2022 ACO Publications

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Implementation of Cancer Screening in Rural Primary Care Practices after Joining an Accountable Care Organisation: A Multiple Case Study

Date: December 22, 2022
Source: Family Medicine and Community Health
Article

This study examined the unique and collective experiences of eight rural primary care practices to describe common strategies and practice-specific barriers, adaptations, and determinants of cancer screening implementation after joining an ACO. Joining the ACO provided important visit-based and population-based cancer screening strategies to increase cancer screening, although workflows varied widely across practices. Two predominant determinants of cancer screening success at the clinic level were use of the electronic health record and fully engaging nurses in the screening process.

Community-based, Hospital-Affiliated Medical Group Becomes a Successful Accountable Care Organization

Date: November/December 2022
Source: American Journal of Medical Quality
Article

Leadership of a multispecialty group practice within a health system recognized in 2015 that population health management requires quality performance improvement and organizational culture change. While blueprints for building successful ACOs exist in the literature, few describe the journey to achieving both shared savings and high-quality outcomes achieved by a medical group within an academic health system. Clinician education and engagement, prioritizing prevention and achieving benchmarks, developing supportive roles, more precise documentation of accurate diagnostic coding, and risk stratification constituted the approach. When first participating as an ACO, the medical group built programs and teams to improve quality, while CMS simultaneously changed quality measurements from pay-for-reporting to pay-for-performance. Quality scores initially dipped, though scores have since risen to 98.44% in 2020. Between 2015 and 2017, financial results were more than $10 million below the threshold, while in performance years 2018 to 2020, Northeast Medical Group achieved $24 million in aggregate in shared savings.

Characteristics Associated with Risk-Standardized Acute Admission Rates Among Patients with Heart Failure Enrolled in Accountable Care Organizations

Date: October 30, 2022
Source: Circulation
Article

This study found variation across ACOs in hospitalization rates for patients with heart failure (HF) when examining risk-standardized, unplanned ACO admission rates (RSAARs). Researchers identified a sample of Medicare fee-for-service beneficiaries with HF who were assigned to a Medicare Shared Savings Program (MSSP) ACO in 2017 and survived at least 30 days into 2018. Among 1,232,222 beneficiaries with HF, 283,795 were assigned to one of 467 MSSP ACOs (mean age 81 years, 54% female, 86% white, 78% urban). Median RSAAR [IQR] was 87 [82-92] admissions per 100 persons. A 5% increase in the percentage of Black beneficiaries in the ACO corresponded to an increase of 0.65 admissions per 100 HF patients (95% CI 0.31, 0.99, p<0.001). ACOs in the Northeast had higher RSAAR (B=5.16, 95% CI 3.25, 7.07, p<0.001), while ACOs in the West had lower RSAAR (B=-4.36, 95% CI -6.64, -2.09, p<0.001) Among Medicare beneficiaries with HF, there is variation in admission rates across ACOs. Region was strongly associated with RSAAR. Further studies should examine whether regional variation in admission rates is related to ACO quality or regional variation in admission more generally.

The Impact of Medicare Shared Savings Program Participation on Hospital Financial Performance: An Event-Study Analysis

Date: October 2022
Source: Health Services Research
Article

This study evaluated examined the impact of hospital participation in the Medicare Shared Savings Program (MSSP) on financial performance from 2011 to 2018. Researchers used an event-study design to estimate the temporal effects of MSSP participation on hospital financial outcomes and compared within-hospital changes over time between MSSP and non-MSSP hospitals while controlling for hospital and year fixed effects and organizational and service-area characteristics. The following financial outcomes were evaluated: outpatient revenue, inpatient revenue, net patient revenue, Medicare revenue, operating margin, inpatient revenue share, Medicare revenue share, and allowance and discount rate. Controlling for trends in non-MSSP hospitals, MSSP participation was associated with differential increases in net patient revenue by $3.28 million (p < 0.001), $3.20 million (p < 0.01), and $4.20 million (p < 0.01) in the second, third, and fourth year and beyond after joining MSSP, respectively. Medicare revenue differentially increased by $1.50 million (p < 0.05), $2.24 million (p < 0.05), and $4.47 million (p < 0.05) in the first, second, and fourth year and beyond. Inpatient revenue share differentially increased by 0.29% (p < 0.05) in the second year and 0.44% (p < 0.05) in the fourth year and beyond. Medicare revenue share differentially increased by 0.17% (p < 0.01), 0.25% (p < 0.01), 0.32% (p < 0.01), and 0.41% (p < 0.01) in consecutive years following MSSP participation. MSSP participation was associated with 0.33% (p < 0.05) and 0.39% (p < 0.05) differential reduction in allowance and discount rate in the second and third years. MSSP participation was associated with differential increases in net patient revenue, Medicare revenue, inpatient revenue share, and Medicare revenue share, and a differential reduction in allowance and discount rate.

The evidence of no decline in operating margins after MSSP participation alleviates the policy concern that the MSSP may threaten hospitals’ financial viability.

Using The Medicare Shared Savings Program to Innovate Primary Care Payment

Date: October 17, 2022
Source: Health Affairs Forefront
Article

In this commentary, the authors propose a dramatic redesign of Medicare payment for current and new primary care functions and increased payment levels, arguing that the U.S. can no longer afford to wait for pilot programs to generate change at scale. Primary care practices provide most mental health services that patients receive, in place of, or in collaboration with, mental health specialists. Primary care is also the most common source of preventive services, care coordination, and partnership with other sectors outside health care, such as social services, that are necessary to achieve health equity. The U.S. grossly underfunds primary care and restricts payment to a narrow set of services not reflective of what patients need and not in accord with how high-performing primary care practices work. A decade of experimentation with medical home and value-based payment models points the way to permanent solutions, captured in recent recommendations from the National Academes of Science, Engineering, and Medicine. A bold approach to improving mental health and addressing inequity at a large scale would focus on primary care payment in the Medicare Shared Savings Program (MSSP). This would provide a solid chassis on which to ultimately integrate multiple payment innovations into Medicare’s flagship value-based payment program.

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

Date: September 30, 2022
Source: JAMA Health Forum
Article

In this cohort study of 589 Medicare Shared Savings Program ACOs from January 2012 to December 2018, ACOs with a higher proportion of patients of racial and ethnic minority groups were more likely to exit the Medicare Shared Savings Program. In multivariable analysis, the higher exit rate was associated with significant differences in beneficiary complexity and ACO structure. The study results suggest that ACOs that served a higher proportion of beneficiaries 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.

Evaluating the Accuracy of Medicare Risk Adjustment For Alzheimer’s Disease And Related Dementias

Date: September 2022
Source: Health Affairs
Article

In 2020 Medicare reintroduced Alzheimer’s disease and related dementias (ADRD) Hierarchical Condition Categories (HCCs) to risk-adjust Medicare Advantage and ACO payments. The potential for Medicare spending increases from this policy change are not well understood because the baseline accuracy of ADRD HCCs is uncertain. Using linked 2016–18 claims and electronic health record data from a large ACO, researchers evaluated the accuracy of claims-based ADRD HCCs against a reference standard of clinician-adjudicated disease. An estimated 7.5 percent of beneficiaries had clinician-adjudicated ADRD. Among those with ADRD HCCs, 34 percent did not have clinician-adjudicated disease. The false-negative and false-positive rates were 22.7 percent and 3.2 percent, respectively. Medicare spending for those with false-negative ADRD HCCs exceeded that of true positives by $14,619 per beneficiary. If, after the reintroduction of risk adjustment for ADRD, all false negatives were coded as having ADRD, expenditure benchmarks for beneficiaries with ADRD would increase by 9 percent. Monitoring ADRD coding could become challenging in the setting of concurrent incentives to decrease false-negative rates and increase false-positive rates.

Medicaid ACOs and Managed Care: A Tale of 2 States

Date: September 2022
Source: American Journal of Accountable Care
Article

CMS aims to transition most Medicaid beneficiaries into accountable care relationships in the coming years. With more than 70% of Medicaid beneficiaries enrolled in managed care, CMS cannot reach this goal if Medicaid ACOs focus exclusively on the fee-for-service population, as most Medicare ACOs do. Researchers used a case study approach focused on the experiences of Minnesota and Massachusetts implementing a Medicaid ACO model that includes managed care, with details on stakeholder engagement, beneficiary attribution, and payment methodologies. Massachusetts took an approach that significantly changed the managed care organization (MCO)–provider–enrollee relationship by blurring the line between MCO and ACO, while Minnesota left existing MCO structure largely unchanged for the beneficiary and provider. As Medicaid agencies increasingly adopt ACO models, the experiences of Minnesota and Massachusetts can help policymakers understand the effects of different implementation approaches.

Aligning Specialist Physicians with Accountable Care Organizations

Date: September 2022
Source: American Journal of Accountable Care
Article

This commentary examines the need for more courageous leadership from health care executives with power to change the status quo even when doing so is uncomfortable for their organizations. Accountable care is an important pathway to a more patient-centered, value-based health care system. But ACOs are neither a silver bullet nor monolithic. Historically, many of the highest-performing ACOs have been physician-led organizations that don’t own or operate health care facilities. The performance of large health system ACOs has been mixed. In these systems, the ACO or population health departments make valuable contributions but frequently don’t get the resources or authority they need to transform care across their parent organizations. Specialists and facilities generate the bulk of systems’ revenue and therefore control the flow of resources. Most large health systems are still addicted to fee-for-service payment, and ACO initiatives that endanger their cash flow are viewed as a threat. For the past decade, ACOs have focused much of their work on enhancing primary care. Among ACO leaders, there is a perception that most medical specialists are either unaware of or perhaps not particularly interested in the work of the ACO. Taking accountable care to the next level will require alignment of specialist physicians with value-based care initiatives. That will require an enhanced focus by specialist physicians on the whole patient, more careful assessment of the appropriateness of both routine and high-cost services, increased collaboration with primary care providers, and organized efforts to reduce use of low-value services. So how can ACOs effectively align with specialist physicians? Many are considering strategies that include the following elements: (1) education on value-based care, (2) performance measurement and reporting, (3) systems designed to catalyze PCP-specialist collaboration, and (4) steering referrals to preferred specialists.

Intensive Care Management of a Complex Medicaid Population: A Randomized Evaluation

Date: September 2022
Source: American Journal of Managed Care
Article

This study evaluated the impact of an intensive care management program on utilization and cost among those with highest cost (top 5%) and highest utilization in a Medicaid ACO population.

