2024 ACO Publications

The Effect of Next Generation Accountable Care Organizations on Medicare Expenditures

Date: July 2024
Source: Health Affairs
Article

The Next Generation Accountable Care Organization (NGACO) model (active during 2016-21) tested the effects of high financial risk, payment mechanisms, and flexible care delivery on health care spending and value for fee-for-service Medicare beneficiaries. Researchers used quasi-experimental methods to examine the model’s effects on Medicare Parts A and B spending. Sixty-two ACOs with more than 4.2 million beneficiaries and more than 91,000 practitioners participated in the model. The model was associated with a $270 per beneficiary per year, or approximately $1.7 billion, decline in Medicare spending. After shared savings payments to ACOs were included, the model increased net Medicare spending by $56 per beneficiary per year, or $96.7 million. Annual declines in spending for the model grew over time, reflecting exit by poorer-performing NGACOs, improvement among the remaining NGACOs, and the COVID-19 pandemic. Larger declines in spending occurred among physician practice ACOs and ACOs that elected population-based payments and risk caps greater than 5 percent.

The Road to Value Can’t Be Paved with a Broken Medicare Physician Fee Schedule

Date: July 2024
Source: Health Affairs
Article

Value-based payment has been promoted for increasing quality, controlling spending, and improving patient and practitioner experience. Meanwhile, needed reforms to fee-for-service payment (the Medicare Physician Fee Schedule) have been ignored as policy makers seek to move payment toward alternatives, even though the fee schedule is an intrinsic part of alternative payment models (APMs). This article discusses how value-based payment and the fee schedule should be viewed as complementary, rather than as separate silos. The authors trace the origins of embedded flaws in the fee schedule that must be fixed if value-based payment is to succeed. These include payment distortions that directly compromise value by overpaying for certain procedures and imaging services while underpaying for services that add value for beneficiaries. The article also shows how the fee schedule can accommodate bundled payments and population-based payments that are central to APMs. The authors draw two conclusions. First, CMS should correct misvalued services and establish a hybrid payment for primary care that blends fee-for-service and population-based payment. Second, Congress should alter the 35-year-old statutory basis for setting Medicare fees to allow CMS to explicitly consider policy priorities such as workforce shortages in refining fee levels.

Medicare Payments and ACOs for Dementia Patients Across Race and Social Vulnerability

Date: July 2024
Source: The American Journal of Geriatric Psychiatry
Article

This study investigated variations in Medicare expenditures for Alzheimer’s disease and related dementia (ADRD) by race, ethnicity, and neighborhood social vulnerability, together with cost variation by beneficiaries’ enrollment in MSSP ACOs. The study analyzed Medicare payments for patients newly diagnosed with ADRD for the year preceding the diagnosis and for the subsequent three years. The dataset included 742,175 Medicare fee-for-service (FFS) beneficiaries aged 65 and older with a new diagnosis of ADRD in 2017 who remained in Medicare FFS from 2016 to 2020. Among those newly diagnosed, Black and Hispanic patients encountered the higher total costs, compared to White patients, and ADRD patients living in the most vulnerable areas experienced the highest total costs compared to patients living in other regions. These cost differences persisted over three years post-diagnosis. Patients enrolled in ACOs incurred lower costs across all racial and ethnic groups and SVI areas. For ADRD patients living in the areas with the highest vulnerability, the cost differences by ACO enrollment of the total Medicare costs ranged from $4,403.1 to $6,922.7 and beneficiaries’ savings ranged from $114.5 to $726.6 over a three-year period post-ADRD diagnosis by patient’s race and ethnicity.

The COVID-19 Pandemic Led to a Large Decline in Physician Gross Revenue Across All Specialties In 2020

Date: July 2024
Source: Health Affairs
Article

This study examined how revenue during the Covid pandemic in 2020–22 varied by physician specialty and practice setting. Researchers linked medical claims from a large national federation of commercial health plans to physician and practice data to estimate pandemic-associated impacts on physician revenue (defined as payments to eligible physicians) by specialty and practice characteristics. Surgical specialties, emergency medicine, and medical subspecialties each experienced a greater than 9 percent adjusted gross revenue decline in 2020 relative to pre-pandemic baselines. By 2022, pathology and psychiatry revenue experienced robust recovery, whereas surgical and oncology revenue remained at or below baseline.  Physicians practicing in larger and hospital-owned practices and practices participating in ACOs had greater revenue recovery than smaller and independent practices and those not participating in ACOs. This may imply that existing referral mechanisms were disrupted in practices that did not participate in ACOs during the pandemic, and ACO participation may have allowed practices to weather challenges to finances and referral networks. This finding may encourage physicians, in both primary care and specialty care, to participate in ACOs compared with fee-for-service reimbursement.

