2020 ACO Research
Post-Acute Care for Medicare Beneficiaries in Accountable Care Organizations
Date: December 16, 2020
Source: Innovation in Aging
Article
As part of the evaluation of the Centers for Medicare & Medicaid Services (CMS) Next Generation ACO (NGACO) Model, researchers examined NGACOs’ approaches to post-acute care (PAC) services and the impact of these efforts on utilization and cost. Researchers conducted interviews and surveys with NGACO leadership and providers and performed a difference-in-differences analysis of utilization and spending based on Medicare claims data. The study found that NGACOs focused specifically on establishing partnerships with skilled nursing facilities (SNF) to facilitate transitions in care by establishing new channels of communication, sharing performance data, embedding staff in SNFs, and (in some cases) sharing financial risk. The study found a statistically significant decrease in SNF spending, a trend toward fewer SNF days, and statistically significantly lower expenditures for other PAC settings (e.g., inpatient rehabilitation and long-term acute care facilities). These findings suggest that NGACOs have contributed to improving transitions in care and diverting beneficiaries from intensive PAC settings. Nonetheless, the reduction in PAC spending alone did not translate to a decline in total cost of care. Future ACOs may need to expand their focus to the inpatient utilization and spending that precedes PAC to impact total cost of care.
Evaluating a Pharmacist-Led Intervention on Cardiovascular- and Diabetes-Related Quality Measures in a Primary Care-Based Accountable Care Organization
Date: December 11, 2020
Source: Journal of Pharmacy Practice
Article
This study evaluated the impact of pharmacist-led interventions on cardiovascular- (CV) and diabetes-related quality measures within a primary care-based ACO. The study focused on the following quality measures: ACO-27 (Diabetes Mellitus: Hemoglobin A1c Poor Control); ACO-41 (Diabetes: Eye Exam); and ACO-42 (Statin Therapy for the Prevention and Treatment of Cardiovascular Disease. Of 105 patients meeting study inclusion criteria, 77.1% were on statin therapy prior to intervention. After pharmacist intervention, the prevalence of patients on statin therapy increased to 80.0% (p = 0.083). All patients had a HbA1c less than 9% pre-intervention. Sixty-one (58.1%) patients had a documented dilated eye exam prior to intervention. Post-intervention, the prevalence of exams increased to 73.3% (p < 0.0005). Pharmacists can assist primary care providers in the ACO setting meet CV- and diabetes-related quality measures, demonstrating the value of the pharmacist in value-based health care settings.
Prospective or Retrospective ACO Attribution Matters for Seriously Ill patients
Date: December 8, 2020
Source: American Journal of Managed Care
Article
Since 2019, the Medicare Shared Savings Program has allowed ACOs to choose either retrospective or prospective attribution of beneficiaries. To understand how ACOs’ choice of attribution method affects incentives for care among seriously ill Medicare beneficiaries, this study compared beneficiary characteristics and Medicare per capita expenditures between prospective and retrospective attribution of ACO populations. The study describes survival, patient characteristics, and Medicare spending for Medicare fee-for-service beneficiaries identified with serious illness (n = 1,600,629) during 2014-2016. Compared with retrospectively attributed Medicare ACO populations, prospectively attributed Medicare ACO populations included more decedents and had higher per-beneficiary per-year expenditures among seriously ill Medicare beneficiaries. In evaluating ACO financial performance, the Medicare Shared Savings Program truncates the extremely high costs of 1 in 4 decedents, substantially reducing the difference in per capita expenditures between prospectively and retrospectively attributed ACO populations. The difference in survival and spending for ACO populations captured by prospective vs. retrospective attribution methods means that ACOs may need to employ different care management strategies to improve performance depending on their attribution method.
Differences in Savings and Quality by Type of ACO Model
Date: December 8, 2020
Source: American Journal of Accountable Care
Article
This study examined differences in savings and quality scores across Medicare
Shared Savings Program (MSSP) ACOs and Next Generation ACOs (NGACOs). Researchers studied 737 unique ACOs (680 MSSP ACOs and 74 NGACOs, with 17 ACOs switching from one type of ACO to the other) from 2016 to 2018. On average, the NGACOs had more aligned beneficiaries, but no statistically significant differences emerged in average gross savings ($1.90 million for NGACOs vs $2.21 million for MSSP ACOs; P = .78) after adjusting for size and fixed effects. The study also found mostly insignificant differences across 37 quality measures used to calculate the share of savings that ACOs receive. NGACO and MSSP cost and quality data show similar performance, suggesting that increasing financial risk to health systems may not affect performance.
