2021 ACO Research

Facilitators and Barriers to Care Coordination Between Medicaid Accountable Care Organizations and Community Partners: Early Lessons from Massachusetts

Date:  April 26, 2023
Source:  Medical Care Research and Review
Article 

This study offers early findings from a unique approach to care coordination delivered by 17 Medicaid ACOs and 27 partnering community-based organizations for individuals with behavioral health conditions and/or those needing long-term services and supports. Interview data from 54 key informants were qualitatively analyzed to understand factors affecting cross-sector integrated care. Key themes emerged, essential to implementing the new model statewide: clarifying roles and responsibilities; promoting communication; facilitating information exchange; developing workforce capacity; building essential relationships; and responsive, supportive program management through real-time feedback, financial incentives, technical assistance, and flexibility from the state Medicaid program. 

What Can We Learn from Medicaid About Making ACOs Equitable? 

Date:  April 13, 2023
Source:  Health Affairs Forefront
Article

With careful design and monitoring, ACOs can serve as a platform for improving health equity. While much of the innovation and research related to ACOs has occurred in the context of Medicare and commercial insurance, Medicaid ACOs may have the most to teach us about how payers can structure their ACO initiatives to improve care for the most disadvantaged patients and thereby improve health equity. We derived related insights about Medicaid ACOs from two sources: a review of published literature and reports on the implementation and impact of Medicaid ACOs, and interviews with Medicaid agency leaders and safety-net providers in four states with and four without Medicaid ACOs. More details can be found in a Commonwealth Fund Issue Brief where we summarize empirical evidence related to the impact of Medicaid ACOs and describe respondent views on the prospects for ACOs in their state, along with barriers and facilitators to successful implementation. 

Population Turnover and Leakage in Commercial ACOs 

Date:  April 10, 2023
Source:  American Journal of Managed care
Article

This study examined the magnitude of turnover and leakage within a commercial ACO using detailed information from multiple commercial ACO contracts within a large health care system between 2015 and 2019. Researchers examined patterns of entry and exit and the characteristics that predicted remaining in the ACO compared with leaving the ACO, as well as examining predictors of the amount of care delivered in the ACO compared with outside the ACO. Among the 453,573 commercially insured individuals in the ACO, approximately half left the ACO within the initial 24 months after entry. Approximately one-third of spending was for care occurring outside the ACO. Patients who remained in the ACO differed from those who left earlier, including being older, having a non-HMO plan, having lower predicted spending at entry, and having more medical spending for care performed within the ACO during the initial quarter of membership. Both turnover and leakage hamper the ability of ACOs to manage spending. Modifications that address potentially intrinsic vs. avoidable sources of population turnover and increase patient incentives for care within vs. outside of ACOs could help address medical spending growth within commercial ACO programs. 

Evaluating Inpatient Hospital Charges Associated with Trauma Service Patients Participating in an Accountable Care Organization 

Date:  April 10, 2023
Source:  Health Services Insights
Article

This study evaluated inpatient hospital charges associated with trauma service utilization of patients participating in a Medicare ACO compared to non-ACO patients. A total of 80 patients were included in the ACO cohort and 80 matched in the general trauma cohort. Patient demographics were similar. Comorbidities were similar with the exception of a higher incidence of hypertension (75.0% vs. 47.5%, P < .001) and cardiac disease (35.0% vs. 17.5%, P = .012) in the ACO cohort. Both the ACO and general trauma cohort had similar injury severity scores, number of visits, and length of stay. Both charge total ($76,148.93 vs. $70,916.82, P = .630) receipt total ($15,080.26 vs $14,180, P = .662) charges were similar between ACO and general trauma patients. In spite of increased incidence of hypertension and cardiac disease in ACO trauma patients, mean injury severity score, number of visits, length of hospital stay, ICU admission rate, and charge total was similar compared to general trauma patients presenting to a Level 1 adult trauma center.

Telehealth Medication Management and Health Care Spending in a Medicare Accountable Care Organization 

Date:  April 2023
Source:  Journal of Managed Care and Specialty Pharmacy
Article

This study, using claims data from 2015 to 2020, evaluated the impact of a scalable pharmacist-driven telehealth intervention to improve medication management on health care spending for clinically complex patients enrolled in a Medicare Next Generation ACO. There were 581 patients who received the intervention and 1,765 who served as controls. The telehealth intervention reduced total medical spending by $2,331.85 per patient over the first 6 months of the service ($388.50 per month; P = 0.0261). Across a range of estimates for the cost of service delivery, the study found a return on investment of 3.6:1 to 5.2:1. 

Changes in Medicare Accountable Care Organization Spending, Utilization, and Quality Performance 2 Years Into the COVID-19 Pandemic 

Date:  March 29, 2023
Source:  JAMA Network Open
Article

This study examined whether Medicare Shared Savings Program (MSSP) ACO spending and utilization recovered to pre–COVID-19 levels in 2021 and assessed how quality of care has evolved. Researchers analyzed the ACO per capita spending overall and across inpatient, post-acute, and outpatient care, with COVID-19–related spending excluded per MSSP financial accountability rules. The study also analyzed changes in utilization, quality performance, and patient experience measures. In 2021, mean total non–COVID-19 spending per capita recovered statistically to 2019 levels after an 8.5% decline in 2020 (P < .001) However, mean acute inpatient spending in 2021 remained 12.4% lower than 2019 levels (P < .001), while outpatient spending increased to 3.8% higher than 2019 levels (P < .001). Post-acute spending remained statistically flat. Mean utilization remained lower than pre–COVID-19 levels across acute inpatient discharges, post-acute discharges, and emergency department (ED) visits, but primary care use returned to baseline. Mean quality performance in 2021 decreased to 5.1 points lower than 2019 levels (P < .001). Nonetheless, MSSP had improved screening rates for depression, falls, and tobacco use as well as increased influenza vaccination. Mean blood pressure control remained worse in 2021 than in 2019, while diabetes control recovered to 2019 levels. Patient experience scores decreased across nearly all measures from 2019 to 2021. Despite a decrease in post-acute facility discharges, the lack of statistical reduction in post-acute care spending is explained in part by a coinciding increase in hospice spending. Notably, initial concerns about a post–COVID-19 surge in admissions from delayed care have thus far not materialized in the MSSP. Notable declines occurred in scores for timely care, specialist access, and shared decision-making, which may reflect system challenges with managing the rebound in outpatient utilization amid workforce shortages and fatigued clinicians. Nevertheless, 99% of ACOs met the quality threshold for shared savings eligibility. 

Eliminating Defects in Value: Turnaround of an MSSP ACO 

Date:  March 15, 2023
Source:  American Journal of Accountable Care
Article

This article explores the journey of Cleveland-based University Hospitals Health System ACO to design and implement a framework to eliminate its defects with three frames: believing, belonging, and building. Using purpose-driven, principle-led, and people-centered approaches, the health system was able to implement a management system that includes declaring goals, roles, and resources; creating an enabling infrastructure; creating peer learning communities; and reporting transparently and creating shared accountability systems. After employing these tactics, the health system saw a reduction in annual Medicare expenditures and improvements in quality between 2017 and 2020. 

The Impact of Nurse Practitioner Care and Accountable Care Organization Assignment on Skilled Nursing Services and Hospital Readmissions 

Date:  March 15, 2023
Source:  Medical Care
Article

This study examined the relationship between ACO attribution and nurse practitioner (NP) care delivery during skilled nursing facility (SNF) stays. Researchers used a sample of 527,329 fee-for-service Medicare beneficiaries with one or more SNF stays between 2012 and 2017. The study found that Greater participation by the NPs in care delivery in SNFs was associated with a reduced risk of patient readmission to hospitals. 

Sacubitril/Valsartan in Medicare Alternative Payment Models

Date:  March 14, 2023
Source:  American Journal of Accountable Care
Article

Objectives:  This study evaluated the association between sacubitril/valsartan (SAC/VAL) use and medical expenditures for beneficiaries with heart failure (HF) with reduced ejection fraction (HFrEF) within the framework of the Bundled Payments for Care Improvement (BPCI) initiative or the Medicare Shared Savings Program (MSSP). Researchers used 100% Medicare enrollment and Parts A/B/D claims to identify beneficiaries with HFrEF during (1) replicated BPCI episodes between 2016 and 2018 or (2) calendar year 2018 and managed by a MSSP ACO participant. For the BPCI initiative, 13,785 episodes with SAC/VAL were matched to 41,355 with ACEIs/ARBs; 12,003 episodes with SAC/VAL were matched to 36,009 with neither treatment. Parts A/B expenditures for patients treated with SAC/VAL were not statistically different compared with those treated with ACEIs/ARBs (mean difference, –$447; 95% CI, –$1227 to $333) and $10,249 less vs patients receiving neither treatment (95% CI, –$11,335 to –$9163). For the MSSP, 18,004 patients utilizing SAC/VAL were matched to 54,012 patients receiving ACEIs/ARBs; 7186 patients utilizing SAC/VAL were matched to 21,558 receiving neither treatment. The SAC/VAL cohort had 2018 annual Parts A/B expenditures that were $875 less vs the ACEI/ARB cohort (95% CI, –$1650 to –$101) and $21,467 less vs. neither treatment (95% CI, –$11,376 to –$7361). 