Researchers conducted a randomized controlled quality improvement trial of intensive care management, provided by a nonprofit care management vendor, for Medicaid ACO patients at two academic centers. Patients were identified using claims, chart review, and primary care validation, then randomly assigned 2:1 to intervention and control groups. Among 131 patients included in intent-to-treat analysis, 87 and 44 were randomly assigned to the intervention and control groups, respectively. Patients in the intervention group were eligible to receive intensive care management in the community/home setting and, in some cases, home-based primary care. Patients in the control group received standard of care, including practice-based care management. Prespecified primary outcome measures included total medical expense (TME), emergency department (ED) visits, and inpatient utilization. Relative to controls, patients randomly assigned to receive intensive care management had a $1,933 smaller increase per member per month in TME (P = .04) and directionally consistent but nonsignificant reductions in ED visits (17% fewer; P = .40) and inpatient admissions (34% fewer; P = .29) in the 12 months post randomization compared with the 12 months prerandomization. The study results support that targeted, intensive care management can favorably affect TME in a health system–based high-cost, high-risk Medicaid population.

Post-Acute Care Use Associated with Medicare Shared Savings Program and Disparities

Date: September 2022
Source: Journal of the American Medical Directors Association
Article

This study examined the impact of hospital participation in the MSSP on institutional PAC among three Medicare patient groups: ischemic stroke, hip fracture, and total joint arthroplasty (TJA), finding participation in the MSSP was associated with slightly increased institutional post-acute care (PAC) use for ischemic stroke Medicare patients. Also, compared to non-MSSP participating hospitals, MSSP-participating hospitals were more likely to discharge racial minority patients for elective total joint arthroplasty (TJA) and patients dually eligible for Medicaid and Medicare for ischemic stroke to institutional PAC.

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

Date: September 2022
Source: Journal of Health Policy, Politics and Law
Article

ACOs were envisioned as a way to address both health care cost growth and uneven quality in U.S. health care. 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 U.S. health care system remains uncertain.

To What Extent Are ACO and PCMH Models Advancing the Triple Aim Objective? Implications and Considerations for Primary Care Medical Practices

Date: October/December 2022
Source: Journal of Ambulatory Care Management
Article

ACOs and patient-centered medical homes (PCMHs) have emerged to advance the health care system by achieving the triple aim of improving population health, reducing costs, and enhancing patient experience. This review examines evidence regarding the relationship between these innovative care models and care outcomes, costs, and patient experiences. The 28 articles summarized in this review show that ACO and PCMH models play an important role in achieving the triple aim, when compared with conventional care models. However, there can be drawbacks associated with model implementation. The long-term success of these models still merits further investigation.

ACO Participation Associated with Decreased Spending For Medicare Beneficiaries With Serious Mental Illness

Date: August 2022
Source: Health Affairs
Article

To date, limited evidence exists evaluating whether Medicare ACOs are associated with decreased spending among people with serious mental illness (SMI). Using national Medicare data from the period 2009–17, researchers performed difference-in-differences analyses evaluating changes in spending and use associated with enrollment in the Medicare Shared Savings Program (MSSP) among beneficiaries with SMI. After five years, participation in MSSP ACOs was associated with small savings for beneficiaries with SMI (−$233 per person per year) in total health care spending, primarily related to savings from chronic medical conditions (excluding mental health; −$227 per person per year) and not from savings related to mental health services (−$6 per person per year). Savings were driven by reductions in acute and post-acute care for medical conditions.

Evaluation of Spending Differences Between Beneficiaries in Medicare Advantage and the Medicare Shared Savings Program

Date: August 23, 2022
Source: JAMA Health Forum
Article

This study examines how spending and utilization differ between Medicare Advantage (MA) and Medicare Shared Savings Program (MSSP) ACO beneficiaries after accounting for clinical risk in a health system participating in both programs. The retrospective economic evaluation used data from 15,763 propensity score-matched beneficiaries who were continuously enrolled in MA or MSSP from January 1, 2014, to December 31, 2018, with diabetes, congestive heart failure (CHF), chronic kidney disease (CKD), or hypertension. Participants received care at a large nonprofit academic health system in the southern United States that bears risk for Medicare beneficiaries through both the MA and MSSP programs. Differences in beneficiary risk were mitigated by propensity score matching using validated clinical criteria based on data from administrative claims and electronic health records. Data were analyzed from January 2019 to May 2022. The study found that spending was 22% to 26% higher for MSSP beneficiaries than for MA beneficiaries even after controlling for detailed clinical risk factors. This was accounted for by higher outpatient hospital spending for MSSP beneficiaries. In this study, spending differences between MA and MSSP beneficiaries persisted after accounting for granular clinical risk factors, suggesting the need for aligning program designs and accounting for unmeasured social determinants of health. The sample of 15,763 participants included 12,720 (81%) MA and 3,043 (19%) MSSP beneficiaries. MA beneficiaries, compared with MSSP beneficiaries, were more likely to be older (median [IQR] age, 75.0 [69.9-81.8] years vs 73.1 [68.3-79.8] years), male (5515 [43%] vs 1119 [37%]), and White (9644 [76%] vs 2046 [69%]) and less likely to live in low-income zip codes (2338 [19%] vs 750 [25%]). After matching on clinical risk and demographic factors, MSSP spending was higher for patients with diabetes (mean per-member per-year spending difference in 2015: $2,454; 95% CI, $1,431-$3,574), CHF ($3,699; 95% CI, $1,235-$6,523), CKD ($2,478; 95% CI, $1,172-$3,920), and hypertension ($2,258; 95% CI, $1,616-2,939). Higher MSSP spending among matched beneficiaries was consistent over time. In the matched cohort in 2018, MSSP total spending ranged from 23% (CHF) to 30% (CKD) higher than MA. Adjusting for differential trends in coding intensity did not affect these results. Higher outpatient hospital spending among MSSP beneficiaries contributed most to spending differences between MSSP and MA, representing 49% to 62% of spending differences across disease cohorts.

Care Coordination for Healthcare Referrals under a Shared-Savings Program

Date: August 23, 2022
Source: Production and Operations Management
Article

This study examined care coordination for health care referrals between Medicare Shared Savings Program (MSSP) ACOs and preferred external providers for specialized health services. Researchers looked at financial incentive mechanisms between the ACO and its preferred external provider to achieve integrated care coordination in referral markets under the MSSP. They found that traditional fee-for-service and capitation agreements do not provide sufficient incentives for care coordination in referral markets. However, a risk- and cost-sharing mechanism can induce integrated care coordination efforts while satisfying the ACO and provider’s participation constraints. The study characterizes a family of such mechanisms and numerically studies the variability of the ACO and the external provider’s profit. The findings indicate that that type of agreement can be used not only to induce integrated care coordination but can also result in a Pareto improvement in profit variability. The study also illustrates the impact of the different MSSP risk track parameters on the performance of this care coordination mechanism, including their effect on the quality of care and the payer’s mean spending.

Changes in Spending, Utilization, and Quality of Care among Medicare Accountable Care Organizations During the COVID-19 Pandemic

Date: August 12, 2022
Source: PLoS One
Article

The COVID pandemic disrupted health care spending and utilization, and the Medicare Shared Savings Program (MSSP), Medicare’s largest value-based payment model with 11.2 million assigned beneficiaries, was no exception. Despite COVID, the 513 ACOs in MSSP returned a program record $1.9 billion in net savings to Medicare in 2020. To understand the extent of COVID’s impact on MSSP cost and quality, the study describes how ACO spending changed in 2020 and further analyzes changes in measured quality and utilization. Researchers found that non-COVID per capita spending in MSSP fell by 8.3 percent from $11,496 to $10,537 (95% confidence interval (CI),-1,223.8 to-695.4, p<0.001), driven by 14.6% and 7.5% reductions in per capita acute inpatient and outpatient spending, respectively. Utilization fell across inpatient, emergency, and outpatient settings. On quality metrics, preventive screening rates remained stable or improved, while control of diabetes and blood pressure worsened. Large reductions in non-COVID utilization helped ACOs succeed financially in 2020, but worsening chronic disease measures are concerning. The appropriateness of the benchmark methodology and exclusion of COVID-related spending, especially as the virus approaches endemicity, should be revisited to ensure bonus payments reflect advances in care delivery and health outcomes rather than COVID-related shifts in spending and utilization patterns

Innovations in Care Delivery for Patients With Serious Mental Illness Among Accountable Care Organizations

Date: August 1, 2022
Source: Psychiatric Services
Article

This study examined whether and how organizations participating in ACO contracts integrate primary care and treatment for patients with serious mental illness. The study used responses to the 2017–2018 National Survey of ACOs (55% response rate) to measure ACO-reported use of three integrated care strategies: care manager to address physical health treatment coordination or nonmedical needs (e.g., job support and housing), patient registries to track physical health conditions, and primary care clinician co-located in a specialty mental health setting. Logistic regression was used to determine associations between ACO characteristics and strategy use.

Of 399 respondents who answered questions on integration, 303 (76%) reported using at least one integrated care strategy in at least one location. Use of care managers (defined by the respondent) was most common (N=281, 70%), followed by use of a patient registry (N=146, 37%) and co-location of a primary care clinician in a specialty mental health setting (N=118, 30%). Respondents reporting that their largest Medicaid contract or largest commercial contract included quality measures specific to serious mental illness (e.g., antipsychotic adherence) were more likely to use each integrated care delivery strategy. Self-reported use of three collaborative care strategies (care management, patient registry, or mental health consulting clinician) for treatment of depression or anxiety was associated with use of integrated primary care and treatment for serious mental illness.

ACO Participation Associated with Decreased Spending for Medicare Beneficiaries with Serious Mental Illness

Date: August 2022
Source: Health Affairs
Article

Using national Medicare data from 2009-17, researchers performed difference-in-differences analyses evaluating changes in spending and use associated with enrollment in the MSSP ACOs among beneficiaries with serious mental illness (SMI). After five years, participation in MSSP ACOs was associated with small savings for beneficiaries with SMI (−$233 per person per year) in total health care spending, primarily related to savings from chronic medical conditions (excluding mental health; −$227 per person per year) and not from savings related to mental health services (−$6 per person per year). Savings were driven by reductions in acute and post-acute care for medical conditions.