Accountable Care Organizations and Spending for Patients Undergoing Long-Term Dialysis
Date: November 2020
Source: Clinical Journal of the American Society of Nephrology
Article Link
The study examined the association between ACO alignment and total spending for long-term dialysis beneficiaries prior to ACO implementation (2009-2011) through implementation of the Comprehensive End State Renal Disease Care model in October 2015. During the study period, 135,152 beneficiaries on long-term dialysis were identified. The percentage of long-term dialysis beneficiaries aligned to an ACO increased from 6% to 23% from 2012 to 2016. Spending on ACO-aligned beneficiaries was $143 (95% confidence interval, $5 to $282) less per beneficiary-quarter than spending for nonaligned beneficiaries. In analyses stratified by whether beneficiaries received care from a primary care physician, savings by ACO-aligned beneficiaries were limited to those with care by a primary care physician ($235; 95% confidence interval, $73 to $397). There was a substantial increase in the percentage of long-term dialysis beneficiaries aligned to an ACO from 2012 to 2016. Moreover, in adjusted models, ACOs were associated with modest cost savings among long-term dialysis beneficiaries with care by a primary care physician.
Evolution of ACO Readiness to Optimize Medication Use: Are We There Yet?
Date: November 2020
Source: Journal of Managed Care and Specialty Pharmacy
Article Link
This article examines how ACO capabilities to support, monitor, and ensure appropriate medication use for enrollees have changed since 2014. Such capabilities include the ability to transmit prescriptions electronically; view prescription and medical data in a single system; encourage generics when appropriate; communicate and manage potential adverse medication interactions; integrate a clinical pharmacist into care teams; and engage patients in treatment decisions and outcomes. As the ACO model has matured over time, a growing body of evidence-based research and resources has identified key factors associated with successful ACOs, including strategies for optimizing the use and value of medications. Given the vital role and value of medications in treating chronic conditions and other diseases, optimizing medication use inside and outside of accountable care environments can help improve patient outcomes and contain costs.
The Past Decade of Paying for Value: From the Affordable Care Act to COVID-19
Date: November 2020
Source: North Carolina Medical Journal
Article Link
The article examines the role of the Affordable Care Act in transitioning American health care away from fee-for-service payment and explores the spread of payment reforms, including ACOs, since the implementation of the ACA, both nationally and in North Carolina; the corresponding effects on health care costs and quality; and further steps needed to achieve greater transformation.
Understanding the Latest ACO “Savings”: Curb Your Enthusiasm and Sharpen Your Pencils
Date: November 12 and 13, 2020
Source: Health Affairs Blog
Article Links: Part 1 and Part 2
This analysis provides a rigorous and nuanced interpretation of Medicare Shared Savings Program (MSSP) ACO performance data, describes problems with the program’s design, lays out key considerations for improving the MSSP over the long haul, and discusses how to strengthen ACO incentives to save in the MSSP while encouraging ACO participation and advancing the program’s broader goals.
Evaluation of Medicare Alternative Payment Models: What the Data Show
Date: November 12, 2020
Source: Health Affairs Blog
Article Link
This analysis of the evaluations of more than a dozen Medicare value-based initiatives over the past eight years showed that no other alternative payment model (APM) came close to the cost savings associated with ACO models. After years of testing myriad APMs, data show that population-focused, total cost of care models are consistently producing savings that episodic-based or disease-specific models are not. While the Centers for Medicare & Medicaid Services continues to experiment by rolling out new models and fine-tune existing ones, we have enough evidence now to support what is working better. Based on these results, it may be time to slow the proliferation of narrowly focused APMs and place priorities on how to expand and improve the population-focused accountable care model.
How ACOs in Rural and Underserved Areas Responded to Medicare’s ACO Investment Model
Date: November 10, 2020
Source: Health Affairs Blog
Article Link
Rural areas have lagged urban areas in establishing Medicare ACOs. To help establish ACOs in more areas of the country, the Centers for Medicare and Medicaid Services (CMS) developed the ACO Investment Model (AIM) to provide participating ACOs with up-front and ongoing monthly payments over 24 months to fund ACO infrastructure investments and staffing. As part of the Medicare Shared Savings Program (MSSP), the payments were to be recouped through any shared savings earned by the ACOs that sufficiently decreased costs relative to a financial benchmark. Forty-one new MSSP ACOs, primarily located in rural and underserved health care markets, joined AIM in 2016. An evaluation of the AIM ACO implementation and impacts over the three performance years (2016 to 2018) examined the close partnerships with management companies formed by AIM ACOs; strategies—beyond local care coordination—for reducing spending in dispersed markets adopted by AIM ACOs; and the extent to which single-sided financial risk may suffice to induce care transformations.
