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.

Assessing Hospital Quality Scores By Proportion Of Patients Dually Eligible For Medicare And Medicaid

The Centers for Medicare and Medicaid Services has been reporting hospital star ratings since 2016. Some stakeholders have criticized the star ratings methodology for not adjusting for social risk factors. We examined the relationship between 2021 star rating scores and hospitals' proportion of Medicare patients dually eligible for Medicaid. We found that, on average, hospitals caring for a greater proportion of dually eligible patients had lower star ratings, but there was significant overlap in performance among hospitals when we stratified them by quintile of dually eligible patients. Hospitals in the highest quintile (those with the greatest proportion of dually eligible patients) had the best mean mortality scores (0.28) but the worst readmission (-0.44) and patient experience (-0.78) scores. We assigned star ratings after stratifying the readmission measure group by proportion of dually eligible patients and found that a total of 142 hospitals gained a star and 161 hospitals lost a star, of which 126 (89 percent) and 1 (<1 percent) were in the highest quintile, respectively. Adjusting public reporting tools such as star ratings for social risk factors is ultimately a policy decision, and views on the appropriateness of accounting for factors such as proportion of dually eligible patients are mixed, depending on the organization and stakeholder.

The Association of Readmission Reduction Activities with Primary Care Practice Readmission Rates

BACKGROUND

A great deal of research has focused on how hospitals influence readmission rates. While hospitals play a vital role in reducing readmissions, a significant portion of the work also falls to primary care practices. Despite this critical role of primary care, little empirical evidence has shown what primary care characteristics or activities are associated with reductions in hospital admissions.

OBJECTIVE

To examine the relationship between practices' readmission reduction activities and their readmission rates.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective study of 1,788 practices who responded to the National Survey of Healthcare Organizations and Systems (fielded 2017-2018) and 415,663 hospital admissions for Medicare beneficiaries attributed to those practices from 2016 100% Medicare claims data. We constructed mixed-effects logistic regression models to estimate practice-level readmission rates and a linear regression model to evaluate the association between practices' readmission rates with their number of readmission reduction activities.

INTERVENTIONS

Standardized composite score, ranging from 0 to 1, representing the number of a practice's readmission reduction capabilities. The composite score was composed of 12 unique capabilities identified in the literature as being significantly associated with lower readmission rates (e.g., presence of care manager, medication reconciliation, shared-decision making, etc.).

MAIN OUTCOMES AND MEASURES

Practices' readmission rates for attributed Medicare beneficiaries.

KEY RESULTS

Routinely engaging in more readmission reduction activities was significantly associated (P < .05) with lower readmission rates. On average, practices experienced a 0.05 percentage point decrease in readmission rates for each additional activity. Average risk-standardized readmission rates for practices performing 10 or more of the 12 activities in our composite measure were a full percentage point lower than risk-standardized readmission rates for practices engaging in none of the activities.

CONCLUSIONS

Primary care practices that engaged in more readmission reduction activities had lower readmission rates. These findings add to the growing body of evidence suggesting that engaging in multiple activities, rather than any single activity, is associated with decreased readmissions.

Survey of Information Exchange and Advanced Use of Other Health Information Technology in Primary Care Settings: Capabilities In and Outside of the Safety Net

BACKGROUND

Advanced use of health information technology (IT) functionalities can support more comprehensive, coordinated, and patient-centered primary care services. Safety net practices may benefit disproportionately from these investments, but it is unclear whether IT use in these settings has kept pace and what organizational factors are associated with varying use of these features.

OBJECTIVE

The aim was to estimate advanced use of health IT use in safety net versus nonsafety net primary care practices. We explore domains of patient engagement, population health management (decision support and registries), and electronic information exchange. We examine organizational characteristics that may differentially predict advanced use of IT across these settings, with a focus on health system ownership and/or membership in an independent practice network as key factors that may indicate available incentives and resources to support these efforts.

RESEARCH DESIGN

We conduct cross-sectional analysis of a national survey of physician practices (n=1776). We use logistic regression to predict advanced IT use in each of our domains based on safety net status and other organizational characteristics. We then use interaction models to assess whether ownership or network membership moderate the relationship between safety net status and advanced use of health IT.

RESULTS

Health IT use was common across primary care practices, but advanced use of health IT functionalities ranged only from 30% to 50% use. Safety net settings have kept pace with adoption of features for patient engagement and population management, yet lag in information exchange capabilities compared with nonsafety net practices (odds ratio=0.52 for federally qualified health centers, P<0.001; odds ratio=0.66 for other safety net, P=0.03). However, when safety net practices are members of a health system or practice network, health IT capabilities are comparable to nonsafety net sites.

CONCLUSIONS

All outpatient settings would benefit from improved electronic health record usability and implementation support that facilitates advanced use of health IT. Safety net practices, particularly those without other sources of centralized support, need targeted resources to maintain equitable access to information exchange capabilities.