The Medicare Value-Based Care Strategy: Alignment, Growth, And Equity

Date: July 21, 2022
Source: Health Affairs Forefront
Article

The Medicare Shared Savings Program is now one of the largest value-based purchasing programs in the country, covering more than 11 million people with over 525,000 participating clinicians. The relationship between a MSSP ACOs and their assigned beneficiaries is a good example of an accountable care relationship. Reflecting on the significant progress toward value-based care across the nation, CMS announced the ambitious goal of having all people with traditional Medicare in an accountable care relationship with a health care provider by 2030 in its CMS Innovation Center strategy refresh and vision for Medicare. This article builds off of these recent publications to outline a cohesive value-based care strategy for Medicare along three main pillars: alignment, growth, and equity. From a health care provider perspective, alignment of value-based payment arrangements within Medicare and across multiple payers is critical. Growth of accountable care relationships in both traditional Medicare and Medicare Advantage can improve quality and increase savings for beneficiaries by promoting innovative care delivery that better provides whole-person care. Health equity is fundamental to high-quality care for all people. For far too long, profound inequities have existed across our health care system that are often rooted in intersecting social determinants of health. The design of value-based arrangements in Medicare can be an important tool for advancing health equity by encouraging the movement of care upstream to address the health-related social needs and disparities that can lead to or exacerbate poor health outcomes.

An Option for Medicare ACOs to Further Transform Care

Date: July 15, 2022
Source: Health Affairs Forefront
Article

The Biden administration’s commitment to have all Medicare beneficiaries in a care relationship with accountability for quality and total cost of care by 2030 and aligning ACO models across all of Medicare are important steps in moving delivery system reform efforts forward. As a permanent part of the Medicare program, the Medicare Shared Savings Program (MSSP) is well-positioned to bring the benefits of accountable care to the most beneficiaries—including those in underserved communities and demographic groups who have not yet engaged with ACOs. The MSSP model is also an important potential lever for implementing primary care payment reforms called for by the National Academy for Science Engineering and Medicine (NASEM), which recommended that “CMS should increase the overall portion of spending going to primary care” while transitioning to a hybrid payment model for primary care composed of both prospective payment and fee-for-service payment. The administration should consider offering an opportunity for MSSP ACOs to participate in such primary care hybrid payment models. Offering optional, partial capitation payments within total-cost-of-care models such as MSSP can effectively drive value transformation. CMS has the authority to implement partial capitation. Due to diversity among ACOs and varying levels of experience with non-fee-for-service payment structures, some may be better equipped to manage capitation than others. Therefore, capitation payments should be an MSSP optional component with appropriate flexibilities that recognize an ACO’s ability to administer capitation.

“REACHing” for Equity — Moving from Regressive toward Progressive Value-Based Payment

Date: July 14, 2022
Source: New England Journal of Medicine
Article

A bright spot in the value-based payment era has been ACOs — groups of providers that are given incentives to reduce spending below a benchmark — some of which have produced savings for Medicare. Health-equity concerns persist, however. Recent evidence suggests that some ACOs may strategically drop “high risk” beneficiaries (e.g., those with multiple chronic conditions and high expected medical spending) or clinicians whose panels consist of large numbers of such patients to reduce spending and increase their chances of earning shared savings. In the absence of explicit incentives to invest in equity, value-based payment models can elicit responses that widen disparities. In an important shift, the Center for Medicare and Medicaid Innovation recently announced a new model — the ACO Realizing Equity, Access, and Community Health (ACO REACH) model — partly in response to concerns about the inequitable effects of value-based payment programs. This model explicitly names promoting equity—not just value—as a central goal. Several provisions of ACO REACH could help advance health equity, including a new “health equity benchmark adjustment” that supports ACOs caring for socioeconomically disadvantaged patients.

Primary Care Physicians’ Participation in the Medicare Shared Savings Program and Preventive Services delivery: Evidence from the First 7 Years

Date: July 9, 2022
Source: Health Services Research
Article

This study examined whether primary care physicians’ participation in MSSP ACOs was associated with changes in their preventive services delivery. Using data from 2012 through 2018, researchers evaluated the following preventive services: influenza vaccination, pneumococcal vaccination, clinical depression screening, colorectal cancer screening, breast cancer screening, body mass index (BMI) screening and follow-up, tobacco use assessment, and annual wellness visits. Both the likelihood of providing services and the volume of services delivered were evaluated. Researchers found that MSSP participation was associated with an increase in the likelihood of providing influenza vaccination (0.7 percentage-points), pneumococcal vaccination (2.0 percentage-points), clinical depression screening (2.1 percentage-points), tobacco use assessment (0.3 percentage-points), and annual wellness visits (4.1 percentage-points). A similar increase was found for the volume of services delivered per 100 patients for several preventive services: influenza vaccination (0.18), pneumococcal vaccination (0.56), clinical depression screening (0.46), and annual wellness visits (1.52). MSSP participation was associated with a decrease in the likelihood (−0.4 percentage-points) and the volume of colorectal cancer screening (−0.03). Primary care physicians’ participation in MSSP was associated with an increase in the likelihood and the volume of several preventive services.

ACO Participation Associated with Decreased Spending for Medicare Beneficiaries with Serious Mental Illness

Date: August 2022
Source: Health Affairs
Article Link: https://doi.org/10.1377/hlthaff.2022.00096

The Medicare Value-Based Care Strategy: Alignment, Growth, And Equity

Date: July 21, 2022
Source: Health Affairs Forefront
Article Link: https://www.healthaffairs.org/do/10.1377/forefront.20220719.558038

ACO Participation Associated with Decreased Spending for Medicare Beneficiaries with Serious Mental Illness

Date: August 2022
Source: Health Affairs
Article Link: https://doi.org/10.1377/hlthaff.2022.00096

The Medicare Value-Based Care Strategy: Alignment, Growth, And Equity

Date: July 21, 2022
Source: Health Affairs Forefront
Article Link: https://www.healthaffairs.org/do/10.1377/forefront.20220719.558038

An Option for Medicare ACOs to Further Transform Care

Date: July 15, 2022
Source: Health Affairs Forefront
Article Link: https://www.healthaffairs.org/do/10.1377/forefront.20220713.922286

“REACHing” for Equity — Moving from Regressive toward Progressive Value-Based Payment

Date: July 14, 2022
Source: New England Journal of Medicine
Article Link: https://doi.org/10.1056/nejmp2204749

Primary Care Physicians’ Participation in the Medicare Shared Savings Program and Preventive Services delivery: Evidence from the First 7 Years

Date: July 9, 2022
Source: Health Services Research
Article Link: https://doi.org/10.1111/1475-6773.14030

Medicare’s Specialty-Oriented Accountable Care Organization: First-Year Results For People With End-Stage Renal Disease

Date: June 2022
Source: Health Affairs
Article

The Comprehensive End-Stage Renal Disease (ESRD) Care (CEC) Model was the first Medicare specialty-oriented ACO model. This study examined whether this model provided better results for beneficiaries with ESRD than primary care-based ACO models. The study found significant decreases in Medicare payments ($126 per beneficiary per month), hospitalizations (5 percent), and likelihood of readmissions (8 percent) among beneficiaries with ESRD during the first year of alignment with the CEC Model and no impacts on these measures among beneficiaries with ESRD who were aligned with primary care–based ACOs, relative to fee-for-service Medicare beneficiaries. Neither the CEC nor primary care–based ACO models significantly reduced the likelihood of catheter use, but fistula use increased for CEC Model beneficiaries to levels just above statistical significance. Other populations with chronic conditions may benefit from the testing of a specialty-oriented ACO model. In addition, primary care-based ACOs may benefit from applying CEC Model strategies to high-need subpopulations. Last, the strategies that enabled ESRD Seamless Care Organizations to achieve reductions in hospitalizations and readmissions even without hospital participation as owners could inform physician-led ACOs’ efforts to coordinate with hospitals.

Identifying Drivers of Health Care Value: A Scoping Review of the Literature

Date: June 30, 2022
Source: BMC Health Services Research
Article

This scoping literature review identified 22 studies for analysis to identify potential drivers of health care value. Although results were mixed, several consistent findings emerged. First, insurance incentive structures may affect value. For example, patients in ACOs had reduced rates of low-value care utilization compared to patients in traditionally structured insurance plans. Second, higher intensity of care was associated with higher rates of low-value care. Third, culture is likely to contribute to value. This was suggested by findings that recent medical school graduation and allopathic training were associated with reduced low-value service utilization and that provider organizations had larger effects on value than did individual physicians. System, hospital, provider, and community characteristics influence low-value care provision. To improve health care value, strategies aimed at reducing use of low-value services and promoting high-value care across various levels will be essential.

Can Alternative Payment Models and Value-Based Insurance Design Alter the Course of Diabetes in the United States?

Date: June 27, 2022
Source: Health Affairs
Article

Diabetes process and outcome measures are common quality measures in payment reform models, including alternative payment models (APMs) and value-based insurance design (VBID). In this commentary, the authors review evidence from selected research to examine whether these payment models can improve the value of diabetes care. They found that higher-risk APMs yielded greater improvements in diabetes process measures than lower-risk APMs, and that VBID models appeared to improve medication adherence but not other quality measures. The authors contend that these models are promising first steps in redesigning the payment system to improve diabetes care. However, greater coordination and alignment across models is needed to enhance their impact on providers’ behavior, diabetes care processes, and patient health outcomes.

Using a Mixed-Effect Model with a Parameter-Space of Heterogenous Dimension to Evaluate Whether Accountable Care Organizations Are Associated with Greater Uniformity Across Constituent Practices

Date: June 27, 2022
Source: Statistics in Medicine
Article

ACOs were designed to improve patient outcomes by inducing greater coordination of care and adoption of best practices. Using a mixed-effect model with a difference-in-difference design, this study evaluated the effect of a patient receiving care from an ACO on patient outcomes and whether an ACO is associated with increased uniformity across its constituent practices. The task is complicated by the organizations within an ACO forming an additional layer in the multilevel model, due to medical practices and hospitals that form an ACOs being nested within the ACO, making the number of model levels variable and the dimension of the parameter space time-varying. Researchers developed the model and a procedure for testing the hypothesis that ACO formation was associated with increased uniformity among its constituent practices. Researchers applied the procedure to a cohort of Medicare beneficiaries followed over 2009-2014. Although there is extensive heterogeneity of becoming an ACO across practices, the study found that ACO formation appears to be associated with greater uniformity of patient outcomes among its constituent practices.

Medicare Accountable Care Organizations: Post-Acute Care Use and Post-Surgical Outcomes in Urologic Cancer Surgery

Date: June 27, 2022
Source: Urology
Article

This study examined associations between hospital participation in Medicare ACOs on post-acute care (PAC) use and spending and post-surgical outcomes in Medicare beneficiaries undergoing urologic cancer surgeries. Researchers conducted a longitudinal analysis of 2011-2017 Medicare claims data to compare post-surgical outcomes between Medicare ACO and non-ACO patients before and after implementation of Medicare shared savings program (MSSP). Outcomes of interest were PAC use (overall, institutional, and home health), skilled nursing facility (SNF) length of stay and Medicare spending for SNF patients, 30-day and 90-day unplanned readmissions, and complications after the index procedure. The study sample included 334,514 Medicare patients undergoing bladder, prostate, and kidney cancer surgeries at 524 Medicare ACO and 2,066 non-ACO hospitals. For bladder cancer surgery, Medicare ACO participation was associated with significantly reduced overall PAC use but not with changes in readmission or complication rate. For prostate cancer and kidney cancer surgery, there were no significant association between hospital participation in Medicare ACOs and PAC use or post-surgical outcomes. The authors concluded that hospital participation in MSSP ACOs led to lower PAC use without compromising patient outcomes for Medicare beneficiaries undergoing bladder cancer surgery. Future research is needed to understand longer-term impact of ACO participation on urologic cancer surgery outcomes. .