Maternity Care Clinician Inclusion in Medicaid Accountable Care Organizations 

Date:  March 8, 2023
Source:  Plos One
Article

This study examined the inclusion of obstetrician-gynecologists (OB/GYN), maternal-fetal medicine specialists (MFM), certified nurse midwives (CNM), and acute care hospital inclusion in 16 Massachusetts Medicaid ACOs from December 2020 to January 2021. Using publicly available provider directories, researchers found Primary Care ACO plans included 1,185 OB/GYNs, 51 MFMs, and 100% of Massachusetts acute care hospitals, but CNMs were not easily identifiable in the directories. Across Accountable Care Partnership Plans, a mean of 305 OB/GYNs (median: 97; range: 15–812), 15 MFMs (Median: 8; range: 0–50), 85 CNMs (median: 29; range: 0–197), and half of Massachusetts acute care hospitals (median: 23.81%; range: 10%-100%) were included. The study found substantial differences in maternity care clinician inclusion across and within ACO types. Characterizing the quality of included maternity care clinicians and hospitals across ACOs is an important target of future research. Highlighting maternal health care as a key area of focus for Medicaid ACOs–including equitable access to high-quality obstetric providers–will be important to improving maternal health outcomes. 

Provider Survey of the Roles of Clinical Pharmacists in Primary Care in a Federally Qualified Health Center Versus an Accountable Care Organization 

Date:  March 2023
Source:  Exploratory Research in Clinical and Social Pharmacy
Article

This study surveyed providers’ views of clinical pharmacy services and compared and contrasted the shared-visit model in rural FQHCs and an ACO collaborative practice agreement model in a mid-sized metropolitan area. Primary care providers completed a five-domain 22-item survey of provider patient care, provider pharmacy consults, provider ranking of pharmacy-services, disease treatment, and provider views on the value of clinical pharmacists. Primary care providers reported high satisfaction with and benefits of clinical pharmacy services. Drug information resource and disease-focused management were documented by providers as valuable pharmacy services. Providers promoted expanding the role of clinical pharmacists with providers, and integration into primary care teams.

Performance of Accountable Care Organizations: Health Information Technology and Quality–Efficiency Trade-Offs 

Date: December 15, 2021
Source: Information Systems Research
Article

To better understand the role of health information technology (IT) in a value-based care environment, this study examined potential trade-offs between ACO efficiency and quality and whether effective use of health IT enables ACOs to balance competing efficiency and quality objectives. The study found that efficient ACOs do not make trade-offs with respect to quality, compared with inefficient ACOs. Additionally, researchers found a positive association between efficiency and quality for hospitals participating in ACOs and using IT effectively for care coordination with other providers. ACOs with higher levels of meaningful use achievement of health IT demonstrate better patient health outcomes because of greater information integration with other care providers. The findings suggest that value-based incentives alone are not sufficient to resolve trade-offs between quality and efficiency, and policy needs to incorporate appropriate incentives to foster effective IT use for health information sharing and care coordination between health care providers. 

Disparities in the Use of In-Person and Telehealth Primary Care Among High- and Low-Risk Medicare Beneficiaries During COVID-19 

Date: December 13, 2021
Source: Journal of Patient Experience
Article

Using a difference-in-differences design to estimate differences in primary care outpatient clinic visit utilization among high- and low-risk Medicare ACO beneficiaries during the COVID-19 pandemic compared to a control cohort from the previous year. High-risk was defined as having a Hierarchical Condition Category score of 2 or higher. A total of 582,101 patient-month records were analyzed. After adjusting for patient characteristics, those in the high-risk group had 339 (95% CI [333, 345]) monthly outpatient encounters (in-person and telehealth) per 1,000 patients compared to 186 (95% CI [182, 190]) in the low-risk group. This represented a 22.8% and 26.5% decline from the previous year in each group, respectively. Within each group, there was lower utilization among those who were older, male, or dually eligible for Medicaid in the high-risk group and among those who were younger, male, or non-white in the low-risk group. Telehealth use was less common among patients who were older, dually eligible for Medicaid or living in rural/suburban areas compared to urban areas. The study found significant disparities based on age, gender, insurance status, and non-white race in primary care utilization during the pandemic among Medicare beneficiaries. With the exception of gender, these disparities differed between high- and low-risk groups. Interventions targeting these vulnerable groups may improve health equity in the setting of public health emergencies. 

Direct Contracting with Accountable Care Organizations: The Purchaser Perspective 

Date: December 9, 2021
Source: American Journal of Accountable Care
Article

This article provides insight into health care purchaser priorities and considerations for direct contracting opportunities, along with considerations for interested ACOs. The health care purchaser marketplace is steadily moving toward value-based arrangements that align incentives between providers and health care purchasers (plan sponsors, including employers), reward performance, and transparently share the savings between both parties. The pandemic has intensified pressure on employers and other plan sponsors. A reduction in sales and tax bases, along with a continued increase in health care costs, has driven exploration of alternative approaches. 

An Analysis of Medicare Accountable Care Organization Expense Reports

Date: December 2, 2021
Source: American Journal of Managed Care
Article

Researchers conducted a systematic review and categorization of all available and approved quarterly expenses reported by ACOs participating in Medicare’s ACO Investment Model to better understand how model participants invested to achieve program goals. AIM ACOs reported expenses of $264.8 million over three performance years (2016-2018). The majority of the $264.8 million in expenditures was incurred for personnel (55.5%), followed by infrastructure (22.3%), management firm expenses (15.3%), and internal programs and systems (6.9%). The dominant identifiable ACO strategy was care coordination and management, accounting for 52.9% of related ACO expenses. AIM ACOs invested most heavily in personnel, information technology, and care management, with less than half of the investments explicitly tied to a strategy for improving quality or reducing spending. Efforts to change clinician practice patterns, alter the way patients access the health care system, and institute other practice redesigns were not primary targets for investment. Knowing how ACOs are allocating resources to achieve the goals of reducing spending and improving quality is critical to understanding the costs of these efforts, what strategies ACOs are pursuing, and in turn how future models can be designed to better facilitate these goals. Understanding what ACOs do when provided financial assistance can help policy makers understand how investments can best facilitate the expansion of value-based care into areas with lower levels of participation. 

Clinicians’ Attitudes and System Capacity Regarding Transitional Care Practices Within a Health System: Survey Results From the Partners-PCORI Transitions Study 

Date: December 1, 2021
Source: Journal of Patient Satisfaction
Article

Successful efforts to improve transitional care depend in part on local attitudes, workload, and training. Before implementing a multifaceted transitions intervention within an Accountable Care Organization, an understanding of contextual factors among providers involved in care transitions in inpatient and outpatient settings was needed. As part of the Partners-Patient-Centered Outcomes Research Institute (PCORI) Transitions Study, researches purposefully sampled inpatient and outpatient providers in the ACO. Survey questions focused on training and feedback on transitional tasks and opinions on the quality of care transitions. Researchers also surveyed unit- and practice-level leadership on current transitional care practices. Among 387 providers surveyed, 220 responded (response rate = 57%) from 15 outpatient practices and 26 inpatient units. A large proportion of respondents reported never receiving training (50%) or feedback (68%) on key transitional care activities, and most (58%) reported insufficient time to complete these tasks. Respondents on average reported transitions processes led to positive outcomes some to most of the time (mean scores = 4.70-5.16 on a 1-7 scale). Surveys of leadership showed tremendous variation by unit and by practice in the performance of various transitional care activities. Many respondents reported that training, feedback, and time allotted to key transitional care activities were inadequate. Satisfaction with the quality of the transitions process was middling. Understanding these results, especially variation by location, was important to customizing implementation of the intervention and will be key to understanding variation in the success of the intervention across locations. 

Spending Outcomes Among Patients with Cancer in Accountable Care Organizations 4 Years After Implementation 

Date: November 12, 2021
Source: Cancer
Article

The study examined the association of a practice becoming an ACO and effects on cancer spending among a random sample of more than 850,000 Medicare beneficiaries with cancer, finding yearly cancer spending per patient in the first 4 years after ACO implementation did not change significantly. Practices that became ACOs in the Medicare Shared Savings Program were matched to non-ACO practices. Total, cancer-specific and service category-specific yearly spending per patient was calculated. A difference-in-differences model was used to determine spending changes associated with ACO status for patients with cancer in the 4 years after ACO implementation. 