Avoiding Medicaid: Characteristics Of Primary Care Practices With No Medicaid Revenue

Primary care access for Medicaid patients is an ongoing area of concern. Most studies of providers' participation in Medicaid have focused on factors associated with the Medicaid program, such as reimbursement rates. Few studies have examined the characteristics of primary care practices associated with Medicaid participation. We used a nationally representative survey of primary care practices to compare practices with no, low, and high Medicaid revenue. Seventeen percent of practices received no Medicaid revenue; 38 percent and 45 percent were categorized as receiving low and high Medicaid revenue, respectively. Practices with no Medicaid revenue were more often small, independent, and located in urban areas with higher household income. These practices also have lower population health capabilities.

No Permanent Fix: MACRA, MIPS, and the Politics of Physician Payment Reform

Organized medicine long yearned for the demise of Medicare's Sustainable Growth Rate (SGR) formula for updating physician fees. Congress finally obliged in 2015, repealing the SGR as part of the Medicare Access and CHIP Reauthorization Act (MACRA). MACRA established value-based metrics for physician payment and financial incentives for doctors to join alternative delivery models like patient-centered medical homes. Throughout the law's initial implementation, the politics of accommodation prevailed, with federal officials crafting final rules that made MACRA more favorable for physicians. However, the era of accommodation could be short-lived. The discretion that the Centers for Medicare and Medicaid Services had during the first two years of implementation is ending. Additionally, euphoria over the SGR's repeal has given way to concerns over the new program's value-based purchasing arrangements and uncertainty over their sustainability. MACRA eliminated the SGR, but not the politics of physician payment.

Payments for acute myocardial infarction episodes-of-care initiated at hospitals with and without interventional capabilities

BACKGROUND

It is unknown whether hospitals with percutaneous coronary intervention (PCI) capability provide costlier care than hospitals without PCI capability for patients with acute myocardial infarction. The growing number of PCI hospitals and higher rate of PCI use may result in higher costs for episodes-of-care initiated at PCI hospitals. However, higher rates of transfers and postacute care procedures may result in higher costs for episodes-of-care initiated at non-PCI hospitals.

METHODS AND RESULTS

We identified all 2008 acute myocardial infarction admissions among Medicare fee-for-service beneficiaries by principal discharge diagnosis and classified hospitals as PCI- or non-PCI-capable on the basis of hospitals' 2007 PCI performance. We added all payments from admission through 30 days postadmission, including payments to hospitals other than the admitting hospital. We calculated and compared risk-standardized payment for PCI and non-PCI hospitals using 2-level hierarchical generalized linear models, adjusting for patient demographics and clinical characteristics. PCI hospitals had a higher mean 30-day risk-standardized payment than non-PCI hospitals (PCI, $20 340; non-PCI, $19 713; P<0.001). Patients presenting to PCI hospitals had higher PCI rates (39.2% versus 13.2%; P<0.001) and higher coronary artery bypass graft rates (9.5% versus 4.4%; P<0.001) during index admissions, lower transfer rates (2.2% versus 25.4%; P<0.001), and lower revascularization rates within 30 days (0.15% versus 0.27%; P<0.0001) than those presenting to non-PCI hospitals.

CONCLUSIONS

Despite higher PCI and coronary artery bypass graft rates for Medicare patients initially presenting to PCI hospitals, PCI hospitals were only $627 costlier than non-PCI hospitals for the treatment of patients with acute myocardial infarction in 2008.

National patterns of risk-standardized mortality and readmission after hospitalization for acute myocardial infarction, heart failure, and pneumonia: update on publicly reported outcomes measures based on the 2013 release

BACKGROUND

The Centers for Medicare & Medicaid Services publicly reports risk-standardized mortality rates (RSMRs) within 30-days of admission and, in 2013, risk-standardized unplanned readmission rates (RSRRs) within 30-days of discharge for patients hospitalized with acute myocardial infarction (AMI), heart failure (HF), and pneumonia. Current publicly reported data do not focus on variation in national results or annual changes.

OBJECTIVE

Describe U.S. hospital performance on AMI, HF, and pneumonia mortality and updated readmission measures to provide perspective on national performance variation.

DESIGN

To identify recent changes and variation in national hospital-level mortality and readmission for AMI, HF, and pneumonia, we performed cross-sectional panel analyses of national hospital performance on publicly reported measures.

PARTICIPANTS

Fee-for-service Medicare and Veterans Health Administration beneficiaries, 65 years or older, hospitalized with principal discharge diagnoses of AMI, HF, or pneumonia between July 2009 and June 2012. RSMRs/RSRRs were calculated using hierarchical logistic models risk-adjusted for age, sex, comorbidities, and patients' clustering among hospitals.

RESULTS

Median (range) RSMRs for AMI, HF, and pneumonia were 15.1% (9.4-21.0%), 11.3% (6.4-17.9%), and 11.4% (6.5-24.5%), respectively. Median (range) RSRRs for AMI, HF, and pneumonia were 18.2% (14.4-24.3%), 22.9% (17.1-30.7%), and 17.5% (13.6-24.0%), respectively. Median RSMRs declined for AMI (15.5% in 2009-2010, 15.4% in 2010-2011, 14.7% in 2011-2012) and remained similar for HF (11.5% in 2009-2010, 11.9% in 2010-2011, 11.7% in 2011-2012) and pneumonia (11.8% in 2009-2010, 11.9% in 2010-2011, 11.6% in 2011-2012). Median hospital-level RSRRs declined: AMI (18.5% in 2009-2010, 18.5% in 2010-2011, 17.7% in 2011-2012), HF (23.3% in 2009-2010, 23.1% in 2010-2011, 22.5% in 2011-2012), and pneumonia (17.7% in 2009-2010, 17.6% in 2010-2011, 17.3% in 2011-2012).