Participation in Delivery System Reform Programs and U.S. Acute Care Hospital Integration into Behavioral Health

Date: June 25, 2022
Source: Journal of Hospital Management and Health Policy
Article Link: https://jhmhp.amegroups.com/article/view/7050/html

This study examined the relationship between hospital participation in two delivery system reform programs—ACOs and medical homes—and behavioral health integration among U.S. acute care hospitals. On average, hospitals that were only participating in an ACO reported 1.09 times more behavioral health integration areas, relative to hospitals that were not participating in any delivery system reform programs. Similarly, hospitals with an established medical home program reported 1.21 times more behavioral health integration areas, on average, relative to hospitals that were not participating in any delivery system reform programs. Hospitals participating in both an ACO and an established medical home program reported 1.31 times more behavioral health integration areas, relative to hospitals with neither. The analysis indicates that participation in either an ACO or medical home program, by itself, may be sufficient to support behavioral health integration. However, having an established medical home program may stimulate more robust integration than ACO participation. Likewise, hospitals participating in both programs may promote even greater behavioral health integration than single program participation.

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

Date: June 15, 2022
Source: Population Health Management
Article

The purpose of this study was two-fold: (1) to analyze the change in diabetes-related hospitalization rates of rural Latino older adult patients compared with their White counterparts and (2) to determine what factors, including rural health clinic (RHC) participation in ACOs, are related to reduced disparities in diabetes-related hospitalization rates. Data for Latino Medicare beneficiaries 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 three 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 was 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 provision of services to Latinos, rural, and other vulnerable populations.

Impactability Modeling for Reducing Medicare Accountable Care Organization Payments and Hospital Events in High-Need High-Cost Patients: Longitudinal Cohort Study

Date: June 13, 2022
Source: Journal of Medical Internet Research
Article

This study evaluated the impact on Medicare ACO savings of developing a score to measure the benefit to patients enrolled in a historic case management program, prospectively implementing the score, and evaluating the results in a new case management program. Researchers conducted a longitudinal cohort study of 76,140 patients in a Medicare ACO with multiple before-and-after outcome measures using linked electronic health records and Medicare claims data from 2012 to 2019. There were 489 patients in the historic case management program, with 1,550 matched comparison patients, and 830 patients in the new program, with 2,368 matched comparison patients. The historic program targeted high-risk patients and assigned a centrally located registered nurse and social worker to each patient. The new program targeted high- and moderate-risk patients and assigned a nurse physically located in a primary care clinic. Primary outcomes were any unplanned hospital events (admissions, observation stays, and emergency department visits), count of event-days, and Medicare payments.

In the historic program, as expected, high-benefit patients enrolled in case management had fewer events, fewer event-days, and an average U.S. $1.15 million reduction in Medicare payments per 100 patients over the subsequent year when compared with the matched comparison patients. For the new program, high-benefit, high-risk patients enrolled in case management had fewer events, while high-benefit, moderate-risk patients enrolled in case management did not differ from matched comparison patients. Although there was evidence that a benefit score could be extended to a new case management program for similar (i.e., high-risk) patients, there was no evidence that it could be extended to a moderate-risk population. Extending a score to a new program and population should include evaluation of program outcomes within key subgroups. With increased attention on value-based care, policymakers and measure developers should consider ways to incorporate impactability modeling into program design and evaluation.

Seriously Ill Individuals—A Canary in the Coal Mine for Medicare’s Transition to Accountable Health Care?

Date: June 9, 2022
Source: JAMA Health Forum
Article

As fundamental changes to payment models for health care are underway, it is important to ensure that vulnerable populations such as the seriously ill and dying are protected. One of the strategic objectives of the Centers for Medicare & Medicaid Services (CMS) Innovation Center is to increase the number of Medicare beneficiaries in a “care relationship with accountability for quality and total cost of care.” Medicare Advantage (MA) is on track to cover care for 69% of Medicare beneficiaries by 2030. In 2018, 48% of Medicare decedents already were in MA or an ACO, and 7.9% (161,158) of Medicare decedents aged 66 years or older were in an MA or ACO program during the year prior to death but lost attribution (ACO) or disenrolled from their MA plan. Ensuring that vulnerable populations such as the seriously ill and dying are protected will require the development and rigorous testing of accountability measures as part of demonstration programs evaluating new models of care. Ultimately, seriously ill persons are the canaries in the coal mine that demand close attention as new Medicare payment models are implemented to ensure person- and family-centered care.

ACO REACH Brings Next Era of Medicare Payment Models

Date: June 9, 2022
Source: American Journal of Accountable Care
Article

The Accountable Care Organization Realizing Equity, Access, and Community Health (ACO REACH) Model provides the next great opportunity in moving health care payment toward paying for value, rewarding preventive care, and keeping patients healthy. According to the authors, the future of accountable care in Medicare was at a crossroads as the Biden administration strongly considered canceling the Global and Professional Direct Contracting (GPDC) Model. Fortunately, cooler heads prevailed, and CMS evolved GPDC to a more traditional ACO model, adding numerous beneficiary protections and creating the first Medicare payment model with serious, tangible health equity requirements. The ACO REACH Model will officially launch next year after a summer-long application process.

With Medicare’s solvency in serious jeopardy, we need more emphasis than ever on growing accountable care models that improve patient care while reducing costs. ACO REACH increases the voice of providers and further ensures patients’ rights while sending a strong signal that advancing toward value-based care is the direction we need to take.

Using a Home Time Measure to Differentiate ACO Performance for Seriously Ill Populations

Date: May 26, 2022
Source: Journal of the American Geriatrics Society
Article

This study examines the feasibility of using a days at home (DAH) measure to evaluate the performance of ACOs in caring for seriously ill populations. Researchers calculated DAH for Medicare fee-for-service beneficiaries aged 68 and older who were retrospectively attributed to a Medicare ACO between 2014 and 2018 and met the seriously ill criteria. They then aggregated to the ACO level DAH for each ACO’s seriously ill beneficiaries and risk-adjusted this aggregated measure. Finally, researchers evaluated associations between risk-adjusted DAH per person-year and ACO, beneficiary, and market characteristics.

ACOs’ seriously ill beneficiaries spent an average of 349.3 risk-adjusted DAH per person-year. Risk-adjusted ACO variation, defined as the interquartile range, was 4.21 days (IQR = 347.32–351.53). Beneficiaries of ACOs opting for two-sided risk models and operating in markets with fewer hospital and skilled nursing facility beds had more DAH. Substantial variation across ACOs in the DAH measure for seriously ill beneficiaries suggests the measure can differentiate between high and low performing provider groups. Key to the success of the metric is accurate risk adjustment to ensure providers have adequate resources to care for seriously ill beneficiaries. Organizational factors, such as the ACO size and level of risk, are strongly associated with more days at home.

Integrated Care Planning for Medicaid Members with Complex Needs: Lessons from MassHealth

Date: May 2022
Source: Center for Health Care Strategies
Article

This brief outlines lessons from the MassHealth Care Planning Learning Collaborative where Massachusetts ACOs and community partners integrated care planning across their organizations to improve care for Medicaid members with complex needs. Integrated and cross-organizational care teams—including care coordinators, care managers, community health workers, nurses, nurse practitioners, physicians, physician assistants, and social workers—offer a valuable solution to provide high-quality care for people with complex health and social needs. Successful integrated care planning places the individual at the center of the care, ensuring that their experience is coordinated among multiple providers and health systems. To achieve this goal, it is important to build relationships, establish clear communication channels, and clarify shared care planning processes. While focused on the MassHealth context, the solutions outlined in this brief can inform providers, payers, and community partners in any setting seeking to enhance services for patients.

Characteristics of Home-Based Care Provided by Accountable Care Organizations

Date: May 12, 2022
Source: American Journal of Managed Care
Article

Study Design: Cross-sectional analysis of 2019 ACO survey.

This study examined the characteristics of ACO home-based care programs serving high-need, high-cost patients. Researchers linked 2019 survey results from 151 ACOs to publicly available information about ACO characteristics, governance, and risk model participation. Twenty-five percent of respondent ACOs had formal home-based care programs, 25% offered occasional home visits, and 17% were actively developing new programs. Home-based primary care was the most common program type. Half of programs were established within the past 3 years. The programs utilized multidisciplinary care teams, but two-thirds had fewer than 500 visits annually. Funding sources included direct billing for services, health system subsidies, and ACO shared savings. A majority of respondents expressed interest in expanding services but were concerned about demonstrating a return on investment, which was reported as a major or moderate challenge by three-quarters of respondents. ACOs deliver a diverse array of home-visit services including primary care, acute medical care, palliative care, care transitions, and interventions to address social determinants of health. Many services provided are not billable, and therefore ACO leaders are hesitant to fund expansions without strong evidence of ROI. Expanding Medicare ACO home-visit waivers to all risk-bearing ACOs and covering integrated telehealth services would improve the financial viability of these programs.

Advancing Equity for The Dually Eligible Population In Alternative Payment Models

Date: May 9, 2022
Source: Health Affairs Forefront
Article

The nearly one in five Medicare beneficiaries dually enrolled in Medicaid (duals) are a medically and socially vulnerable patient population who experience inequitable access to care and marked health outcome disparities. Duals are 5 times more likely to have a disability and 2.6 times more likely to be of minority race or ethnicity than their non-dual counterparts. They have markedly worse health outcomes, being twice as likely to be hospitalized or die after adjusting for comorbidities, than nondual beneficiaries. There is strong evidence that, compared to non-duals, duals have less access to high-quality care, including some of the most innovative ACO models.

Duals are also less likely to access needed specialty care than other Medicare beneficiaries. Furthermore, the standard risk adjustment and payment model used by Medicare to pay ACOs and Medicare Advantage plans, as well as to adjust clinician performance measures in the Merit-Based Incentive Payment System, systematically underpredicts dual enrollees’ annual Medicare costs by as much as 35 percent, effectively institutionalizing underpayment of providers and plans caring for this population. In this article, the authors argue that CMS should take action within its quality measurement and incentive programs to remedy such inequities by updating current incentive structures within Medicare that disincentivize care of duals and to instead reward clinicians and health systems for providing high-quality care to this population.