An Analysis of Ambulance Transport and Out-of-Network Emergency Department Utilization in an Accountable Care Organization

Date: October 18, 2021
Source: Population Health Management
Article 

For hospital-affiliated ACOs, emergency care represents a unique challenge for coordination of care and a major source of ACO leakage. The study analyzed emergency department (ED) visits among ACO members to assess the potential impact of ambulance transport on the use of in-network versus out-of-network EDs. To better understand factors influencing the use of in-network versus out-of-network EDs, 2018 claims data from members of a regional subset of a large ACO in the greater Boston area were analyzed. Within this population, multivariable logistic regression was used to assess the relationship between ambulance transport as well as demographic factors, insurance type, and hospital distance on the use of in-network versus out-of-network EDs. Arrival to an ED via ambulance was found to be significantly associated with reduced odds of presenting to an in-network ED compared to arriving by private transportation (odds ratio 0.70, 95% confidence interval: 0.58–0.85). Age older than 65 years, commercial insurance (relative to Medicare), proximity to an in-network ED, and distance from an out-of-network ED also were significantly associated with use of in-network EDs relative to out-of-network EDs. Given the central role of the ED as a primary source of hospital admissions in the United States, emergency care represents a key potential target for interventions aimed at reducing patient leakage. Future efforts should aim to identify and evaluate new ways that emergency medical services can be leveraged to promote effective care coordination. 

The Medicare Shared Savings Program In 2020: Positive Movement (And Uncertainty) During A Pandemic 

Date: October 14, 2021
Source: Health Affairs Blog
Article 

This article outlines key findings from MSSP ACO 2020 performance data, including the following:

• Overall, 513 different ACOs participated in MSSP in 2020, a 5 percent decrease from last year, but the number of overall covered lives increased. The average ACO was slightly larger in size compared to 2019.
• The program saw savings in 2020, exceeding $1.86 billion in net savings to CMS compared to benchmarks.
• ACOs generated approximately $190 net savings per attributed beneficiary, an increase over the $85–$88 net program savings per beneficiary from 2019.
• Sixty-seven percent of ACOs received the shared savings bonus in 2020, compared to 50–57 percent of ACOs in 2019.
• Similar to 2019’s results, all types and sizes of ACOs achieved net savings per capita.
• Thirty-seven percent of ACOs adopted two-sided risk models (up from 33 percent in 2019), with 88 percent of ACOs in downside risk tracks receiving shared savings bonuses compared to 55 percent in upside-only risk.
• While ACO quality is difficult to assess for 2020, initial analysis suggests the feared quality drops did not occur. ACOs may also have been better than other providers at continuing primary care and preventive services during the pandemic.
• ACOs with a larger number of contracts achieved savings at higher rates suggesting that having a critical mass of value-based payment contracts matters.
• While savings are challenging to assess, ACOs may have been in a better position than other providers to continue delivering needed care during a public health emergency and to continue positive shifts in health care delivery, such as appropriate use of telehealth. 

Improving The Health of Rural Americans 

Date: October 13, 2021
Source: Health Affairs Blog
Article

This article reviews the evidence on rural hospital involvement and performance in ACOs and suggests additional approaches to improve the health and health care of rural Americans, including development of the Prevention Institute’s Accountable Communities for Health (ACH) in rural areas. ACH brings together health care providers (including ACOs), public health departments, schools, social service agencies, housing, community-based organizations, and local businesses in a collective effort “to make a community healthier, more equitable, and resilient.”  

From Vision to Design in Advancing Medicare Payment Reform: A Blueprint for Population-based Payments 

Date: October 13, 2021
Source: Brookings Institution
Article 

To help advance the conversation from high-level principles to a more concrete vision of a future payment system in traditional fee-for-service Medicare, this paper provides a sketch of a multi-track population-based payment model building on ACO models. While the authors focus on the structure of a population-based payment system, they acknowledge the important complementary role that episode-based payment can play and envision strategic deployment of episode-based payments integrated with the population-based model we propose. The paper starts with background on the importance of payment reform in traditional Medicare and design lessons from alternative payment models to date. The paper then sketches a proposed payment system and discusses the rationale for its key features.

Disparities in the Use of in-Person and Telehealth Outpatient Visits Among Medicare Beneficiaries in an Accountable Care Organization During COVID-19 

Date: September 15, 2021
Source: Health Services Research
Article 

The study examined whether telehealth visits mitigated COVID-19 pandemic-related impacts on in-person outpatient visits among Medicare beneficiaries, including high-cost, high-need patients—defined as those 65 years or older with two or more hierarchical condition category (HCC) scores. Using a difference-in-difference design, researchers estimated the change in outpatient in-person and telehealth utilization for the COVID-19 pandemic cohort compared to the control cohort in the prior year among Medicare ACO patients. The pandemic cohort included ACO enrollees in 2019–2020 (N = 21,361), and the control cohort included ACO enrollees in 2018–2019 (N = 20,028). The study period was defined as April–September 2020 for the pandemic cohort and the same months in 2019 for the control cohort, with the preceding 12 months used as baseline periods, respectively. The total number of outpatient encounters (in-person and telehealth) in both primary and specialty care decreased by 41.5% in April 2020 compared to the pre-pandemic period. Telehealth comprised 78% of all outpatient encounters in April 2020 but declined to 22% by the end of September 2020. Only about 40% of all patients had at least one telehealth encounter between April–September 2020. Compared to the control cohort, the pandemic cohort experienced a monthly average of 113 fewer primary care encounters per 1,000 patients (OR: 0.75, 95% CI: [0.73, 0.77]) and 49 fewer specialty care encounters (OR: 0.82, 95% CI: [0.80, 0.85]) over the six-month study period. This represented a decline of 25.6% and 17.3% in primary care and specialty encounters, respectively, among high-cost, high-need patients. High-cost, high-need patients or those with disabilities were more likely to use telehealth and experienced a lesser reduction in outpatient care utilization than other Medicare beneficiaries (OR: 1.20 and 1.06). Medicare beneficiaries with dual Medicaid coverage, those of non-white race/ethnic groups, and those living in rural/suburban areas were less likely to use telehealth and experienced a greater reduction in total outpatient care (OR: 0.86, 0.96 and 0.90). 

Increasing Medicare Annual Wellness Visits in Accountable Care Organizations 

Date: September 15, 2021
Source: American Journal of Accountable Care
Article 

Medicare’s annual wellness visit (AWV) was introduced in 2011 as an opportunity for providers to focus on aspects of preventive care for eligible beneficiaries. Despite potential incentives for doing so, adoption of the AWV has been slow, which may be contributing to a relative paucity of data evaluating how conducting AWVs affects patient outcomes and health care spending. In this article, the authors discuss how a large Medicare ACO implemented several innovations aimed at decreasing barriers to scheduling and increasing the efficiency and convenience of conducting AWVs, which led to a substantial increase in AWV rates within 12 months. They also provide a conceptual analysis assessing the potential benefits and costs of implementing the AWV.

Efforts to increase AWV uptake focused broadly on increasing the ease of scheduling AWVs and improving the efficiency and convenience of conducting an AWV, including increased communication, organizational support, and technological innovations. 

More Than “Beating the Benchmark”: 5 Medicare ACOs, 2015-2019 

Date: September 14, 2021
Source: American Journal of Accountable Care
Article

The study examined cost and utilization trends over time for beneficiaries attributed to five MSSP ACOs launched in 2016 compared with traditional Medicare beneficiaries in the regions where the ACOs operate. Using a difference-in-differences design, researchers analyzed Medicare claims data related to preventive and acute service utilization. Over a four-year period, the ACO cohort prevented an estimated 10,917 hospitalizations, 19,338 emergency department visits, and 8,859 skilled nursing facility visits, compared with the region. This is believed to be largely driven by improvements in care transitions and preventive care, such as annual wellness visits, which the cohort of ACOs performed at 265% above the regional average in 2019. The authors conclude that although it takes time to achieve results, value-based care has the potential to meaningfully reduce costs and improve the quality of care delivered by increasing preventive care and reducing utilization of acute services. 

Coordination Without Consolidation? Options for ACOs 

Date: September 14, 2021
Source: American Journal of Accountable Care
Article 

After growing rapidly as a major part of the transition from fee-for-service payments over the past decade, the number of MSSP ACOs has plateaued since 2018, with ACO exits outweighing entrants for the past 2 years. This analysis of MSSP data found that one key category of ACOs has become less likely to join or remain an ACO: physician group-led ACOs. The authors warn that lower entrance and survival rates for physician group-led ACOs are a problem because these ACOs typically achieve positive shared savings and quality results. 

Data-Led Policy Design Using Medicare Shared Savings Program (MSSP) Health Care Cost Trajectories 

Date: September 15, 2021
Source: Health Services Research
Article

This study characterized and identified trajectories of health care spending for individual patients with type 2 diabetes who were hospitalized for a major acute cardiovascular event (MACE) (e.g., myocardial infarction, stroke). Using claims and electronic medical record data from 2015-2017 for an MSSP population from the largest ACO in South Carolina with 58,472 attributed beneficiaries, the study examined spending variability for at least six months following the MACE to estimate variability pre and post the event and to cluster patients into post-event cost trajectories. The analysis found strong evidence of variation in costs for the sample before and after the index event, suggesting investigation of differences in patient characteristics prior to their MACE across cost trajectory clusters. This work contributes a methodology for examining patient cost trajectories that allows health systems and policy makers to point to specific services and programs for interventions that suggests ways for that cost trajectory to be intervened upon. 