Medicare Accountable Care Organizations and the Adoption of New Surgical Technology
Date: October 25, 2020
Source: Journal of the American College of Surgeons
Article Link
The study compared the rate of surgical treatment and use of newer surgical technology for various procedures in ACO and non-ACO hospitals using a 20% sample of 2010-2015 Medicare claims data. Researchers identified hospitals that performed 1 of 6 sets of procedures: abdominal aortic aneurysm repair, aortic valve replacement, carotid endarterectomy or stent, lung lobectomy, colectomy, and prostatectomy and then identified hospitals participating in a Medicare Shared Savings Program ACO and a set of matched non-ACO control hospitals. Using a difference-in-differences approach to compare the rate of surgical treatment and use of newer surgical technology for each set of procedures in ACO and non-ACO hospitals, the study included 707 ACO-hospitals and 1770 control hospitals. ACO-hospitals performed surgery for carotid stenosis at a lower rate than non-ACO hospitals. There was no difference in rate of surgical treatment for all other procedure sets. ACO-hospitals were less likely to use an endovascular approach for abdominal aortic aneurysm repair (85.2% v 88.2%, p<0.001) and more likely to use a minimally invasive approach for lung lobectomy (42.2% v 34.7%, p=0.004) than non-ACO hospitals. In difference-in-differences analysis, ACO participation was not associated with any significant difference in use of surgical care for any of the 6 procedure sets, nor with any significant difference in use of newer surgical technology. Despite ACO policy incentives to selectively adopt newer surgical technology, ACO participation was not associated with differences in rate of surgery or use of newer surgical technology for 6 major surgical procedures.
The Medicare Shared Savings Program In 2019: Positive Results During Major Transitions And On The Eve Of A Pandemic
Date: October 20, 2020
Source: Health Affairs Blog
Article Link
In performance year 2019, Medicare Shared Savings Program (MSS) ACOs continued to show year-over-year improved financial performance, generating $1.2 billion in net savings to the Center for Medicare & Medicaid Services’ (CMS) benchmarks. Actual savings may even be larger since comparing an ACO against its program benchmarks may substantially underestimate true savings. Notably, 2019 was the first year CMS enacted “Pathways to Success,” the most significant redesign of MSSP to date. Pathways to Success policies accelerated the time frame for ACOs to transition to “downside risk” and revised methodologies for calculating benchmarks, shared losses, quality scores, and other key performance specifications. The program, which went into effect on July 1, 2019, resulted in more ACOs of all types in downside risk than in any prior year. Unlike prior years, CMS extended the application period (from January 1, 2019, to July 1, 2019) for ACOs to join or renew participation in MSSP after the Pathways rule went into effect, creating multiple cohorts of ACOs for 2019, with some dropping out mid-year, some joining mid-year, and still others changing their track (from a legacy MSSP track to a Pathways track) in the middle of the year. This complexity limited the ability to draw comparisons to prior years and discern clear program effects over time. Despite these limitations, some key findings include:
- The MSSP achieved net savings for the third year in a row. Net program savings exceeded $1.2 billion, although the bulk of these savings (70 percent) came before Pathways went into effect.
- Similar to 2018 results, all types and sizes of ACOs averaged net savings per capita.
- The majority of ACOs across different cohorts achieved savings relative to their benchmark, and the percent of ACOs achieving shared saving bonuses increased from 37 percent in 2018 to 50 percent in the legacy track and 57 percent under Pathways.
- Nearly half (47 percent) of ACOs in Pathways adopted two-sided risk models. However, fewer than half of ACOs elected to transition to Pathways tracks mid-year (in July 2019), and those that did transition had more experience on average, which likely reflected self-selection bias.
- Nearly three-quarters of ACOs that accepted downside risk in either track achieved shared savings, compared to fewer than half of ACOs in upside-only risk arrangements.
- The majority of ACOs remained in the legacy MSSP track (57 percent), a few ACOs dropped out mid-year (5 percent), and the proportion of new entrants was modest (12 percent). While overall net savings increased in 2019, sustained impact depends on the participating ACOs achieving greater net savings and helping greater numbers of ACOs successfully participate in the program. It is therefore critical to develop policy tools to encourage continued participation while simultaneously meeting CMS’ stated goal of transitioning all ACOs into downside risk.
