circ Cardiovasc Qual Outcomes 2020; 13:e006483. [PMID: 32393125 DOI: 10.1161/circoutcomes.120.006483] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Heart failure (HF) is a leading cause of hospitalizations and readmissions in the United States. Particularly among the elderly, its prevalence and costs continue to rise, making it a significant population health issue. Despite tremendous progress in improving HF care and examples of innovation in care redesign, the quality of HF care varies greatly across the country. One major challenge underpinning these issues is the current payment system, which is largely based on fee-for-service reimbursement, leads to uncoordinated, fragmented, and low-quality HF care. While the payment landscape is changing, with an increasing proportion of all healthcare dollars flowing through value-based payment models, no longitudinal models currently focus on chronic HF care. Episode-based payment models for HF hospitalization have yielded limited success and have little ability to prevent early chronic disease from progressing to later stages. The available literature suggests that primary care-based longitudinal payment models have indirectly improved HF care quality and cardiovascular care costs, but these models are not focused on addressing patients' longitudinal chronic disease needs. This article describes the efforts and vision of the multi-stakeholder Value-Based Models Learning Collaborative of The Value in Healthcare Initiative, a collaboration of the American Heart Association and the Robert J. Margolis, MD, Center for Health Policy at Duke University. The Learning Collaborative developed a framework for a HF value-based payment model with a longitudinal focus on disease management (to reduce adverse clinical outcomes and disease progression among patients with stage C HF) and prevention (an optional track to prevent high-risk stage B pre-HF from progressing to stage C). The model is designed to be compatible with prevalent payment models and reforms being implemented today. Barriers to success and strategies for implementation to aid payers, regulators, clinicians, and others in developing a pilot are discussed.
Collapse
Affiliation(s)
- Karen Joynt Maddox
- Cardiovascular Division, John T. Milliken Department of Internal Medicine, Washington University School of Medicine, and Center for Health Economics and Policy, Institute for Public Health at Washington University, St. Louis, MO (K.J.M.)
| | - William K Bleser
- Robert J. Margolis, MD, Center for Health Policy, Duke University, Washington, DC and Durham, NC (W.K.B., H.L.C., M.H.L., R.S.S., M.B.M.)
| | - Hannah L Crook
- Robert J. Margolis, MD, Center for Health Policy, Duke University, Washington, DC and Durham, NC (W.K.B., H.L.C., M.H.L., R.S.S., M.B.M.)
| | - Adam J Nelson
- Duke Clinical Research Institute, Duke University, Durham, NC (A.J.N.)
| | - Marianne Hamilton Lopez
- Robert J. Margolis, MD, Center for Health Policy, Duke University, Washington, DC and Durham, NC (W.K.B., H.L.C., M.H.L., R.S.S., M.B.M.)
| | - Robert S Saunders
- Robert J. Margolis, MD, Center for Health Policy, Duke University, Washington, DC and Durham, NC (W.K.B., H.L.C., M.H.L., R.S.S., M.B.M.)
| | - Mark B McClellan
- Robert J. Margolis, MD, Center for Health Policy, Duke University, Washington, DC and Durham, NC (W.K.B., H.L.C., M.H.L., R.S.S., M.B.M.)
| | - Nancy Brown
- American Heart Association, Dallas, TX (N.B.)
| | | |
Collapse
|
21
|
Lee JT, Polsky D, Fitzsimmons R, Werner RM. Proportion of Racial Minority Patients and Patients With Low Socioeconomic Status Cared for by Physician Groups After Joining Accountable Care Organizations. JAMA Netw Open 2020; 3:e204439. [PMID: 32383749 PMCID: PMC7210481 DOI: 10.1001/jamanetworkopen.2020.4439] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Jessica T. Lee
- Perelman School of Medicine, Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania, Philadelphia
- Perelman School of Medicine, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, Department of Medicine, University of Pennsylvania, Philadelphia
| | - Daniel Polsky
- Johns Hopkins Bloomberg School of Public Health, Department of Health Policy and Management, Johns Hopkins University, Baltimore, Maryland
| | - Robert Fitzsimmons
- Perelman School of Medicine, Division of General Internal Medicine, Department of Medicine, University of Pennsylvania, Philadelphia
| | - Rachel M. Werner
- Perelman School of Medicine, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Perelman School of Medicine, Division of General Internal Medicine, Department of Medicine, University of Pennsylvania, Philadelphia
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| |
Collapse
|
22
|
Chernew ME, Conway PH, Frakt AB. Transforming Medicare’s Payment Systems: Progress Shaped By The ACA. Health Aff (Millwood) 2020; 39:413-420. [DOI: 10.1377/hlthaff.2019.01410] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Michael E. Chernew
- Michael E. Chernew is the Leonard D. Schaeffer Professor of Health Care Policy and director of the Healthcare Markets and Regulation Lab in the Department of Health Care Policy, Harvard Medical School, in Boston, Massachusetts
| | - Patrick H. Conway
- Patrick H. Conway was the president and CEO of Blue Cross and Blue Shield of North Carolina, in Durham, when this work was performed
| | - Austin B. Frakt
- Austin B. Frakt is director of the Partnered Evidence-Based Policy Resource Center at the Veterans Affairs Boston Healthcare System; an associate professor at the Boston University School of Public Health; and a senior research scientist at the Harvard T. H. Chan School of Public Health, all in Boston
| |
Collapse
|