The Relationship Between Governing Board Composition and Medicare Shared Savings Program Accountable Care Organizations Outcomes: An Observational Study 

Date: September 1, 2021
Source: Journal of General Internal Medicine
Article

Early studies of MSSP ACOs suggested that physician leadership was an important driver of ACO success, but it is unknown whether the demographic and professional composition of current MSSP ACO governing boards is associated with ACOs’ publicly reported outcomes. This study examined whether governing boards with higher physician participation and greater female involvement affect outcomes and included all 2017 MSSP ACOs identified by the CMS ACO public use files. Researchers collected governing board composition from ACO websites in 2019. Of the 339 ACOs that existed in 2019 and had available data, 77% had physician-majority boards and 11.5% had no women on their boards. Eighty-nine percent reported a Medicare beneficiary on their board, of which about one-third had a woman representative. The average number of members on MSSP ACO boards was 12, with a mean of 67% physicians and 24% women. Board composition varied minimally by ACO characteristics, such as geographic region, number of beneficiaries, or type of participants. Higher levels of physician participation in ACO governing boards were associated with lower all-cause unplanned admission rates for patients with heart failure (p = − 0.26, p < 0.001) and for patients with multiple chronic conditions (p = − 0.28, p = 0.001). The number of women on the board was not associated with any outcome differences. MSSP ACO governing boards were predominately male and physician-led. Physician involvement may be important for achieving quality goals, while lack of female involvement showcases an opportunity to diversify boards. 

Evaluation of the Vermont All-Payer Accountable Care Organization Model 

Date: August 2021
Source: NORC at the University of Chicago
Article

The evaluation found that model achieved statistically significant Medicare gross spending reductions at both the ACO and state levels, as well as Medicare net spending reductions at the state level. There were statistically significant declines in acute care stays (at the ACO and state levels) and in 30-day readmissions at the state level. Evaluators found that stakeholders agree that the model provides an important, unifying forum for providers, payers, and the state to engage in meaningful discussions about health care reform and set goals. The model is also strengthening relationships among hospitals, community organizations, designated mental health agencies, primary care practices, and other providers. 

Stratifying for Value: An Updated Population Health Risk Stratification Approach 

Date: August 9, 2021
Source: Population Health Management
Article 

Most risk stratification approaches attempt to predict clinical outcomes rather than value. For a provider organization or health system to have financial success in value-based contracting, future risk models must analyze costs and disease burden. The purpose of this study was to create a customized risk stratification algorithm that considered a patient’s medical spend alongside disease burden while delivering a scoring system that improves the efficiency of a care coordination program. The authors focused on University Hospitals (UH) Health System’s ACO population of 554,805 because this patient cohort is engaged with UH’s primary care network and has the most robust data. The 5-category risk algorithm was found to be meaningful and impactful after integrating the foundation of the Minnesota Tiering system with an expanded comorbidity list and weighting the result by the previous 12 months of medical spend. This new technique can identify patients in need of intensive care coordination. The complex risk tier of the stratification system reduces the number of patients from 551,045 to 27,552, or 5% of the patient population, and accounts for 67.9% ($1,107,822,887) of total annual medical spend. Expanding care coordination efforts to patients in the top two tiers would account for 15% of the patients and 83.2% ($1,357,545,872) of annual medical spend. The novelty of the new approach allows clinical teams to focus intense resources on a smaller sample of the patient population and to identify chronic conditions contributing to costs, and feel confident that they have greater explanatory power regarding value. 

Association of Patient Outcomes with Bundled Payments Among Hospitalized Patients Attributed to Accountable Care Organizations 

Date: August 20, 2021
Source: JAMA Health Forum
Article

In this cohort study of 9,850,080 Medicare beneficiaries, simultaneous inclusion in both ACOs and the Medicare Bundled Payments for Care Improvement (BPCI) initiative was associated with lower spending on institutional post-acute care, fewer readmissions for medical episodes, and fewer readmissions only for surgical episodes compared with inclusion in bundled payments alone. These findings suggest that receiving care under models such as ACOs may improve patient outcomes under bundled payments. Using a difference-in-differences analysis of Medicare claims data from January 1, 2011, to September 30, 2016, researchers compared episode outcomes for patients admitted to BPCI vs non-BPCI hospitals. Outcomes were stratified for patients who were and were not attributed to an ACO. Participants included Medicare fee-for-service beneficiaries receiving care for medical and surgical episodes at US hospitals. 

The Effect of Participation in Accountable Care Organization on Electronic Health Information Exchange Practices in U.S. Hospitals 

Date: July 26, 2021
Source: Health Care Management Review
Article

The study examined the relationship between hospital participation in ACOs and electronic health information exchange (HIE) practices with different care participants and how these practices vary across markets. The researchers hypothesized hospital participation in ACOs to three dimensions of HIE practices (intraorganizational, interorganizational, and provider-patient HIE practices). Based on a sample of 1,926 hospitals, the study found that hospital participation in ACOs is associated with greater intraorganizational and provider-patient HIE practices but not interorganizational HIE practices. The study also found that while the relationship between ACO participation and intra- and interorganizational HIE practices remains unchanged irrespective of the degree of competition in the health care market, the relationship between ACO participation and provider-patient HIE practices holds true only for hospitals operating in noncompetitive markets. 

Implementation of Collaborative Care for Depressive Disorder Treatment Among Accountable Care Organizations 

Date: July 9, 2021
Source: Medicine
Article

Collaborative care—primary care models combining care management, consulting behavioral health clinicians, and registries to target mental health treatment—is a cost-effective depression treatment model, but little is known about uptake of collaborative care in a national setting. Alternative payment models like ACOs, which are responsible for quality and cost for defined patient populations, may encourage collaborative care use. The study examined the

prevalence of collaborative care implementation among ACOs and whether ACO structure or contract characteristics were associated with implementation. Using data from the 2017-2018 National Survey of ACOs, the study found that 17% of ACOs reported implementing all three collaborative care components. Most reported using care managers (71%) and consulting mental health clinicians (58%), but just 26% reported using patient registries. After adjusting for multiple ACO characteristics, ACOs responsible for mental health care quality measures were 15 percentage points (95% CI 5–23) more likely to implement collaborative care. Most ACOs are not utilizing behavioral health collaborative care. Including mental health care quality measures in payment contracts may facilitate implementation of this cost-effective model. Improving provider capacity to track and target depression treatment with patient registries is warranted as payment contracts focus on treatment outcomes.

The Impact of Covid-19 on ACO Economics 

Date: August 2021
Source: Health Data Institute
Article

Health Data Analytics Institute (HDAI) researchers analyzed 10.2 million Medicare beneficiaries for whom there was at least two years of data. Here’s what they found:

• A diagnosis of confirmed COVID was associated with a 60 percent increase in the cost of care across 2020, from $17,383 to $27,808. 
• The volume of services provided to patients without COVID fell dramatically, 34 percent below expected levels.
• For MSSP ACOs, HDAI estimates that CMS spent 9.8 percent less during 2020 as a result of COVID: most beneficiaries were not diagnosed with COVID, and lower costs for these beneficiaries more than made up for cost increases for patients with confirmed. 

Impact of a Pharmacy-Led Transitions of Care Program Within a Primary Care-Based Accountable Care Organization 

Date: June 2021
Source: The Senior Care Pharmacist
Article

This study assessed the impact of a pharmacist-led transitions of care program on 30-day readmission rates for adult Medicare patients who completed a post-discharge follow-up visit at two primary care offices within an ACO in South Florida from July to December 2017.
To supplement post-discharge visits with a primary care provider (PCP), the pharmacy services were also provided two days per week with a PCP. The comparator groups were patients who only saw a PCP or those who saw a PCP and pharmacist. A total of 190 subjects were included. There were 113 patients in the PCP group and 77 patients in the PCP/pharmacist group. There was a reduction in the primary outcome of 30-day readmissions when comparing the PCP-only versus PCP/pharmacist groups (6.2% versus 3.9%; P = 0.74).  Involving pharmacists in patient transitions of care in the primary care setting may be beneficial as previous studies have demonstrated. Further studies evaluating pharmacy services in emerging health care models are needed to most effectively utilize the expertise of the pharmacy team. 

Association of ACO Shared Savings Success and Serious Illness Spending 

Date: May-June 2021
Source: Journal of Healthcare Management
Article 

This study examined spending on seriously ill beneficiaries in ACOs with Medicare Shared Savings Program (MSSP) contracts and the association of spending with ACO shared savings. The population included Medicare fee-for-service beneficiaries identified with serious illness (N = 2,109,573) using the Medicare Master Beneficiary Summary File for 100% of ACO-attributed beneficiaries linked to MSSP beneficiary files (2014–2016). Lower spending for seriously ill Medicare beneficiaries and risk-bearing contracts in ACOs were associated with achieving ACO shared savings in the MSSP. For most ACOs, the seriously ill contribute approximately half of the spending and constitute 8%–13% of the attributed population. Patient and geographic (county) factors explained $2,329 of the observed difference in per beneficiary per year spending on seriously ill beneficiaries between high- and low-spending ACOs. The remaining $12,536 may indicate variation as a result of potentially modifiable factors. Consequently, if 10% of attributed beneficiaries were seriously ill, an ACO that moved from the worst to the best quartile of per capita serious illness spending could realize a reduction of $1,200 per beneficiary per year for the ACO population overall. Though the prevalence and case mix of seriously ill populations vary across ACOs, this association suggests that care provided for seriously ill patients is an important consideration for ACOs to achieve MSSP shared savings. 