Medicare Accountable Care Organization Characteristics Associated with Participation in 2-Sided Risk

Date: May 7, 2022
Source: Journal of Rural Health
Article

This study examines the association of ACO characteristics, including size, rurality of the service area, affiliation with supporting organizations, program experience, and performance, with the likelihood of participation in 2-sided risk tracks in the Medicare Shared Savings Program (SSP) between 2012 and 2020. 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, indicating small and rural ACOs are less prepared to transition into 2-sided risk swiftly.

Improving Care Coordination and Reducing ED Utilization Through Patient Navigation

Date: May 6, 2022
Source: American Journal of Managed Care
Article

This study examined the impact of an emergency department (ED) patient navigation program for patients in a Medicaid ACO across three hospitals in a large health system. The navigator program engages community health workers to promote primary care engagement, facilitate care coordination, and identify and address patients’ health-related social needs. Researchers conducted a retrospective analysis of health care utilization and costs in the 30 days following the index ED visit. Patients with ED visits who received navigation were matched to comparable patients with ED visits without an ED navigator interaction. Outcomes were analyzed using fixed effects logistic regression models adjusted for patient demographics, ED visit characteristics, and preceding utilization. In the sample, there were 1,117 ED visits by patients meeting inclusion criteria with an ED navigator interaction, with 3,351 matched controls. ED navigation was associated with 52% greater odds of a completed follow-up primary care appointment. In patients with no ED visits in the preceding 6 months, ED navigation was associated with 32% decreased odds of repeat ED visits in the subsequent 30 days. There was no statistically significant impact on return ED visits in those with higher baseline ED utilization. The program demonstrates that high-intensity, short-term patient navigation in the ED can help reduce ED visits in those with low baseline ED utilization and facilitate stronger connections with primary care.

End-of-Life Values and Value-Based Care

Date: May 2, 2022
Source: American Journal of Managed Care
Article

To identify patients who might benefit the most from advance care planning (ACP), Aledade and Curia.ai—a health care-focused artificial intelligence company—used medical claims data to codevelop a machine learning algorithm that could identify patients at highest risk of mortality within the next 12 months. Aledade then engaged Iris Healthcare, a national provider of ACP solutions, to implement a comprehensive ACP program for these high-risk patients. Patients at high risk of mortality were divided into a treatment group that would receive comprehensive ACP and a control group that received treatment as usual. Physicians were given the choice to opt any patient out of receiving the intervention. Common reasons for physicians removing patients from the intervention group included that the patient had advanced dementia, was no longer under their care, or was already enrolled in hospice. The period of evaluation ran from 2018 through 2021. Curia.ai’s mortality algorithm targeted patients who were enrolled from 2019 onward, so the results focus on this cohort.

Forty-five primary care practices across 14 states participated, with a total of 335 patients receiving the service. According to a survey, 92% of responding physicians reported that they considered it a beneficial service, and 58% reported that it reduced their own workload. Surveyed patients reported a Net Promoter Score of +92 (the Net Promoter Score is a commonly used measure of customer satisfaction, with scores ranging from –100 through +100). Overall, the treatment led to a $994 per-member, per-month lower cost compared with the control group. With a mean time receiving the service of 14 months, this meant a total of $13,916 in reduced costs per patient. Much of the savings occurred at the highest range, indicating that the service may be best at reducing costs for patients at risk for the highest costs. At the ACO level, accounting for a financial stop-loss built into the Medicare Shared Savings Program, savings were $292 per patient per month for a mean of 14 months, for a total savings of $4,088 per patient.

The Complex Intersection of Race and Rurality: The Detrimental Effects of Race-Neutral Rural Health Policies

Date: April 28, 2022
Source: Health Equity
Article

In this commentary, the authors discuss their experiences as women of different races growing up in the same rural area and how these experiences relate to health and health policy. The authors urge greater consideration of place-intentional and race-intentional rural health policies. Despite nearly 5 million Black people living in nonmetro areas, rural Black Americans face erasure in the rural narrative—a detriment to the overall uplifting of rural communities and elimination of the compounded disparities of being rural and Black. Place-neutral health policies fail to consider their differential impact on rural versus urban areas, despite knowing the multitude of ways in which these areas differ. One example of this type of policy is ACOs, which are managed-care models aimed at improving health and continuity of care among Medicare patients while reducing overall health care costs. Rural residents generally have worse health, higher rates of poverty, and more barriers to care than urban residents, which suggests they could greatly benefit from ACOs. However, it is especially challenging for rural health care providers to transform into ACOs due to the significant financial and infrastructure investments necessary to make the transformation. This policy fails to consider the differences between rural and urban areas, which diminishes its value at improving rural health despite there being an increased need in rural areas.

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

Date: April 15, 2022
Source: JAMA Health Forum
Article

The study found that ACOs with higher percentages of members of racial and ethnic minority groups also tended to have higher percentages of out-of-network primary care. That meant the patient’s routine care was delivered by a provider with no connection to the ACO, and therefore no potential financial benefit if they hit the quality benchmarks. The study used data from nearly 4 million Medicare beneficiaries whose providers belonged to 538 ACOs in the MSSP. The percentage of patients receiving primary care outside the ACO was nearly 13% in the ACOs that had the highest percentage of participants from racial or ethnic minorities, compared with about 10% of patients in the other ACOs. But even when the researchers left out the ACOs that had the highest percentage of out-of-network primary care, they still saw differences in quality of care. Older adults in ACOs with the highest percentages of minority participants were less likely to get diabetes and cholesterol checks, and those who had been hospitalized were more likely to end up back in the hospital within a month. On the other hand, in the ACOs that had the lowest percentage of patients who got their primary care out of the ACO network, there were no differences in quality performance between ACOs with different percentages of members from minority groups. The findings suggest that efforts by ACOs to encourage use of in-network primary care may reduce health care disparities among racial and ethnic minority patients.

Market and Organizational Factors Associated with Hospital Leadership of Accountable Care Organizations

Date: April 11, 2022
Source: Hospital Topics
Article

This study examined the organizational characteristics and environmental factors that are associated with hospitals that are leading an ACO. Using data from the American Hospital Association Annual Survey of Hospitals for 2018, the Area Health Resources Files, and the Medicare Cost Reports, researchers found that nearly one-third of the hospitals studied were leading an ACO. System affiliated and not-for-profit hospitals were more likely to lead an ACO. Hospitals leading an ACO offered more clinical services and had better financial performance. Metropolitan core-based statistical areas and per capita income were significantly positively associated with leading an ACO. However, the proportion of population aged 65 and over and the percentage of Medicare Advantage penetration were significantly negatively associated with leading an ACO. Hospitals vary in leading an ACO, which may provide critical resources for them by creating an infrastructure that enables accountable care, extends their services into population health, and value-based care programs increasingly promoted by public and commercial payers.

Using Social Network Analysis Methods to Identify Networks of Physicians Responsible for the Care of Specific Patient Populations

Date: April 8, 2022
Source: BMC Health Services Research
Article

Based on the Accountable Care in Germany (ACD) project, the study presents a framework for and investigates the feasibility of applying social network analysis (SNA) to routine data to identify networks of ambulatory physicians who can be considered responsible for the care of specific patients. SNA provides a methodology to identify physicians who have patients in common and ensure that they are involved in health care provision. An expert panel consisting of physicians, health services researchers, and data specialists examined the concept of network construction through informed decisions. The procedure was structured by five steps and was applied to routine data from three German states. In total, 510 networks of ambulatory physicians met predefined inclusion criteria. The networks had between 20 and 120 physicians, and 72% included at least 10 different medical specialties. Overall, general practitioners accounted for the largest proportion of physicians in the networks (45%), followed by gynecologists (10%), orthopedists, and ophthalmologists (5%). The specialties were distributed similarly across the majority of networks. The number of patients this study allocated to the networks varied between 95 and 45,268 depending on the number and specialization of physicians per network. The networks were constructed according to the predefined characteristics following the ACD study objectives, e.g., size of and specialization composition in the networks. This study shows that it is feasible to apply SNA to routine data to identify groups of ambulatory physicians who are involved in the treatment of a specific patient population. Whether these doctors are also mainly responsible for care and if their active collaboration can improve the quality of care still needs to be examined.

Engaging Frontline Physicians in Value Improvement: A Qualitative Evaluation of Physician-Directed Reinvestment

Date: April 8, 2022
Source: Journal of Healthcare Leadership
Article

New strategies are needed to combat rising healthcare costs. Physicians, whose decisions directly influence care utilization, are prohibited from receiving direct financial incentives to reduce costs due to legal and ethical barriers. This study evaluated an alternative physician engagement method known as “physician-directed reinvestment,” a value-sharing arrangement where a health system reinvests a portion of savings attributed to physician-led cost reduction initiatives back into professional areas of the physician’s choosing. A qualitative assessment explored one such program July-November 2019 at Stanford Health Care, a large academic medical center. Researchers conducted 32 interviews with program physician participants, physician non-participants, and administrative stakeholders to understand the breadth and depth of physician engagement in the program, adherence to program requirements, and factors influencing program growth. Results indicate limited breadth of engagement with just 14 physician participants in the first-year cohort out of approximately 2,300 faculty. However, these physicians were highly engaged and described how the reinvestment fund structure provided intrinsic (autonomy, purpose, positive relations) and extrinsic (resources, external recognition) motivators. Ongoing challenges included the need to increase physician awareness of healthcare costs to encourage more high-yield project ideas and to clarify which projects rise above one’s job responsibilities to justify acceptance into the program. A directional estimation of the program’s impact on cost based on self-reported time estimates and public salary data suggested a favorable 11-fold return on investment from the health system’s perspective. These results indicate a physician-directed reinvestment program may facilitate frontline physician innovation toward value.

What Comes Next in Prioritizing Equity in Payment? The ACO REACH Model

Date: April 6, 2022
Source: Health Affairs Forefront
Article

The forthcoming ACO Realizing Equity, Access, and Community Health (REACH) model makes several foundational advances required for promoting equity through payment model design. These advances include intentional planning on how participants will improve health equity, collection of data on individual-level social determinants, and use of financial incentives directly tied to equity. The REACH model builds on CMS’ equity-based payment incentive in the End-Stage Renal Disease Treatment Choices Model announced last year, the first time a model has directly financially rewarded equity gap closure. While individual organizations in existing ACO programs may be working on advancing equity in their own settings, ACO REACH is also the first model built on a CMS Innovation Center strategic refresh oriented explicitly around this goal. More broadly, ACO REACH underscores a call to action for health care stakeholders to take several steps as part of a broader framework for addressing equity by going beyond traditional approaches to value-based payment. This article outlines how the REACH model takes several foundational steps needed to prioritize equity in health care payment and describes additional work that still needs to be done.