Accountable Care Hospitals and Preventable Emergency Department Visits for Rural Dementia Patients
Date: October 7, 2020
Source: Journal of the American Geriatrics Society
Article Link
This study examined urban/rural differences in the frequency of preventable emergency department (ED) visits among patients with Alzheimer’s disease and related dementias (ADRD), with a focus on the variation of ACO participation status for hospitals in urban and rural areas.
Researchers used the 2015 State Emergency Department Databases, the American Hospital Association Annual Survey of Hospitals, and the Area Health Resource File to conduct a cross-sectional study using individual‐, county‐, and hospital‐level characteristics and state fixed effects for model specification. The study included 117,196 patients with ADRD from seven states who visited the ED and had routine discharges. The outcome was preventable ED visits classified using the New York University Emergency Department visit algorithm. Rural patients with ADRD had 1.13 higher adjusted odds (P = .007) of going to the ED for a preventable visit compared with their urban counterparts. In addition, ACO‐affiliated hospitals had .91 lower adjusted odds (P = .005) of preventable ED visits for ADRD patients compared with hospitals not affiliated with an ACO. ACO delivery systems have the potential to decrease rural preventable ED visits among ADRD patients.
Association of Use of an Integrated Specialty Pharmacy with Total Medical Expenditures Among Members of an Accountable Care Organization
Date: October 6, 2020
Source: JAMA Network Open
Article Link
The study examined the association between the use of integrated specialty pharmacies and total medical expenditure (TME) among members of the largest ACO in central Massachusetts— UMass Memorial Medicare ACO (UMMACO). Using data from January 2016 through December 2018, patients receiving care from a specialty department were assigned to the intervention group if they were enrolled in the UMMACO integrated specialty pharmacy at the start of the study period and the control group if they were not. Their status did not change throughout the study period. To account for baseline differences between the groups, patients were matched on age, sex, and level of care based on the UMMACO risk stratification model for care management. The outcome was the per-member per-month costs (PMPM) of TME, which were calculated for each month during the study period. After adjusting for comorbidities, PMPM costs were similar in 2016 but increased for patients who did not use the integrated specialty pharmacy while decreasing for those who did. Costs decreased by $267 (95% CI, −$1,586 to $1,052) for those who did use integrated specialty pharmacy while increasing by $1,007 (95% CI, $270 to $1,743) for patients who did not. The difference of difference for average net savings of integrated specialty pharmacy users vs. nonintegrated specialty pharmacy users was $1,274; however, this difference was not statistically significant (95% CI, −$215 to $2764) for the sample in this study. The findings suggest that integrated specialty pharmacy use by patients enrolled in UMMACO is associated with net savings of more than $1,000 per month from 2016 to 2018 compared with matched counterparts within UMMACO who did not use an integrated specialty pharmacy. Although not statistically significant, the magnitude of health care savings is notable in the context of previous findings of much smaller savings.
Translating Evidence into Practice: ACOs’ Use of Care Plans for Patients with Complex Health Needs
Date: October 1, 2020
Source: Journal of General Internal Medicine
Article Link
This qualitative study examined how Medicare ACOs use care plans to manage patients with complex clinical needs. Researchers conducted 39 semi-structured interviews across 18 Medicare ACOs with executive-level leaders and associated clinical and managerial staff.
Most (11) of the interviewed ACOs reported using care plans to manage care of complex patients. All care plans include information about patient history, current medical needs, and future care plans. Beyond the core elements, care plans included elements based on the ACO’s planned use and level of staff and patient engagement with care planning. Most care plans were developed and maintained by care management (not clinical) staff. ACOs are using care plans for patients with complex needs, but their use of care plans does not always align with prescribed best practices. Additionally, ACOs are adapting use of care plans to better fit the needs of patients and providers.
Health Care Leader Perspectives on State Government–Sponsored Accountable Care for Public Employees
Date: September 16, 2020
Source: American Journal of Accountable Care
Article Link
Most studies of ACOs have focused on contracts with commercial payers, Medicare, or Medicaid. This study describes implementation of an ACO for public employees, contracted by Washington state government under a federally funded State Innovation Model grant. Researchers conducted 17 semi-structured qualitative interviews with 20 clinical and administrative representatives of five participating health care systems and identified key themes in ACO implementation, with a focus on the role of state government. Respondents discussed conditions for ACO adoption, components of implementation, likely effectiveness, and expectations about sustainability. The state government influenced ACO development by creating opportunities for innovation in care delivery, leveraging purchasing power, providing data, developing and maintaining strategic contracts, and encouraging public employees to enroll in accountable care plans. In some organizations, the ACO may have had a spillover effect, improving care for patients who were not public employees. Findings indicate that this state-led ACO shared traits with other public ACOs contracted under Medicare and Medicaid. By implementing an ACO for public employees, state governments may serve as catalysts in improvements in health care and influence the direction of payment reform.