Pharmacist Medication Review: An Integrated Team Approach to Serve Home-Based Primary Care Patients 

Date: May 25, 2021
Source: PLOS One
Article

This study outlines a pilot model of care where a remote corporate-based clinical pharmacist employed by an ACO implemented comprehensive medication reviews for a cohort of medically complex home-based primary care (HBPC) patients. Ninety-six medically complex patients were assessed for medication-related problems. Data collected on these patients were: number of chronic conditions, number of medications, appropriate indication for each medication, dose appropriateness, drug interactions, recommendations for medication optimization and deprescribing. The number of accepted recommendations by the HBPC practice was analyzed. On average, the patients were 82 years old and had 13 chronic conditions. They were taking a median of 17 medications. Over a four-month pilot period, 175 medication recommendations were made, and 53 (30.3%) of them were accepted, with most common being medication discontinuation, deprescribing, and dose adjustments. Sixty-four (66.7%) patients were on a medication listed as potentially inappropriate for use in older adults. The most common potentially inappropriate medication was a proton-pump inhibitor (38.5%), followed by aspirin (24%), tramadol (15.6%), a benzodiazepine (13.5%) or an opioid (8.3%). Eighty-one medications were recommended for deprescribing and 27 medications were discontinued (33.3%). There were 24 recommended dose adjustments and 11 medications were dose adjusted (45.8%). Thirty-four medications were suggested as an addition to the current patient regimen, 2 medications were added (5.9%). Pharmacist comprehensive medication review is a necessary component of the HBPC healthcare continuum. Additional research is needed to examine whether aligning pharmacists to deliver support to HBPC improves clinical outcomes, reduces healthcare expenditures and improves the patient’s experience. 

Leveraging Accountable Care Organizations to Address Health Equity: Examples from States 

Date: May 2021
Source: Center for Health Care Strategies
Article

State Medicaid agencies are leveraging contracts and procurement processes to require investment and attention to health equity through a variety of opportunities, including Medicaid ACOs. This report outlines promising examples of state Medicaid ACO incentives and requirements that can be used to advance health equity. ACOs can be a powerful resource for addressing health equity given their mission to facilitate better coordination and higher quality care across a spectrum of providers. 

Effect of Community Health Workers on 30-Day Hospital Readmissions in an Accountable Care Organization Population: A Randomized Clinical Trial 

Date: May 20, 2021
Source: JAMA Open Network
Article

This study examined whether community health worker (CHW) care reduced 30-day hospital readmissions in inpatient adults participating in ACOs. The randomized clinical trial, which included 550 adults, found that intervention patients who received CHW care were significantly less likely to experience 30-day hospital readmissions than control participants. In post hoc subgroup analysis, the effect remained significant for participants discharged to short-term rehabilitation but not for those discharged home. In this study, CHW care improved post-discharge outcomes in clinically complex patients covered by ACOs, particularly for those discharged to short-term rehabilitation. Value-based care within ACOs has magnified the importance of reducing preventable hospital readmissions, and CHW interventions may address patients’ unmet psychosocial and clinical care needs but have been underused in inpatient and post-discharge care. 

Evolving Radiologist Participation in Medicare Shared Savings Program Accountable Care Organizations 

Date: May 20, 2021
Source: Journal of the American College of Radiology
Article

This study examined radiologist participation in Medicare Shared Savings Program (MSSP) ACOs between 2013 and 2018, finding the percentage of Medicare-participating radiologists affiliated with MSSP ACOs increased from 10.4% to 34.9%. During that time, the share of large ACOs (>20,000 beneficiaries) with participating radiologists averaged 87.0%, while the shares of medium ACOs (10,000-20,000) and small ACOs (<10,000) with participating radiologists rose from 62.5% to 66.0% and from 26.3% to 51.6%, respectively. In recent years, radiologist participation in MSSP ACOs has increased substantially. ACOs with radiologist participation are large and more diverse in their physician specialty composition. 

Abstract MP20: Implementation of Social Determinants of Health Screening and Referrals in a Medicaid Accountable Care Organization: A Qualitative Study 

Date: May 18, 2021
Source: Circulation
Article 

Systematic screening for social determinants of health (SDOH), such as food and housing insecurity, is increasingly implemented in primary care, particularly in the context of ACOs, to improve health outcomes. This study explored aspects of implementation of annual SDOH screening and referrals in a Medicaid ACO, including facilitators and barriers and experiences of community resource staff. Qualitative interviews were conducted between January and March 2020 with 15 staff (eight frontline resource staff and seven managers) in a large health care system in Massachusetts and focused on barriers and facilitators of screening for and addressing SDOH. Facilitators for addressing SDOH included close collaborations with community organizations, updated resource lists, leadership buy-in, and trusting relationships with patients. Barriers that prevented staff from addressing patients’ social needs effectively included high caseloads, time constraints, inefficiencies in workflows, lack of availability of resources, and patient characteristics (e.g., immigration status, mental health challenges). Resource staff described rewarding and stressful aspects of their jobs, including distress when unable to address challenging social needs such as housing. Facilitators and barriers for successful SDOH screening and referrals occur at the health system, community, and individual levels and must be considered for developing effective screening and referral processes. The psychological burden on resource staff is an important and underrecognized factor that could impact patient care and contribute to staff burnout. 

Dying with Dementia in Medicare Advantage, Accountable Care Organizations, or Traditional Medicare

Date: May 14, 2021
Source: Journal of the American Geriatrics Society
Article

This retrospective study compared end-of-life care for deceased beneficiaries in 2017-18 with dementia enrolled in Medicare Advantage (MA), attributed to a Medicare ACO, or enrolled in traditional Medicare (TM). Decedents had a nursing home stay between 91 and 180 days prior to death, two or more functional impairments, and mild to severe cognitive impairment. Researchers examined rates of hospitalization, invasive mechanical ventilation (IMV) use, and in-hospital death in the last 30 days of life reported in Medicare billing. Among 370,094 persons with dementia, 93,801 (25.4%) were in MA (mean age [SD], 86.9 [7.7], 67.6% female), 39,586 (10.7%) were ACO attributed (mean age [SD], 87.2 [7.6], 67.3% female), and 236,707 (63.9%) were in TM (mean age [SD], 87.0 [7.8], 67.6% female). The proportion hospitalized in the last 30 days of life was higher among TM enrollees (27.9%) and those ACO attributed (28.1%) than among MA enrollees (20.5%, p ≤ 0.001). After adjustment for socio-demographics, cognitive and functional impairments, comorbidities, and hospital referral region, adjusted odds of hospitalization in the 30 days prior to death was 0.72 (95% confidence interval [CI] 0.70–0.74) among MA enrollees and 1.05 (95% CI 1.02–1.09) among those attributed to ACOs relative to TM enrollees. Relative to TM, the adjusted odds of death in the hospital were 0.78 (95% CI 0.75–0.81) among MA enrollees and 1.02 (95% CI 0.96–1.08) for ACO participants. Dementia decedents in MA had a lower likelihood of IMV use (adjusted odds ratio 0.80, 95% CI 0.75–0.85) compared to TM. Among decedents with dementia, MA enrollees but not decedents in ACOs experienced less costly and potentially burdensome care compared with those with TM. Policy changes are needed for ACOs. 

Left Behind Again: Rural Home Health Services in a Medicaid Pediatric Accountable Care Organization 

Date: May 12, 2021
Source: The Journal of Rural Health
Article 

This study examined trends in rural and urban pediatric home health care use among Medicaid ACO enrollees in Ohio. Using Medicaid administrative claims between 2010 and 2019, researchers found that pediatric home health care use increased markedly in the low-income and disabled Medicaid categories. Over the past 10 years, low-income children enrolled in Medicaid from urban communities have seen more home health visits, fewer emergency department (ED) visits, and more well child visits compared to their rural counterparts. Children enrolled due to disabilities in urban communities have also seen more home health visit use but fewer preventive care visits than their rural counterparts. Within a pediatric ACO, rural home health care use has remained relatively stagnant over a 10-year period, a stark contrast to increases in home health care use among comparable urban populations. There are likely multiple explanations for these differences, including overuse in urban communities, lack of access in rural communities, and changes to home health reimbursement. More can be done to improve rural home health access. Such improvement will likely require large-scale changes to home health care delivery, workforce, and financing. Improvements should be evaluated for return-on-investment not only in terms of direct costs, that is, reduced inpatient or ED costs, but also in terms of patient and family quality-of-life or key indicators of child well-being such as educational attainment.