Value-Based Proposition of an Adapted Integrated Care Telehealth Service for Accountable Care Organization Members

Date: July 2024
Source: Psychiatric Services
Article

The article describes a real-world application of virtually integrated primary and behavioral health care implemented within an ACO system. Cost-of-care data from before and after a 6-month intervention were analyzed for 121 Medicaid and Child Health Plan Plus ACO members. The intervention was associated with a significant shift in the distribution of health care costs, from inpatient and emergency care to outpatient and preventive care. The program demonstrates a flexible and replicable approach to integration that can help expand effective primary care.

Advancing Health Equity Through Value-Based Care: CMS Innovation Center Update

Date: June 4, 2024
Source: Health Affairs Forefront
Article

Since 2021, the CMS Center for Medicare and Medicaid Innovation (Innovation Center) has been guided by a renewed vision to build “a health system that achieves equitable outcomes through high-quality, affordable, and person-centered care.” Health equity is one of the five strategic objectives that guide this vision. Models, or pilot programs, that have been designed since the release of the 2021 strategy incorporate requirements for sociodemographic data collection and reporting, development of health equity plans, and screening and referral for health-related social needs (HRSNs). This article provides an update on progress since last year and lays out new work in 2024 in three areas: safety-net provider participation in models to improve care for more beneficiaries, data collection that supports whole-person care, and payment innovations to narrow disparities.

Oral Health Screening by MassHealth Accountable Care Organizations: An Opportunity for Equity-Focused Interventions

Date: June 2024
Source: Journal of Dental Hygiene
Article

Establishing reliable access to dental services for publicly insured patients is an important part of achieving equitable oral health care. In 2023, an oral health screening requirement was added to the MassHealth ACO contract. The goal of the oral health screening requirement is to identify MassHealth-insured patients who do not have reliable access to dental services and to provide them with resources to establish a dental home with a MassHealth-participating dentist. This article describes the oral health screening program at one MassHealth ACO and presents some of the data collected during the first year of implementation, in addition to discussing how these data are being used to guide equity-focused interventions with the potential for policy implications.

Accountable Care Organizations and Specialists: Opportunities for Neurologists 

Date: February 2024
Source:  Neurology: Clinical Practice
Article

More than 700,000 physicians and advanced practice clinicians participate in Medicare ACOs, which are responsible for the cost and quality of care for more than 13 million beneficiaries. Nearly 40 percent of neurologists who treat Medicare patients are already in an ACO. CMS is now implementing a strategy for value-based specialty care that promotes active ACO management of specialty services. Some ACOs are starting to direct referrals to preferred specialist networks. Neurologists can benefit from engaging with ACOs through enhanced patient data, an emphasis on team-based care, care coordination support for their patients, and financial rewards for performance. Neurologists can help ACOs as the population ages, including by helping ensure appropriate use of expensive new therapies for neurologic conditions. 

Primary Care-Based Housing Program Reduced Outpatient Visits; Patients Reported Mental and Physical Health Benefits 

Date: February 2024
Source:  Health Affairs
Article

Screening for housing instability has increased as health systems move toward value-based care, but evidence on how health care-based housing interventions affect patient outcomes comes mostly from interventions that address homelessness. In this mixed-methods evaluation of a primary care–based housing program in Boston, Massachusetts, for 1,139 patients enrolled in a Medicaid ACO with housing-related needs that extended beyond homelessness, researchers found associations between program participation and health care use. Patients enrolled in the program between October 2018 and March 2021 had 2.5 fewer primary care visits and 3.6 fewer outpatient visits per year compared with those who were not enrolled, including fewer social work, behavioral health, psychiatry, and urgent care visits. Patients in the program who obtained new housing reported mental and physical health benefits, and some expressed having stronger connections to their health care providers. Many patients attributed improvements in mental health to compassionate support provided by the program’s housing advocates. Health care-based housing interventions should address the needs of patients facing imminent housing crises. Such interventions hold promise for redressing health inequities and restoring dignity to the connections between historically marginalized patient populations and health care institutions. 