Accountable Care Organization Reform: Past Challenges and Future Opportunities for Public Health

Date: April 2022
Source: Public Health
Article

This descriptive study analyzed the regulatory landscape governing ACOs in the United States and the effects on ACO participation over time. The authors conclude that ACO participation has been undermined by a shifting regulatory landscape. Under the Trump administration, ACOs had to take on additional risk earlier, contributing to the lowest number of participating ACOs in the program’s history. The Biden administration has the opportunity to remake regulations governing ACO development and support.

What Can Canada Learn From Accountable Care Organizations: A Comparative Policy Analysis

Date: April 1, 2022
Source: International Journal of Integrated Care
Article

ACOs implemented in the United States aim to reduce costs and integrate care by aligning incentives among providers and payers. In this comparative study, researchers performed a narrative literature review to examine how Canadian health systems could support ACO models.

Researchers reviewed empirical studies (published 2011–2020) that evaluated ACO impacts in the U.S. Thematic analysis and critical appraisal were performed to identify factors associated with positive ACO impacts, with researchers identifying that physician-led models, global budgets and financial incentives, and focus on collaborative care may optimize ACO impacts.

The Effect of Network-Level Payment Models on Care Network Performance: A Scoping Review of the Empirical Literature

Date: April 1, 2022
Source: International Journal of Integrated Care
Article

Traditional payment models reward volume rather than value. Moving from reimbursing separate providers to network-level reimbursement is assumed to support structural changes in health care organizations needed to improve patient care. This scoping review evaluated the performance of care networks that have adopted network-level payment models on the following metrics: quality, utilization, spending, and other consequences and scored whether performance increased, decreased, or remained stable due to the payment model. The 76 included studies, most from the U.S., investigated network-level capitation, disease-based bundled payments, pay-for-performance and blended global payments. Studies generally concluded that performance in terms of quality and utilization increased or remained stable. Most payment models were associated with improved spending performance. Overall, the review shows that network-level payment models are moderately successful in improving network performance.

Evaluating A Nonemergency Medical Transportation Benefit For Accountable Care Organization Members

Date: March 2022
Source: Health Affairs
Article

Nonemergency medical transportation benefits, often using smartphone application–based ridesharing services, are increasingly offered as part of population health management programs. However, the impact of these programs on health care use and costs remains understudied. Researchers conducted a mixed-methods evaluation of a nonemergency medical transportation benefit offered to members of a Medicare ACO within a large academic health system, the UNC Health Alliance ACO. Participation in the transportation program was associated with a greater number of per person per year outpatient visits (9.2) and higher outpatient spending ($4,420) than in a comparison group. However, there was no difference in inpatient admissions or emergency department visits, and the program was not cost saving. Qualitative analyses found that participants were highly satisfied with the program, reporting that it eased financial burdens and made them feel safer, more empowered, and better able to take control of their health. The findings suggest that although transportation programs are commonly introduced as ways to contain health care spending, it may be better to think of them as programs to improve health care access for people facing difficult circumstances.

Trends in Health Disparities of Rural Latinos Pre- and Post-Accountable Care Organization Implementation

Date: March 28, 2022
Source: Health and Health Care Inequities, Infectious Diseases and Social Factors
Article

This study compared health disparities of rural Latino older adult patients diagnosed with diabetes to their non-Latino White counterparts. A pre-post design was implemented using Medicare ACO participation by rural health clinics (RHCs) as an intervention and using diabetes-related hospitalizations to measure disparities. Data for a nationwide panel of 2,683 RHCs were analyzed for 2008–2015. In addition, data were analyzed for a subset of 116 RHCs located in Florida, Texas, and California that participated in a Medicare ACO in one or more years of the study period. Two broad findings resulted: First, for both the nationwide panel of RHCs and the three-state sample of “ACO RHCs,” there was a decrease in the mean disparities in diabetes-related hospitalization rates over the eight-year study period. Second, in comparing a three-year period after Medicare ACO implementation in 2012 to a four-year period before the implementation, a statistically significant difference in mean disparities was found for the nationwide panel. There are a number of factors that may contribute to the decrease in diabetes-related hospitalization rates for Latinos in more recent years.

Small Practice Participation and Performance in Medicare Accountable Care Organizations

Date: March 11, 2022
Source: American Journal of Managed Care
Article

Incentives that encourage provider collaboration may ease participation for small practices in alternative payment models (APMs). Researchers conducted a modified difference-in-differences analysis comparing large and small practices before and after the Medicare ACO Shared Savings Program (MSSP) started, between 2010 and 2016. The sample included Medicare fee-for-service beneficiaries with 12 months of Medicare Part A and Part B (unless death) who were attributed to small (≤ 15 providers) and large (> 15 providers) practices participating in ACOs and non-ACOs. The outcome was patient annual spending based on CMS’ total per capita costs. Patients attributed to small practices in ACOs had annual Medicare spending decreases of $269 (95% CI, $213-$325; P < .001) more than patients attributed to large practices in ACOs. Small ACO practices reduced spending more than large practices by $165 for physician services (95% CI, $140-$190; P < .001), $113 for hospital/acute care (95% CI, $65-162; P < .001), and $52 for other services (95% CI, $27-$77; P < .001). Small practices in ACOs spent $253 more on average at baseline than small practices in non-ACOs. ACOs with a higher proportion of small practices were more likely to receive shared savings payments. Historically, small practices struggle in pay-for-performance models, but they appear to achieve success in the ACO model.

Leveraging Accountable Care Organization Infrastructure for Rapid Pandemic Response in Independent Primary Care Practices

Date: March 8, 2022
Source: Healthcare
Article

During the early weeks of the COVID-19 pandemic, Aledade, which in spring 2020 operated 39 MSSP ACOs with 440,000 attributed patients, aimed to leverage existing ACO capabilities to support 467 primary care practices across 27 states with pandemic response. Aledade used Medicare claims and electronic health records to identify patients with increased COVID-19 vulnerability for proactive outreach and guidance for “Staying Well at Home.” Of the 302,125 patients meeting intervention criteria, 45% were reached within the first 6 weeks. Engagement in the initiative was uneven among ACO-participating practices. ACO staff identified prior practice engagement in core ACO workflows as a major facilitator of success and staffing shortages as a major barrier. Small practice size, non-metropolitan location, penetration of value-based payment models in the practice, and pre-pandemic annual wellness visit completion rates were independently associated with successful outreach to COVID-vulnerable patients. Rapid adaptation of ACO infrastructure assisted independent practices across the country to reach vulnerable patients with proactive guidance for staying well at home. The initiative was most successful in smaller, non-metropolitan practices and those with greater engagement in core ACO initiatives pre-pandemic. Our experience suggests that primary care participation in accountable care models can contribute to preparedness for future public health crises.

Policy Solutions to Facilitate the New eCQM ACO Reporting and Advancement of Interoperability

Date: March 3, 2022
Source: American Journal of Accountable Care
Article

This article describes the challenges associated with aggregating and reporting quality data via electronic health records and discusses corresponding policy solutions. How Medicare measures quality is undergoing a seismic shift. Currently, many physician practices and ACOs use the CMS Web Interface to submit requisite quality data. Quality data submitted via the Web Interface are used to assess performance in alternative payment models (APMs), including MSSP ACOs. Starting in 2025, CMS will require APM participants to stop using the Web Interface and instead submit electronic clinical quality measures (eCQMs) at the APM entity level. At a high level, eCQMs are quality measures that are generated and reported via certified electronic health record (EHR) technology. Many APM participants find eCQMs controversial because they include all patients who meet measure criteria, regardless of insurance status. Others argue that the measures themselves are not applicable to all specialties. This article aimed to set aside debates about the appropriateness of the measure selection and specifications and instead focus on the reporting process. In theory, eCQMs are touted as reducing the manual burden associated with sampling and corresponding data abstraction while promoting interoperability goals. In reality, successfully building, aggregating, and reporting eCQM data at the APM entity level is rife with challenges.

Access to Mental Health Support Services in Accountable Care Organizations: A National Survey

Date: March 2022
Source: Healthcare
Article

This study examined whether new payment models such as ACOs facilitate access to mental health support services for patients with serious mental illness. Researchers conducted a national survey of ACOs and found that fewer than 50% of ACOs surveyed reported having the ability to offer or refer patients to supported employment, family psychoeducation, assertive community treatment and illness, management and recovery services. These findings suggest that even among organizations that are early adopters of payment and delivery reforms — those most likely to lead innovations in population health — access to these services is limited.

The Case for Accountable Care Organizations to Partner With Geriatric Emergency Departments

Date: February 17, 2022
Source: Health Affairs Forefront
Article

This article describes geriatric emergency departments and the role they can play in reducing potentially avoidable hospitalizations. Traditionally, health systems that were paid primarily based on fee-for-service may not have seen a business case for a model that could reduce inpatient volume, but in today’s health care landscape of frequently full hospitals and staff shortages, diverting patients who are not critically ill to alternative settings is necessary to make room for patients who require hospital-level care. In addition, geriatric emergency departments should be highly attractive to ACOs, which have financial incentives to manage Medicare spending. The authors argue that there is a great opportunity for ACOs and geriatric emergency departments to work together.

10 Years Accountable Care Organizations in the USA: Impulses for Health Care Reform in Germany?

Date: February 3, 2022
Source: Gesundheitswesen
Article

Ten years after the introduction of ACOs, this paper looks at the impact of ACOs both on quality of care and costs of care to assess if ACOs can be a model of care delivery for Germany.

In a mixed-method approach, a rapid review was conducted in Health System Evidence and PubMed, supported by “snowballing” to identify further papers. After screening the abstracts, researchers included articles containing information on cost and/or quality impact of U.S. Medicare ACOs. The findings of the rapid review were challenged with 16 ACO-experts and stakeholder in the USA. In total, researchers included 60 publications, including 6 reports that were either conducted directly by governmental institutions or ordered by them, along with 3 previous reviews. Among these, 31 contained information on costs of care, 18 contained information on quality of care and 11 had information on both aspects. The publications show that ACOs reduced costs of care. Cost reductions were achieved compared to historic costs, to populations not cared for in ACOs, and counterfactuals. Quality of care stayed the same or improved. ACOs contributed to slowing the cost growth in U.S. Medicare without compromising quality of care. Thus, a transferal of this model of care to Germany should be considered. However, various policies have led to ACOs failing to unleash their full potential. Against this background, and against the background of stark differences between U.S. Medicare and the German health care system, a critical reflection of the necessary policies underlying ACOs-like structures in Germany, needs to be undertaken.