The One‐year Impact of Accountable Care Networks Among Washington State Employees 

Date: April 16, 2021
Source: Health Services Research
Article

This study estimated the impact of a new, two‐sided risk model accountable care network (ACN) on Washington State employees and their families using administrative data from January 2013‐December 2016. Researchers compared monthly health care utilization, health care intensity as measured through proxy pricing, and annual HEDIS quality metrics between the five intervention counties to 13 comparison counties, analyzed separately by age categories (ages 0‐5, 6‐18, 19‐26, 18‐64). The study used difference‐in‐difference methods and generalized estimating equations to estimate the effects after 1 year of implementation for adults and children. The study found an estimated 1‐2 percentage point decrease in outpatient hospital visits due to the introduction of ACNs (adults: −1.8, P < .01; age 0‐5: −1.2, P = .07; age 6‐18: −1.2, P = .06; age 19‐26; −1.2, P < .01). The analysis also found changes in primary and specialty care office visits, with the direction of impact varying by age. Dependents ages 19‐26 also saw inpatient admissions declines (−0.08 percentage points, P = .02). Despite changes in utilization, there was no evidence of changes in intensity of care and mixed results in the quality measures. Washington’s state employee ACN introduction changed health care utilization patterns in the first year but was not as successful in improving quality. 

To Advance Health Equity, Federal Policy Makers Should Build on Lessons from State Medicaid Experiments 

Date: April 14, 2021
Source: Health Affairs Blog
Article 

This post describes the current landscape of state and national health care program innovations, including ACOs, to advance health equity. To be sure, the payment reforms currently under consideration are no substitute for broader multiagency social justice reforms in state and federal policy: Racial and ethnic disparities in health outcomes grow out of profound structural injustice in multiple spheres, including incarceration, environmental pollution, economic opportunity, housing, education, and health care itself among others. The health care system, alone, cannot address the root causes of systemic racism. However, it does have unique power—and an essential responsibility—to reduce the disparities that drive people’s health. 

Stroke Utilization and Outcomes Under Alternative Payment Models: A Systematic Review 

Date: April 13, 2021
Source: Neurology
Article

This systematic review evaluated current evidence about the impacts of alternative payment models (APMs) on stroke outcomes, spending, and utilization. Stroke contributes an estimated $28 billion to U.S. health care costs annually, and APMs aim to improve outcomes and lower spending over fee-for-service (FFS) by aligning economic incentives with high-value care. Researchers included all English-language quantitative studies that evaluated an APM vs. a control group, typically FFS. Included studies report at least one clinical, utilization, or spending outcome specific to hemorrhagic or ischemic stroke. Five databases were searched from inception to February 11, 2020. Of 4,875 studies screened, 36 high-quality studies met inclusion criteria and were synthesized in the narrative review. Among studies that reported clinical outcomes (N=29), mortality or readmissions rates were worse in 4/12 studies of capitated payments but improved in 3/12 studies. Functional outcomes were worse in 1/2 studies of capitation and 1/2 studies of prospective payment system (PPS). Some quality metrics were worse in 1/2 studies of pay-for-performance payments. Among studies reporting spending outcomes (N=10), 3/4 studies of PPS reported increased spending, while 1/2 studies of risk-sharing models such as ACOs and bundled payments and 2/3 studies of capitation reported decreased spending. Among studies reporting acute and post-acute care utilization (N=20), capitation and risk-sharing models generally decreased utilization, but effects were mixed in studies of PPS. ACOs (N=4) had evidence for decreased spending and no evidence of worse clinical outcomes. While more evidence is needed, payment models that incentivize coordination of care across care settings, such as ACOs and bundled payments, show potential for lowering spending while maintaining or improving quality of care. 

Findings from a Commercial ACO Patient Experience Survey 

Date: April 7, 2021
Source: Journal of Patient Experience
Article 

This cross-sectional study examined whether ACO arrangements within a preferred provider organization and a health maintenance organization (HMO) affected patient experience. A modified Consumer Assessment of Healthcare Providers and Systems ACO survey was used to assess care domain differences overall and by product. The association between ACO and non-ACO populations and items in each significant care domain, flu vaccination, and delayed and emergency department care were explored using multivariable logistic regression. ACO patients were more likely to report it was easy to get a specialist appointment and less likely to report visiting the emergency department for care. Reported experience differed for access to specialists between ACO and non-ACO groups among overall and HMO respondents (79.4% vs 74.7% and 79.9% vs 75.5%, P < .05, respectively). The ACO patient experience was not substantially better. Strategies incorporating satisfaction and experience, whether linked to contracts or not, should be encouraged given ACOs’ goal to optimize patient care. Survey instruments must be improved to capture nuances of provider care and patient bond that is vital in ACO integrated systems. 

Provider Perceptions of Pharmacists in Primary Care–Based Accountable Care Organizations 

Date: April 7, 2021
Source: The American Journal of Accountable Care
Article

Clinical pharmacists are in an ideal position to manage multiple aspects of patient care within value-based care models. In 2015, Nova Southeastern University College of Pharmacy founded the Accountable Care Organization Research Network, Services, and Education (ACORN SEED), a team of pharmacy practice faculty dedicated to using innovative approaches to patient care while providing unique learning experiences for pharmacy students by partnering with primary care-based ACOs in South Florida. This review describes experiences with ACORN SEED, addressing provider perceptions and creating methods to overcome several challenges to clinical pharmacist integration, including (1) providing value, (2) collaborative practice, and (3) workflow disruption. Overcoming these challenges is critical for organizations aiming to expand pharmacist integration to improve patient outcomes and reduce health care costs. 

Reinventing the Center for Medicare and Medicaid Innovation 

Date: April 6, 2021
Source: JAMA
Article 

In this commentary, Don Berwick and Rick Gilfillan outline recommendations for how the Center for Medicare & Medicaid Innovation (CMMI), as it enters its second decade, can better fulfill its mission of testing health care payment and service delivery models and scale them up to a national level to reduce health care expenditures and improve quality and safety. Included in the recommendations is using CMMI authority to scale the ACO model nationally by making it mandatory for all Medicare participating clinicians and hospitals. Clinicians, hospitals, and payers find it difficult to operate in an ambiguous world straddling payment for volume and value. Although voluntary participation has made evaluation of ACOs difficult,5 the Medicare Payment Advisory Commission and others have concluded that different CMS ACO models during the last 15 years have consistently produced modest savings for CMS. CMS should gradually but steadily expand ACO adoption during the next 5 years until virtually all Medicare participating organizations and clinicians are operating within accountable organizations. Advanced primary care practice models will be a natural core feature. Part of the expansion should include, as much as feasible, progressing to capitation of ACOs for total cost of care. 

Do Accountable Care Organizations Differ According to Physician-hospital Integration?: A Retrospective Observational Study 

Date: March 26, 2021
Source: Medicine
Article

Physician-hospital integration among ACOs has raised concern over impacts on prices and spending. However, characteristics of ACOs with greater integration between physicians and hospitals are unknown. This study examined whether ACOs systematically differ by physician-hospital integration among 16 commercial ACOs operating in Massachusetts. Using claims data linked to information on physician affiliation, researchers measured hospital integration with primary care physicians for each ACO and categorized them into high-, medium-, and low-integrated ACOs. Researchers conducted cross-sectional descriptive analysis to compare differences in patient population, organizational characteristics, and healthcare spending between the three groups. In addition, using multivariate generalized linear models, the study compared ACO spending by integration level, adjusting for organization and patient characteristics. The study identified non-elderly adults (aged 18-64) served by 16 Massachusetts ACOs from 2009 to 2013. High- and medium-integrated ACOs were more likely to be an integrated delivery system or an organization with a large number of providers. Compared to low-integrated ACOs, higher-integrated ACOs had larger inpatient care capacity, smaller composition of primary care physicians, and were more likely to employ physicians directly or through an affiliated hospital or physician group. A greater proportion of high-/medium-integrated ACO patients lived in affluent neighborhoods or areas with a larger minority population. Healthcare spending per enrollee in high-integrated ACOs was higher, which was mainly driven by higher spending on outpatient facility services. This study shows that higher-integrated ACOs differ from their counterparts with low integration in many respects, including higher healthcare spending, which persisted after adjusting for organizational characteristics and patient mix. Further investigation into the effects of integration on expenditures will inform the ongoing development of ACOs. 

An Analysis of Ambulance Transport and Out-of-Network Emergency Department Utilization in an Accountable Care Organization 

Date: March 2, 2021
Source: Population Health Management
Article

For hospital-affiliated ACOs, emergency care represents a unique challenge for coordination of care and a major source of ACO leakage. The study analyzed emergency department (ED) visits among ACO members to assess the potential impact of ambulance transport on the use of in-network versus out-of-network EDs. To better understand factors influencing the use of in-network versus out-of-network EDs, 2018 claims data from members of a regional subset of a large ACO in the greater Boston area were analyzed. Within this population, multivariable logistic regression was used to assess the relationship between ambulance transport as well as demographic factors, insurance type, and hospital distance on the use of in-network versus out-of-network EDs. Arrival to an ED via ambulance was found to be significantly associated with reduced odds of presenting to an in-network ED compared to arriving by private transportation (odds ratio 0.70, 95% confidence interval: 0.58-0.85). Age older than 65 years, commercial insurance (relative to Medicare), proximity to an in-network ED, and distance from an out-of-network ED also were significantly associated with use of in-network EDs relative to out-of-network EDs. Given the central role of the ED as a primary source of hospital admissions in the United States, emergency care represents a key potential target for interventions aimed at reducing patient leakage. Future efforts should aim to identify and evaluate new ways that emergency medical services can be leveraged to promote effective care coordination. 