CONCLUSIONS

We report the first national unplanned readmission results demonstrating declining rates for all three conditions between 2009-2012. Simultaneously, AMI mortality continued to decline, pneumonia mortality was stable, and HF mortality experienced a small increase.

Abstract 20: Socioeconomic Status and Hospital Variation in 30-Day AMI Episode-of-Care Payments

Objective: We examined how payments for a 30-day episode-of-care following AMI differ for hospitals with higher and lower proportions of dual-eligible AMI patients.

Background: With the implementation of bundled payment programs, an increasing number of providers are being reimbursed for episodes-of-care as opposed to fee-for-service. Providers may have concerns about how their patient mix impacts this change in reimbursement. For example, low SES patients may require greater healthcare resources due to higher disease burden or lack of social support thereby increasing the costs of care for an episode.

Methods: We performed a national hospital-level study of Medicare fee-for-service beneficiaries 65 or older hospitalized with AMI (principal discharge diagnosis of ICD-9 codes 410.xx excluding 410.x2) in 2008. To create comparable 30-day episode-of-care payments across hospitals, we standardized payments by removing or averaging Medicare-specific geographic and policy payment adjustments associated with each care setting. For each hospital, we calculated a risk-standardized payment (RSP) using hierarchical generalized linear models. We risk-adjusted payments for patient age, history of cardiac procedures, and select comorbidities in the 12 months prior to and including the index admission. We limited our analyses to hospitals with 25 or more AMI index admissions and compared RSPs for hospitals with the highest (>30%) and lowest ( < 10%) proportion of dual-eligible AMI patients. We also compared the proportion of unadjusted payments attributed to index and post-acute care for these two groups. Data were analyzed using two-sample t-tests (alpha=0.05).

Results: Our final sample included 1,864 hospitals. 268 had >30% dual-eligible AMI patients and 531 had < 10%. Hospitals with the highest proportion of dual-eligible patients had a significantly lower (p < 0.0001) RSP (mean = $19,962) than hospitals with the smallest proportion of dual-eligible patients (mean RSP = $20,455). In addition, hospitals with the highest proportion of dual-eligible patients spent a significantly lower (p < 0.0001) proportion of their overall payments during the index admission (mean = 74.5%) than hospitals with the lowest proportion of dual-eligible patients (mean = 77.4%).

Conclusions: As a group, hospitals that cared for the highest proportion of dual-eligible patients had a lower RSP for a 30-day episode-of-care for AMI, spent a lower proportion of 30-day episode-of-care payments during the index admission, but a higher proportion during post-acute care. Given current practice patterns, this finding may suggest that bundled payments for AMI episodes-of-care generally would not penalize hospitals that provide for high proportions of low SES patients.

A comparison of low molecular weight heparin and low dose unfractionated heparin prophylaxis in subacute myelopathy

Deep vein thrombosis (DVT) and pulmonary embolism (PE) are common life threatening complications of acute myelopathy. Prophylaxis with low dose unfractionated heparin (LDUH) has been the standard of care. Studies suggest that low molecular weight heparin (LMWH) has superior efficacy, but advantages may be offset by higher expense. Since LMWH (enoxaparin sodium) became available, standard practice at our institution has been to treat all inpatients with myelopathy with LMWH. To examine the impact of this practice, all inpatients diagnosed with myelopathy and treated with LMWH were sequentially matched by diagnosis and compared in a retrospective review with inpatients treated with LDUH. In each group, 11 patients had traumatic injury, four had transverse myelitis, four had neoplasms and five had spinal stenosis. Characteristics of the LMWH/LDUH groups were: mean age--48.5/50.4; spinal level--cervical 13/7, thoracic 9/12, lumbar 2/5; American Spinal Injury Association impairment scale-A, 8/9; B, 2/2; C, 8/5; D, 6/8. There were five DVTs and two PEs in five patients taking LDUH; there were no cases of DVT or of PE in the LMWH group (p = 0.04, two-tailed chi-square test). Isolated DVTs occurred in two patients with traumatic injuries and in one patient with transverse myelitis; PE + DVT occurred in one patient with a primary and one patient with a metastatic tumor. All developed within 3.5 months of the onset of spinal dysfunction. One patient with a traumatic injury on ibuprofen and dexamethasone had a gastrointestinal hemorrhage while receiving LMWH. The cost of administration of LMWH was $24,499 compared with $5,700 for LDUH. The LDUH group spent a total of 57 days in an acute care facility, costing $57,000.00 and patients treated with LMWH spent nine days, costing $9,000.00. We conclude that treatment with LMWH was associated with a significant decrease in incidence of DVT/PE and an overall decline in health care costs of approximately $30,000 or approximately $1,250 per patient.