ACO Awareness and Perceptions Among Specialists Versus Primary Care Physicians: A Survey of a Large Medicare Shared Savings Program

Date: February 2022
Source: Journal of General internal Medicine
Article

This study analyzed data from a survey administered in 2018 to clinicians in the Physician Organization of Michigan ACO, which at the time was the largest MSSP ACO in Michigan and among the 10 largest nationally. The analysis focused on non-pediatrician physician respondents (n = 1,022, 34% response rate) practicing in 10 provider organizations. Researchers classified respondents based on whether they were a primary care physician (PCP) or specialist—internal medicine subspecialist, surgeon, or other specialist such as a radiologist or neurologist. Physician respondents included PCPs (23%) and specialists (77%), including internal medicine subspecialists (20%), surgeons (14%), and other specialists (43%). Specialists were less likely to be aware of ACO participation and incentives. Compared to PCPs, specialists were 25 percentage points less likely to know that they were in an ACO (43% vs. 69%). In addition, specialists were 18 percentage points less likely to know that their ACO was accountable for both spending and quality or that their ACO had lowered spending in the previous year. Specialists were also less likely to perceive that joining an ACO had changed how they practiced medicine, their compensation, or whether they received useful performance feedback. Similarly, specialists were less likely to perceive that the ACO had improved patient or professional outcomes, including care coordination, management between visits, medically complex patients’ health, professional satisfaction, finances, staff morale, or administrative burden.

Accountable Care Organizations and Physician Antibiotic Prescribing Behavior

Date: February 2022
Source: Social Science & Medicine
Article

Physician ACO affiliation has been found to reduce cost and improve quality across metrics that are directly measured by the Medicare ACO programs. However, little is known about potential spillover effects from this program onto non-measured physician behavior such as antibiotic prescribing. Researchers compared antibiotic prescribing patterns among physicians in an ACO and a comparison group of physicians unaffiliated with an ACO while adjusting for volume, patient, physician and institutional characteristics. Researchers found that ACO affiliation helped reduce antibiotic prescribing by 20.4 prescriptions (about 19.5%) per year. Researchers also found wide variation by specialty, with internal medicine physicians experiencing an average decrease of 23.6 antibiotic prescriptions, family and general practice physicians a decrease of 22.1, nurse practitioners a decrease of 7.1, general surgeons a decrease of 9.6, and orthopedic surgeons a reduction of 8.1 per year. In assessing the impact of Medicare ACO programs, it is important to account for spillover effects, concluding that ACO affiliation has had a measurable impact on physician antibiotic prescribing.

Organizational Capacity of Hospitals Co-Participating in Accountable Care Organizations and Bundled Payments

Date: January/February 2022
Source: American Journal of Medical Quality
Article

Building organizational capacity is critical for hospitals participating in payment models such as bundled payments and ACOs, particularly “co-participant” hospitals with experience in both models. This study used a national survey of American Hospital Association member hospitals with bundled payment experience, with (co-participant hospitals) or without (bundled payment hospitals) ACO experience. Questions examined capacity in four domains: performance feedback, post-acute care provider utilization, care management, and health information technology. Of 424 hospitals, 38% responded. Both co-participant and bundled payment hospitals reported high capacity for performance feedback and risk stratification and predictive risk assessment using HIT. The hospital groups did not differ in care management capacity, but bundled payment hospitals reported higher post-acute care provider utilization capacity. Experience with multiple payment models may prompt hospitals to make different investments or adopt different strategies than hospitals with experience in a single model.

Collaboration Structures in Integrated Healthcare Delivery Systems: An Exploratory Study of Accountable Care Organizations

Date: January 24, 2022
Source: Manufacturing & Services Operations Management
Article

This study explored the performance implications of collaboration structures in an integrated health care delivery system, namely, an ACO. There is a dearth of empirical studies on how to develop collaboration structures. Studies in the healthcare operations management primarily have focused on collaboration within a single organization, shedding little light on this problem. The study addressed this issue by exploring two distinct dimensions of collaboration: partnership scope and scale. Partnership scope measures the presence of providers from the preacute, acute, and/or postacute care-continuum stages, while partnership scale measures the presence of providers within a single care-continuum stage. Assembling a unique data set of provider types, collaboration structures, and system-level performance for 528 ACOs from 2013–2016, researchers examined the impact of partnership scope and scale on ACO performance as measured by experiential quality and 30-day readmission rates. As additional tests, researchers investigated their research questions by assembling data sets at both the hospital level (20,975 hospital-year panel data spanning 2009 to 2015) and patient level (859,145 Medicare patients admitted to 39 California hospitals over a four-year period from 2012 to 2015). The study found that synergies exist between partnership scope and scale with respect to ACO performance. Specifically, an average-sized ACO can realize 3.2% more improvement in experiential quality and a 6.6% greater reduction in 30-day readmission rates through partnership scope and scale synergies in the preacute care stage. The study also found that the benefits of increasing partnership scope are consistent across providers and patient-level analysis. Further, researchers found that these benefits come at some cost, suggesting an initial cost-quality trade-off when developing collaboration structures. The findings offer important insights into designing effective health care delivery systems extending beyond a single organization.

The Case for ACOs: Why Payment Reform Remains Necessary

Date: January 24, 2022
Source: Health Affairs Forefront
Article

This article lays out the critical role that ACOs can play as CMS expands population-based payment models. The evolution of population-based payment models has spawned recent controversy, with some calling for a halt to ACO programs. For this reason, it is worth stepping back and reviewing the original motivation for these models and their merits (and challenges). It is important to recognize that any policy option must be viewed relative to an alternative, in this case, the traditional Medicare fee for service (FFS) payment system.

Use of Electronic Health Record Systems in Accountable Care Organizations

Date: January 2022
Source: American Journal of Managed Care
Article

This study examined the ability of MSSP ACOs to use electronic health record (EHR) data for quality reporting. Using a national survey of MSSP ACOs, researchers asked about the number of EHR systems used across all providers in the ACO and barriers to reporting EHR-based quality measures. Just 9% of ACOs used a single EHR system, while 77% used six or more EHR systems. The more EHR systems an ACO used, the less likely it was to report having the infrastructure to aggregate EHR data and the more concerned it was about the short-term viability and accuracy of EHR-based quality measures. Among the 37% of ACOs with 16 or more EHR systems, concerns about EHR-based quality measures included access to data, standardization of data elements, and cost of integrating across systems. ACOs have diverse structures that often result in use of multiple EHR systems. This has the potential to cause serious delays when CMS begins requiring ACOs to report their quality measures through their EHRs in 2022.

ACO Investment Model Produced Savings, But the Majority of Participants Exited When Faced With Downside Risk

Date: January 2022
Source: Health Affairs
Article

This study examined the performance of 41 small, rural ACOs that received up-front funding to invest in care delivery improvements through Medicare’s ACO Investment Model (AIM). Researchers estimated that the model saved a net $381.5 million over three years, primarily by reducing utilization of inpatient and other institutional care. 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 MSSP when faced with the requirement to assume downside financial risk, starting in year four of participation. As CMS builds on AIM and rural hospital global payment models, the 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.

Achieving Large-Scale Quality Improvement in Primary Care Annual Wellness Visits and Hierarchical Condition Coding

Date: January 19, 2022
Source: Journal of General Internal Medicine
Article

Completion of Medicare annual wellness visits (AWV) and documentation of hierarchical condition categories (HCC) are important metrics in ACOs with quality and financial implications. To improve performance in large health care organizations, quality improvement (QI) efforts need to be scaled up in a way that is feasible within available system-wide resources.

The study describes a a 3-year effort using a multifaceted QI framework called the fractal management system for AWV and HCC performance. Researchers conducted a pre-post evaluation of a multi-level, health system-wide QI management system intervention between 2018 and 2020. The system provided project management, coaching, communications, performance feedback, and health informatics. The intervention was delivered to all 97 primary care practices within an Ohio-based ACO, comprising 72,603 attributed Medicare and Medicare Advantage patients as of 2018. Eighty-nine of these practices were included in the analysis.

AWV completion was defined as percent of eligible patients with a documented AWV during the calendar year. HCC completion was defined as documented reassessment of all prior-year HCC conditions. The study found that AWV completion at the practice level increased from 23.7% (SD .14) in 2018 to 34.9% (SD .18) in 2019, and 59.8% (SD .17) in 2020. More than half (56.2%) of practices met or exceeded the 60% goal in 2020. Practice-level HCC completion tracking started in 2019 (M = 75.9%, SD 7.4%) and increased in 2020 (M = 79.7%, SD 7.1%); t(172) = 2.0, p < .001.

Growth in Health Information Exchange with ACO Market Penetration

Date: January 17, 2022
Source: American Journal of Managed Care
Article

This study assessed whether hospitals expand the network breadth of their health information exchange (HIE) partners after joining an ACO and whether HIE network expansion varies across markets with differing levels of ACO penetration. Using a difference-in-differences analyses of U.S. nonfederal acute care hospitals in 2014-2017, researchers measured hospital ACO participation, HIE network breadth (defined as number of different partner types), and ACO market penetration at the hospital referral region level. In combined analyses, HIE breadth increased by 0.35 partner types with ACO participation, a 30.7% increase (P < .001). In stratified analyses, this effect was larger for hospitals in high-ACO penetration markets (0.41 partner types, a 32.0% increase; P < .001) and smaller for hospitals in low-ACO penetration markets (0.25 partner types, a 24.8% increase; P < .05). Hospitals that joined ACOs increased their HIE breadth, but this effect varied across markets and across time. The findings illustrate a “network effect,” with large, immediate effects in HIE breadth following ACO participation in high-ACO penetration markets and smaller, delayed effects in low-ACO penetration markets.

ACO Spending and Utilization Among Medicare Patients at the End of Life: An Observational Study

Date: January 12, 2022
Source: Journal of General Internal Medicine
Article

End-of-life (EOL) costs constitute a substantial portion of U.S. health care spending and have been increasing. ACOs may offer an opportunity to improve quality and curtail EOL spending.