High-Functioning Rural Medicare ACOs – A Qualitative Review 

Date: February 2021
Source: RUPRI Center for Rural Health Policy Analysis
Article 

This qualitative analysis identified six common ACO success factors among high-performing rural Medicare ACOs: 

Prior collaboration experience – All ACOs noted the importance of collaborative experiences with current partners and newly developed collaborations, such as with community-based organizations.

Volume-to-value transformation strategic focus – The ACOs believed that ACO participation provided an opportunity to gain value-based care experience in a relatively low risk (but not riskless due to ACO implementation and operation costs) environment.

Clinician championship – The ACOs noted the importance of physician and advanced practice providers in both leadership (i.e., board membership) and operations roles.

Shared governance – The ACOs shared governance equitably among member clinics and organizations. Additional ACO governing members included Medicare beneficiaries, a state primary care network representative, and local citizen advisors.

Care coordination services – The ACOs recognized that care coordination (and primary care) is fundamental to population health improvement. Care coordination has the potential to improve clinical care and reduce duplicative or unnecessary services, both necessary for ACO success. Thus, each ACO developed care coordination service lines. Some ACOs used data analytics platforms to risk adjust patients and identify those in need of care coordination. Others developed algorithms in-house to identify high-need/high-cost patients.

Data access and analysis – The ACOs recognized the importance of timely data access and sophisticated analysis. In the three non-system ACOs, multiple electronic health records in use was challenging. Data availability time lags of six to eight weeks was also problematic. But the most important and challenging factor was data analysis. Some ACOs engaged outside data analytic vendors and others developed in-house data analysis capacity.

Estimates of ACO Savings in the Presence of Provider and Beneficiary Selection 

Date: March 2021
Source: Healthcare
Article 

In previous studies, Medicare ACOs were associated with growing savings. However, savings estimates may be biased by beneficiary sorting among providers based on health care needs and by providers opting into the program based on anticipated gains. Using Medicare administrative claims (2009-14), this study compared annual spending changes after provider organizations joined ACOs to changes in non-ACOs (controls). To address provider selection, using novel data to identify non-ACO organizations, researchers restricted controls to comparably large provider organizations. To address beneficiary selection, the study (a) estimated within-organization (including non-ACO comparison organizations) spending changes, (b) estimated within-beneficiary spending changes, (c) incorporated beneficiaries without qualifying health care expenses, and (d) used a fixed beneficiary ACO assignment using the pre-ACO period. Each year, 19% of Medicare beneficiaries switched provider organizations. Spending was higher for switchers than stayers ($3163, p < .001) and grew more the next year ($2004; p < .001). Starting from a baseline regression modeled on previous ACO evaluations, estimated savings varied widely as researchers sequentially introduced methods to address selection. Combining methods, however, generated more stable estimated ACO savings of $46 (p = .022), averaged across cohorts. When implementing a comprehensive suite of methods to adjust for provider and beneficiary selection, estimated ACO savings grew over time. The estimates are in line with, but smaller than, previous estimates in the literature. Implementing piecemeal adjustments produced misleading results. The results confirm the importance of selection for savings estimates and for provider organizations managing costs and quality. Attribution rules that consider multiple years may help mitigate the impact of beneficiary churn for providers and payers. Implementing payment reform by randomizing early participants, or implementing fully across selected markets, may better serve efforts to evaluate and improve payment models. 

Drivers of Cost Differences Between Nurse Practitioner and Physician Attributed Medicare Beneficiaries 

Date: February 2021
Source: Medical Care
Article

The study examined drivers of cost differences between Medicare beneficiaries attributed to primary care nurse practitioners (PCNPs) and primary care physicians (PCMDs).

Researchers used 2009-10 Medicare administrative claims for beneficiaries attributed to PCNPs and PCMDs with risk stratification to control for beneficiary severity. Cost differences between PCNPs and PCMDs were decomposed into payment, service volume, and service mix within low-risk, moderate-risk and high-risk strata. Overall, the average PCMD cost of care was 34% higher than PCNP care in the low-risk stratum, and 28% and 21% higher in the medium-risk and high-risk stratum. In the low-risk stratum, the difference was comprised of 24% service volume, 6% payment, and 4% service mix. In the high-risk stratum, the difference was composed of 7% service volume, 9% payment, and 4% service mix. The cost difference between PCNP and PCMD attributed beneficiaries is persistent and significant, but narrows as risk increases. Across the strata, PCNPs use fewer and less expensive services than PCMDs. In the low-risk stratum, PCNPs use markedly fewer services than PCMDs. Because more primary care will be provided by NPs in the future, results suggests that PCNPs’ conservative use of resources will help contain costs and overall spending growth and, with full integration of PCNPs into alternative payments models, achieve further savings. Although the Affordable Care Act recognizes NPs as “ACO professionals” and authorizes NPs to join ACOs, the claims-based assignment pathway prevents NP beneficiaries from ACO participation unless they are referred to physicians for additional primary care. In other words, some NPs and their beneficiaries are not eligible to receive ACO benefits, or could be made eligible through potentially redundant and unnecessary primary care visits. These contradictory regulations have prompted legislative efforts to improve beneficiary assignment to ACOs by allowing claims-based assignment of beneficiaries seen only by NPs. Results from this study suggest that NPs may enable ACOs to achieve greater cost-savings, while maintaining a high quality of care. 

The Future of Value-Based Payment: A Road Map to 2030 

Date: February 18, 2021
Source: Leonard Davis Institute White Paper
Article 

Since the passage of the Affordable Care Act in 2010, CMS has sought to transform U.S. health care from a system that incentivizes volume to one that rewards value. A key part of this strategy has been shifting from fee-for-service payment to mechanisms that link provider reimbursement to improved quality and reduced costs. CMS has developed advanced alternative payment models (APMs) that hold providers financially accountable for the quality and cost of care delivered to patients. These APMs include accountable care organizations (ACOs), episode-based payment models, Comprehensive Primary Care models, and other arrangements. However, the transition to a health care system that rewards value has slowed in recent years, and the promise of curtailing health care spending while also improving quality has remained elusive. Indeed, quality of care remains variable across health care settings with ongoing unnecessary utilization, low rates of compliance with recommended care, and inequities in health and health care. Meanwhile, though per-beneficiary spending growth in Medicare and Medicaid has slowed, aggregate spending continues to rise due to the aging population and expanded program eligibility. In addition, without increased adoption of alternative payment models into the commercial market, where per-enrollee costs continue to outstrip inflation and wage growth, health care spending will continue to grow. 

Pandemic Pause: Systematic Review of Cost Variables for Ambulatory Care Organizations Participating in Accountable Care Organizations 

Date: February 12, 2021
Source: Healthcare
Article 

Ambulatory health care provider organizations participating in ACOs assume costs beyond typical practice operations that are directly associated with value-based care initiatives. Identifying variables that influence such costs are essential to an organization’s financial viability. To enable the U.S. health care system to respond to the COVID-19 pandemic. CMS issued blanket waivers that permit enhanced flexibility, extension, and other emergency declaration changes to ACO reporting requirements. This relaxation and even pausing of reporting requirements encouraged the researchers to conduct a systematic review and identify variables that have influenced costs incurred by ambulatory care organizations participating in ACOs prior to the emergency declaration. The research findings identified ACO-ambulatory care variables (enhanced patient care management, health information technology improvements, and organizational ownership/reimbursement models) that helped to reduce costs to the ambulatory care organization. Additional variables (social determinants of health/environmental conditions, lack of integration/standardization, and misalignment of financial incentives) were also identified in the literature as having influenced costs for ambulatory care organizations while participating in an ACO initiative with CMS. Findings can assist ambulatory care organizations to focus on new and optimized strategies as they begin to prepare for the post-pandemic resumption of ACO quality reporting requirements once the emergency declaration is eventually lifted. 

Addressing Social Determinants of Health Identified by Systematic Screening in a Medicaid Accountable Care Organization: A Qualitative Study 

Date: February 12, 2021
Source: Journal of Primary Care & Community Health
Article 

Systematic screening for social determinants of health (SDOH), such as food and housing insecurity, is increasingly implemented in primary care, particularly in the context of ACOs. This study’s objective was to explore facilitators and barriers to addressing SDOH identified by systematic screening in a healthcare system participating in a Medicaid ACO. This qualitative case study took place between January and March 2020. Semi-structured interviews were conducted with 15 staff (8 community resource staff and 7 managers) from community health centers and hospitals affiliated with a large healthcare system. Facilitators for addressing SDOH included maintaining updated resource lists, collaborating with community organizations, having leadership buy-in, and developing a trusting relationship with patients. Barriers to addressing SDOH included high caseloads, time constraints, inefficiencies in tracking, lack of community resources, and several specific patient characteristics. Further, resource staff expressed distress associated with having to communicate to patients that they were unable to address certain needs. Health system, community, and individual-level facilitators and barriers should be considered when developing programs for addressing SDOH. Specifically, the psychological burden on resource staff is an important and underappreciated factor that could impact patient care and lead to staff burnout. 