Building for Value: A Foundational Structure to Support Population Health 

Date: February 6, 2024
Source:  Population Health Management
Article

The journey to value relies heavily on a strong foundation in population health and on supporting systems of care. However, as CMS and commercial insurers rethink reimbursements to achieve cost savings, both patients and payments to health care organizations are at risk. The case for value-based care is ever stronger yet health systems will have to mature their culture, population health infrastructure, technologies and analytics capabilities, and leadership and management systems. In this article, the authors describe the functional organizational structure of the clinical transformation team responsible for population health in the University Hospitals ACO. Based on their experiences building and evolving population health for the University Hospitals ACO, the authors layout the three pillars supporting their structure, including operations, clinical design, and data and analytics, and key areas of focus for each pillar. 

A Path to Risk: Critical Elements of a Structured Approach 

Date: February 6, 2024
Source:  Population Health Management
Article

Value-based care arrangements have been the cornerstone of accountable care for decades. Risk arrangements with government and commercial insurance plans are ubiquitous, with most contracts focusing on upside risk only, meaning payers reward providers for good performance without punishing them for poor performance on quality and cost. However, payers are increasingly moving into downside risk arrangements, bringing to mind global capitation in the 1990s when several health systems failed. In this article, the authors focus on their framework for succeeding in value-based arrangements at University Hospitals ACO, including essential structural elements that provider organizations need to successfully assume downside risk in value-based arrangements. These elements include quality performance and reporting, risk adjustment, utilization management, care management and clinical services, network integrity, technology, and contracting and financial reconciliation. Each of these elements has an important place in the strategic roadmap to value, even if downside risk is not taken. This roadmap was developed through an applied approach and intends to fill the gap in published practical models of how provider organizations can maneuver value-based arrangements. 

Financial Performance of Accountable Care Organizations: A 5-Year National Empirical Analysis 

Date: January/February 2024
Source:  The Journal of Healthcare Management
Article 

Of 513 ACOs participating in the MSSP in 2020, 67% generated a positive shared savings of approximately $2.3 billion. This study examined ACO financial performance trends and drivers over time. The unit of analysis was the ACO in each year from 2016 to 2020. The dependent variable was the ACOs’ total shared savings earned annually per beneficiary. The independent variables included ACO age, risk model, clinician staffing type, and provider type (hybrid, hospital-led, or physician-led). Covariates were the average risk score among beneficiaries, payer type, and calendar year. ACOs’ earned shared savings grew annually by 35%, while the proportions of ACOs with positive shared savings grew by 21%. For 1-year increase in ACO age, an additional $0.57 of shared savings per beneficiary was observed. ACOs with two-sided risk contracting were associated with an average marginal increase of $109 in shared savings per beneficiary compared to ACOs with one-sided risk contracting. Primary care physicians were associated with the greatest increase in earned shared savings per beneficiary. In contrast, nurse practitioners/physician assistants/clinical nurse specialists were associated with a reduction in earned shared savings. Under a one-sided risk model, hospital-led ACOs were associated with $18 higher average shared savings earning per beneficiary compared to hybrid ACOs, while physician-led ACOs were associated with lower average saved shared earnings per beneficiary at –$2 compared to hybrid ACOs. Provider-type results were not statistically significant at the 5% nominal level. No statistically significant differences were observed between provider types under a two-sided risk model. For all ACO provider types, building broader primary care provider networks was correlated with positive financial results. Future research should examine whether ACOs are conducting specific preventive screenings for cancer or monitoring conditions such as diabetes, hypertension, heart disease, obesity, mental disorders, and joint disorders. Such studies may answer health policy and strategy questions about the effects of incentives for improved ACO performance in serving a healthier population. 

Practice Site Heterogeneity Within and Between Medicaid Accountable Care Organizations 

Date: January 20, 2024
Source:  Healthcare
Article

Existing research has considered ACOs as whole entities, neglecting potentially important variations in the characteristics and experiences of the individual practice sites comprising ACOs. In this observational cross-sectional study, researchers sought to characterize the experience, capacity, and process heterogeneity at the practice site level within and between Medicaid ACOs, drawing on MassHealth, which launched an ACO effort in 2018. Researchers used a 2019 survey of a representative sample of administrators from practice sites participating in Medicaid ACOs in Massachusetts (n = 225). They quantified the clustering of responses by practice site within all 17 Medicaid ACOs in Massachusetts for measures of process change, previous experience with alternative payment models, and changes in the practices’ ability to deliver high-quality care. The analysis found greater differences within the ACOs than between them for all measures, regardless of practice site and ACO characteristics. The research indicates diverse experience with, and capacity for, implementing ACO initiatives across practice sites in Medicaid ACOs. Future research and program design should account for characteristics of practice sites within ACOs. 