This study examined whether practices that became ACOs altered spending and utilization at the EOL through a retrospective analysis of Medicare claims. Researchers assigned patients who died in 2012 and 2015 to an ACO or non-ACO practice. Practices that converted to ACOs in 2013 or 2014 were matched to non-ACOs in the same region. A total of 23,643 ACO patients were matched to 23,643 non-ACO patients. Using a difference-in-differences model, researchers examined changes in EOL spending and care utilization after ACO implementation. The study found that the introduction of ACOs did not significantly impact overall spending for patients in the last 6 months of life (difference-in-difference (DID) = $192, 95%CI –$841 to $1125, P = 0.72). Changes in spending did not differ between ACO and non-ACO patients across spending categories (inpatient, outpatient, physician services, skilled nursing, home health, hospice). No differences were seen between ACO and non-ACO patients in rates of ED visits, inpatient admissions, ICU admission, mean healthy days at home, and mean hospice days at 180 and 30 days prior to death. However, non-ACO patients had a significantly greater increase in hospice utilization compared to ACO patients at 180 days (DID P-value = 0.02) and 30 days (DID P-value = 0.01) prior to death. With the exception of hospice care utilization, spending and utilization were not different between ACOs and non-ACO patients at the EOL. Longer follow-up may be necessary to evaluate the impact of ACOs on EOL spending and care.

Use of Preventive Care Services and Hospitalization Among Medicare Beneficiaries in Accountable Care Organizations That Exited the Shared Savings Program

Date: January 7, 2022
Source: JAMA Health Forum
Article

This study examined how the exit of an ACO from the MSSP relates to clinical quality delivered to beneficiaries and whether the association changes over time after ACO exit. Researchers found that among more than 1.7 million Medicare beneficiaries, ACO MSSP exit was associated with lower rates of preventive service use. For example, exiting the MSSP was associated with statistically significantly lower rates of annual glycated hemoglobin A1c testing, low-density lipoprotein cholesterol testing, and all diabetes complication screening for beneficiaries with diabetes. ACO exit was not associated with rates of hospital utilization in terms of emergency department visits and 30-day readmission. The associations with ACO exit depended on the length of time since contracts ended. For example, the baseline rate of annual glycated hemoglobin A1c testing was 89.8% but fell to 86.9% and 86.8% in years 1 and 2 after exit, respectively, but then rose to 91.9% in year 3.

Why Not Home?: A Study of the Impact of an Effort to Reduce Postacute Expenditures

Date: January 1, 2022
Source: Professional Case Management
Article

This study examined evidence-based interventions for an ACO-attributed Medicare population designed to improve transitions of care to the least restrictive next site of care on the rate of skilled nursing facility (SNF) admissions per 1,000 patients, SNF length of stay (LOS), and total SNF cost. Using Medicare Shared Savings Plan Part A and Part B beneficiary claims data, researchers analyzed claims data for dates of service 12 months pre- and postintervention for patients admitted to any hospital within the integrated health care system. The analyses suggest that providing education to interprofessional team members that reinforces the tenets of value-based care and the importance of asking “why not home?” for every hospitalized patient and leveraging technology-based insights positively impact discharge rates to SNF and other ACO outcomes. The study found that the rate of SNF discharges changed from 73 per 1,000 patients in the preintervention period to 70 per 1,000 patients in the postintervention period. The total SNF cost in the postintervention period only increased by 3%, with a difference of $616,014, despite the 10% increase in the total ACO-attributed patient population during the same period. The results indicate that a multifaceted intervention designed to shift the transitional care planning paradigm toward discharging to the least restrictive next site of care is an effective strategy for ACOs trying to reduce lost-acute care utilization and spending.

ACO and Social Service Organization Partnerships: Payment, Challenges, and Perspectives

Date: January 1, 2022
Source: NEJM Catalyst
Article

This study examined the Flexible Services Program in Massachusetts, a novel demonstration project of the Delivery System Reform Incentive Payment program under a Medicaid section 1115 waiver. The program allows the state’s Medicaid ACOs to pilot evidence-based initiatives that address a member’s health-related social needs in an effort to improve health outcomes and reduce total costs of care. An examination of payment mechanisms established in the partnerships between the ACOs and the social service organizations, combined with interviews with ACO leaders, identified strengths and outstanding challenges that must be addressed. More attention is needed to vet partnerships and to develop process or outcome measures that demonstrate meaningful impact for patients related to care utilization, equity, experience, and chronic health conditions.

2022 ACO Publications

Implementation of Cancer Screening in Rural Primary Care Practices after Joining an Accountable Care Organisation: A Multiple Case Study

Community-based, Hospital-Affiliated Medical Group Becomes a Successful Accountable Care Organization

Characteristics Associated with Risk-Standardized Acute Admission Rates Among Patients with Heart Failure Enrolled in Accountable Care Organizations

The Impact of Medicare Shared Savings Program Participation on Hospital Financial Performance: An Event-Study Analysis

Using The Medicare Shared Savings Program to Innovate Primary Care Payment

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

Evaluating the Accuracy of Medicare Risk Adjustment For Alzheimer’s Disease And Related Dementias

Medicaid ACOs and Managed Care: A Tale of 2 States

Aligning Specialist Physicians with Accountable Care Organizations

Intensive Care Management of a Complex Medicaid Population: A Randomized Evaluation

Post-Acute Care Use Associated with Medicare Shared Savings Program and Disparities

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

To What Extent Are ACO and PCMH Models Advancing the Triple Aim Objective? Implications and Considerations for Primary Care Medical Practices

ACO Participation Associated with Decreased Spending For Medicare Beneficiaries With Serious Mental Illness

Evaluation of Spending Differences Between Beneficiaries in Medicare Advantage and the Medicare Shared Savings Program

Care Coordination for Healthcare Referrals under a Shared-Savings Program

Changes in Spending, Utilization, and Quality of Care among Medicare Accountable Care Organizations During the COVID-19 Pandemic

Innovations in Care Delivery for Patients With Serious Mental Illness Among Accountable Care Organizations

ACO Participation Associated with Decreased Spending for Medicare Beneficiaries with Serious Mental Illness

The Medicare Value-Based Care Strategy: Alignment, Growth, And Equity

An Option for Medicare ACOs to Further Transform Care

“REACHing” for Equity — Moving from Regressive toward Progressive Value-Based Payment

Primary Care Physicians’ Participation in the Medicare Shared Savings Program and Preventive Services delivery: Evidence from the First 7 Years

ACO Participation Associated with Decreased Spending for Medicare Beneficiaries with Serious Mental Illness

The Medicare Value-Based Care Strategy: Alignment, Growth, And Equity

ACO Participation Associated with Decreased Spending for Medicare Beneficiaries with Serious Mental Illness

The Medicare Value-Based Care Strategy: Alignment, Growth, And Equity

An Option for Medicare ACOs to Further Transform Care

“REACHing” for Equity — Moving from Regressive toward Progressive Value-Based Payment

Primary Care Physicians’ Participation in the Medicare Shared Savings Program and Preventive Services delivery: Evidence from the First 7 Years

Medicare’s Specialty-Oriented Accountable Care Organization: First-Year Results For People With End-Stage Renal Disease

Identifying Drivers of Health Care Value: A Scoping Review of the Literature

Can Alternative Payment Models and Value-Based Insurance Design Alter the Course of Diabetes in the United States?

Using a Mixed-Effect Model with a Parameter-Space of Heterogenous Dimension to Evaluate Whether Accountable Care Organizations Are Associated with Greater Uniformity Across Constituent Practices

Medicare Accountable Care Organizations: Post-Acute Care Use and Post-Surgical Outcomes in Urologic Cancer Surgery

Participation in Delivery System Reform Programs and U.S. Acute Care Hospital Integration into Behavioral Health

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

Impactability Modeling for Reducing Medicare Accountable Care Organization Payments and Hospital Events in High-Need High-Cost Patients: Longitudinal Cohort Study

Seriously Ill Individuals—A Canary in the Coal Mine for Medicare’s Transition to Accountable Health Care?

ACO REACH Brings Next Era of Medicare Payment Models

Using a Home Time Measure to Differentiate ACO Performance for Seriously Ill Populations

Integrated Care Planning for Medicaid Members with Complex Needs: Lessons from MassHealth

Characteristics of Home-Based Care Provided by Accountable Care Organizations

Advancing Equity for The Dually Eligible Population In Alternative Payment Models

Medicare Accountable Care Organization Characteristics Associated with Participation in 2-Sided Risk

Improving Care Coordination and Reducing ED Utilization Through Patient Navigation

End-of-Life Values and Value-Based Care

The Complex Intersection of Race and Rurality: The Detrimental Effects of Race-Neutral Rural Health Policies

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

Market and Organizational Factors Associated with Hospital Leadership of Accountable Care Organizations

Using Social Network Analysis Methods to Identify Networks of Physicians Responsible for the Care of Specific Patient Populations

Engaging Frontline Physicians in Value Improvement: A Qualitative Evaluation of Physician-Directed Reinvestment

What Comes Next in Prioritizing Equity in Payment? The ACO REACH Model

Accountable Care Organization Reform: Past Challenges and Future Opportunities for Public Health

What Can Canada Learn From Accountable Care Organizations: A Comparative Policy Analysis

The Effect of Network-Level Payment Models on Care Network Performance: A Scoping Review of the Empirical Literature

Evaluating A Nonemergency Medical Transportation Benefit For Accountable Care Organization Members

Trends in Health Disparities of Rural Latinos Pre- and Post-Accountable Care Organization Implementation

Small Practice Participation and Performance in Medicare Accountable Care Organizations

Leveraging Accountable Care Organization Infrastructure for Rapid Pandemic Response in Independent Primary Care Practices

Policy Solutions to Facilitate the New eCQM ACO Reporting and Advancement of Interoperability

Access to Mental Health Support Services in Accountable Care Organizations: A National Survey

The Case for Accountable Care Organizations to Partner With Geriatric Emergency Departments

10 Years Accountable Care Organizations in the USA: Impulses for Health Care Reform in Germany?

ACO Awareness and Perceptions Among Specialists Versus Primary Care Physicians: A Survey of a Large Medicare Shared Savings Program

Accountable Care Organizations and Physician Antibiotic Prescribing Behavior

Organizational Capacity of Hospitals Co-Participating in Accountable Care Organizations and Bundled Payments

Collaboration Structures in Integrated Healthcare Delivery Systems: An Exploratory Study of Accountable Care Organizations

The Case for ACOs: Why Payment Reform Remains Necessary

Use of Electronic Health Record Systems in Accountable Care Organizations

ACO Investment Model Produced Savings, But the Majority of Participants Exited When Faced With Downside Risk

Achieving Large-Scale Quality Improvement in Primary Care Annual Wellness Visits and Hierarchical Condition Coding

Growth in Health Information Exchange with ACO Market Penetration

ACO Spending and Utilization Among Medicare Patients at the End of Life: An Observational Study

Use of Preventive Care Services and Hospitalization Among Medicare Beneficiaries in Accountable Care Organizations That Exited the Shared Savings Program

Why Not Home?: A Study of the Impact of an Effort to Reduce Postacute Expenditures

ACO and Social Service Organization Partnerships: Payment, Challenges, and Perspectives

NAACOS

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