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

Date: January 29, 2021
Source: Journal of General Internal Medicine
Article 

ACOs, patient-centered medical homes (PCMHs), and the meaningful use of electronic health records (EHRs) generated particular attention during the last decade. Translating these reforms into meaningful increases in population health depends on improving the quality and clinical integration of primary care providers (PCPs). However, if these innovations spread more quickly among PCPs in urban and wealthier areas, then they could potentially worsen existing geographic disparities in health outcomes. This study examined the market penetration of Medicare Shared Savings Program (MSSP) ACOs, PCMHs, and the meaningful use of EHRs among PCPs across urban and rural Ohio counties. In 2015, the Ohio primary care market penetration of PCMH was 23.4%, ACO was 27.7%, HER meaningful use (MU) stage 1 was 55.8%, and MU stage 2 was 26.6%. By 2018, PCMH and ACO market penetration increased faster in urban counties relative to rural counties, and market penetration of meaningful use of EHR increased faster in rural counties. Market penetration of PCMH and ACOs increased faster in urban markets compared to rural markets. However, the adoption of EHRs increased faster in rural markets. The results are a cause for optimism as well as a call to action: although recent efforts to increase PCMH and ACO adoption were less effective among the rural population in Ohio, federal programs to accelerate adoption of EHRs were overwhelmingly successful in rural areas.

The Effects of Accountable Care Organizations Forming Preferred Skilled Nursing Facility Networks on Market Share, Patient Composition, and Outcomes

Date: January 19, 2021
Source: Medical Care
Article

To improve management and coordination of post-discharge care, ACOs are establishing closer relationships with skilled nursing facilities (SNFs) through the formation of preferred SNF networks. The study evaluated the effects of preferred SNF network formation on care patterns and outcomes in 10 ACOs between 2014 and 2015. Researchers first investigated whether hospitals “steer” patients to preferred SNFs by examining the percentage of patients sent to preferred SNFs within each hospital before and after network formation. Researchers then used a difference-in-difference model with SNF fixed effects to evaluate the changes in patient composition and outcomes of preferred SNF patients from ACO hospitals after network formation relative to patients from other hospitals. The study found that preferred network formation was not associated with higher market share or better outcomes for preferred SNF patients from ACO hospitals. However, researchers found a small increase in the average number of Elixhauser comorbidities for patients from ACO hospitals after network formation, relative to patients from non-ACO hospitals. The study concluded that ACO hospitals sent more complex patients to preferred SNFs, but there was no change in the volume of patients received by these SNFs. Furthermore, preferred network formation was not associated with improvement in patient outcomes. 

Effectiveness of a Nurse-Led Multidisciplinary Intervention vs Usual Care on Advance Care Planning for Vulnerable Older Adults in an Accountable Care Organization: A Randomized Clinical Trial 

Date: January 11, 2021
Source: JAMA Internal Medicine
Article

The study examined whether a nurse navigator-led pathway and an integrated health care professional-facing electronic health record (EHR) discussion documentation interface increase advance care planning (ACP) documentation among vulnerable older adults compared with usual care. The study population included patients 65 years or older with multi-morbidity combined with either cognitive or physical impairments, and/or frailty, assessed from 8 primary care practices in North Carolina ACOs. Participants were randomized to either a nurse navigator-led ACP pathway (n = 379) or usual care (n = 380). Among 759 randomized patients (mean age 77.7 years, 455 women [59.9%]), the nurse navigator-led ACP pathway resulted in a higher rate of ACP documentation (42.2% vs 3.7%, P < .001) as compared with usual care. For patients randomized to the nurse navigator-led ACP pathway, ACP billing codes were used more frequently (25.3% vs 1.3%, P < .001); a surrogate decision maker was designated more frequently (64% vs 35%, P < .001); and ACP legal forms were more likely to be completed (24.3% vs 10.0%, P < .001).  A nurse navigator-led ACP pathway integrated with a health care professional–facing EHR interface increased the frequency of ACP discussions and their documentation. Additional research will be required to evaluate whether increased EHR documentation leads to improvements in goal-concordant care. 

Estimating Heterogeneous Effects of a Policy Intervention Across Organizations when Organization Affiliation Is Missing for the Control Group: Application to the Evaluation of Accountable Care Organizations 

Date: January 4, 2021
Source: Health Services and Outcomes Research Methodology
Article

This study examined the effects of Medicare ACO programs on hospital admissions across hospital referral regions and provider groups between 2009 and 2014. To conduct the analysis, a model for a difference-in-difference study was embellished in multiple ways to account for intricacies and complexity with the data not able to be accounted for using existing models. Of particular note, researchers propose a Gaussian mixture model to account for the inability to observe the practice group affiliation of physicians if the organization they worked for did not become an ACO, which is needed to ensure appropriate partitioning of variation across the different units. The results suggest that the ACO programs reduced the rate of readmission to hospital, that the ACO program may have reduced heterogeneity in readmission rates, and that the effect of joining an ACO varied considerably across medical groups. 

Overlap Between Medicare’s Comprehensive Care for Joint Replacement Program and Accountable Care Organizations 

Date: January 2021
Source: Health Policy & Economics
Article

Overlap between Medicare’s Comprehensive Care for Joint Replacement (CJR) model and ACOs may result in positive or negative synergies. This study examined the overlap between the programs at the beneficiary and hospital levels. Researchers conducted a retrospective study of patient and hospital characteristics using data from 2016 Medicare claims and other sources. On the beneficiary level, researchers conducted two comparisons: (1) among patients who received joint replacement at CJR hospitals, ACO patients (overlap) vs not (CJR-only) and (2) among patients who received joint replacement elsewhere, ACO patients (ACO-only) vs not (neither). On the hospital level, researchers compared hospitals in the top quartile of overlap rate (high overlap) vs those in the bottom 3 (low overlap). They studied 14,519 overlap, 38,972 CJR-only, 26,872 ACO-only, and 68,945 neither beneficiaries. Compared with CJR-only patients, the overlap group was less likely to be older than 85, of Black race, of low socioeconomic status, and burdened with clinical complications. Similar results were observed when the ACO-only group was compared with the neither group. Compared with low overlap hospitals, high overlap ones were more likely to be nonprofit and less likely to be safety net. CJR-ACO overlap is associated with differences in beneficiary and hospital characteristics. 

Despite Early Success, Vermont’s All-Payer Waiver Faces Persistent Implementation Challenges: Lessons From The First Four Years 

Date: January 5, 2021
Source: Health Affairs Blog
Article

In 2016, Vermont was granted a CMS waiver, which allows ACOs in the state to receive payments from Medicare, Medicaid, and commercial insurance and then align payments and quality measures for providers. The all-payer ACO eliminates distinctions between payer sources, theoretically allowing providers to synchronize care and create care efficiencies. The goal of the waiver is to shift the entire state from a fee-for-service payment model to a value-based reimbursement model, with targets for spending growth, population health, and care quality. No other state has such broad waiver authority to redesign health care statewide. The five-year targets for the model are ambitious: no more than 3.5 percent annual cost growth across all payers, 70.0 percent population enrollment into the model—90.0 percent for Medicare—and improved health outcomes ranging from lowered suicide rates to reductions in chronic disease incidence. The post highlights five major challenges that the Vermont health system is currently grappling with: how to incentivize providers to participate; how to attribute patients to providers; how to pay for value; the pernicious effect of fee-for-service benchmarks, and deciding who bears financial risk among providers. 

The Effects of a Multifaceted Intervention to Improve Care Transitions Within an Accountable Care Organization: Results of a Stepped-Wedge Cluster-Randomized Trial 

Date: January 2021
Source: Journal of Hospital Medicine
Article

The study examined the effectiveness of interventions to improve care transitions from hospital to the ambulatory setting to minimize risks for patients in terms of adverse events, poor clinical outcomes, and readmission. The study included 1,679 adult patients who belonged to one of 17 primary care practices and were admitted to a medical or surgical service at either of two participating hospitals within a pioneer ACO. The multicomponent intervention in the 30 days following hospitalization included inpatient pharmacist-led medication reconciliation, coordination of care between an inpatient “discharge advocate” and a primary care “responsible outpatient clinician,” post-discharge phone calls, and a post-discharge primary care visit. The primary outcome was rate of post-discharge adverse events, as assessed by a 30-day post-discharge phone call and medical record review and adjudicated by two blinded physician reviewers. Secondary outcomes included preventable adverse events, new or worsening symptoms after discharge, and 30-day non-elective hospital readmission. Among patients included in the study, 692 were assigned to usual care and 987 to the intervention. Patients in the intervention arm had a 45% relative reduction in post-discharge adverse events (18 vs 23 events per 100 patients; adjusted incidence rate ratio, 0.55; 95% CI, 0.35-0.84). Significant reductions were also seen in preventable adverse events and in new or worsening symptoms, but there was no difference in readmission rates.