Post-Hospitalization Remote Monitoring for Patients with Heart Failure or Chronic Obstructive Pulmonary Disease in an Accountable Care Organization 

Date: January 13, 2024
Source:  BMC Health Services Research
Article

This ACO-based study examined the relationship between remote patient monitoring (RPM) for patients with congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD) and post-hospitalization mortality, hospital readmission, and ED visits. The study included ACO patients offered enrollment in RPM upon hospital discharge between February 2021 and December 2021. RPM included vital sign monitoring equipment (blood pressure monitor, scale, pulse oximeter), tablet device with symptom tracking software and educational material, and nurse-provided oversight and triage. Expected enrollment was for at least 30-days of monitoring, and outcomes were followed for 6 months following enrollment. The co-primary outcomes were (a) the composite of death, hospital admission, or emergency care visit within 180 days of eligibility, and (b) time to occurrence of this composite. Secondary outcomes were each component individually, the composite of death or hospital admission, and outpatient office visits. Adjusted analyses involved doubly robust estimation to address confounding by indication. Of 361 patients offered remote monitoring (251 with CHF and 110 with COPD), 140 elected to enroll (106 with CHF and 34 with COPD). The median duration of RPM-enrollment was 54 days. Neither the 6-month frequency of the co-primary composite nor the time to this composite differed between the groups, but 6-month mortality was lower in the RPM group (6.4% vs 17%). 

Factors Affecting Accountable Care Organizations’ Decisions to Remain In or Exit the Medicare Shared Savings Program Following Pathways to Success 

Date: January 5, 2024
Source:  Health Affairs Scholar
Article

Launched in 2012, most MSSP ACO participants were expected to shift from bearing no financial risk to a 2-sided risk model, yet fewer than 20% did. Therefore, in 2019, CMS launched the Pathways to Success program, which required shifting to a 2-sided model within 12 months. For the first time, more ACOs exited than entered the MSSP. To understand these participation decisions, researchers conducted qualitative interviews with ACO leaders. Pathways caused ACOs to reassess their potential shared savings vs. losses, particularly in light of benchmarking methodology changes; reconsider perceived nonrevenue benefits; and reassess participation in the MSSP vs. other programs. As ACOs, particularly those assuming downside risk, have contained costs and enhanced care quality, policymakers should strive to improve MSSP enrollment rates in downside-risk models through strategies that allow ACOs to achieve shared savings and deliver accountable care.

Accountable Care Organization Attribution and Post-Acute Skilled Nursing Facility Outcomes for People Living with Dementia

Date:  January 2024
Source:  Journal of Post-Acute and Long-Term Care
Article 

Under the ACO model, reductions in health care spending have been achieved by targeting post-acute care, particularly in skilled nursing facilities (SNFs). People with Alzheimer disease and related dementias (ADRD) are frequently discharged to SNF for post-acute care and may be at particular risk for unintended consequences of SNF cost reduction efforts. This study examined SNF length of stay (LOS) and outcomes among ACO-attributed and non-ACO-attributed ADRD patients using a 20% national random sample of fee-for-service Medicare beneficiaries (2013-2017) to identify beneficiaries with a diagnosis of ADRD and with a hospitalization followed by SNF admission (n = 263,676) by ACO (n = 66,842) and non-ACO (n = 196,834) attribution. Hospital readmission and death were measured for three time periods (<30, 31-90, and 91-180 days) following hospital discharge. ACO-attributed ADRD patients had a shorter SNF LOS than their non-ACO counterparts (31.7 vs 32.8 days; P < .001). Hospital readmission rates for ACO vs non-ACO differed at ≤30 days (13.9% vs 14.6%; P < .001) but were similar at 31-90 days and 91-180 days. No significant difference was observed in mortality post–hospital discharge for ACO vs non-ACO at ≤30 days; however, slightly higher mortality was observed for non-ACO at 31-90 days (8.4% vs 8.8%; P = .002) and 91-180 days (7.6% vs 7.9%; P = .011). Being an ACO-attributed patient was associated with shorter SNF LOS but was not associated with changes in readmission or mortality after controlling for other factors. Policies that shorten LOS may not have adverse effects on outcomes for people living with dementia.