Medicare Accountable Care Organizations Reduce Spending on Surgery
Date: September 15, 2020
Source: American Journal of Accountable Care
Article Link
The study examines the impact that Medicare Shared Savings Program (MSSP)ACO alignment has on spending for inpatient and outpatient surgical care using national 2008-2005 Medicare claims. Among a 20% random national sample of beneficiaries, researchers identified adults 65 years or older enrolled in fee-for-service Medicare, distinguishing between those aligned and unaligned with a MSSP ACO. Researchers then evaluated the association between ACO alignment and spending for inpatient and outpatient surgical care. The study identified 37,249,845 beneficiary-year observations, of which 2,950,188 (7.9%) were aligned with an ACO. After adjustment for patient factors, ACO alignment was associated with $181 lower spending per beneficiary-year (95% CI, –$243 to –$118; P < .001). ACO alignment was associated with 2.9% fewer inpatient surgical episodes per year (incidence rate ratio, 0.97; 95% CI, 0.96-0.98; P < .001), but 2.3% more outpatient episodes per year (incidence rate ratio, 1.02; 95% CI, 1.02-1.03; P < .001). Among inpatient surgical episodes, average payments were $956 lower for ACO-aligned beneficiaries (95% CI, –$1218 to –$694; P < .001). The study concluded that MSSP ACO alignment was associated with savings on surgical care resulting from increased use of outpatient surgery and reduced use of inpatient surgery, as well as reduced spending per inpatient surgical episode. Greater focus on surgical care may improve the ability of ACOs to control health care spending.
Promoting Pediatric Preventive Visits Through Quality Improvement Initiatives in the Primary Care Setting
Date: September 2, 2020
Source: The Journal of Pediatrics
Article Link
The study evaluated if quality improvement (QI) capacity-building in affiliated primary care practices in a Medicaid ACO could increase well-child visits (WCVs). Partners For Kids (PFK) is an ACO caring for pediatric Medicaid enrollees in Ohio. PFK QI specialists recruited practices to develop QI projects around increasing WCV rates (proportion of eligible children with WCV during calendar year) for children aged 3 to 6 years and adolescents. The QI specialists supported practice teams in implementing interventions and collecting data through monthly or bimonthly practice visits. Ten practices, serving over 26,000 children, participated in QI projects for a median of 8.5 months (interquartile range: 5.3-17.6). WCV rates in the QI-engaged practices significantly improved from 2016 to 2018 (P < .001 for both age groups). Over time, WCV rates for 3- to 6-year-olds increased by 11.8% (95% CI: 5.4% to 18.2%) in QI-engaged practices, compared with 4.1% (95% CI: 0.1% to 7.4%) in non-engaged practices (p=0.233). For adolescents, WCV rates increased 14.3% (95% CI: -2.6% to 31.2%) compared with 5.4% (95% CI: 1.8% to 9.0%) in QI-engaged vs non-engaged practices over the same period (p=0.215). Although not statistically significant, QI-engaged practices had greater magnitudes of rate increases for both age groups. Through practice facilitation, PFK helped a diverse group of community practices substantially improve preventive visit uptake over time. QI programs in primary care can reach patients early to promote preventive services that potentially avoid costly downstream care.
PharmValCalc: A Calculator Tool to Forecast Population Health Pharmacist Impact
Date: September 2020
Source: Research in Social and Administrative Pharmacy
Article Link
The study describes development of a population health pharmacist (PHP) value calculator to forecast pharmacist staffing, care quality impact, and ROI; provides examples of PHP value through ACO stakeholder perspectives; and discusses the use of the pharmacist value calculator to engage pharmacy, clinical, administrative, and financial leaders in discussions to initiate or expand pharmacist integration within population health initiatives. The role of the pharmacist in population health is evolving as healthcare payment moves toward population-based, value-driven care. However, challenges remain in identifying optimal pharmacist use population health initiatives to maximize quality and cost performance. PharmValCalc was developed to demonstrate the value proposition for PHP interventions. PharmValCalc can be used to forecast PHP impact to: (1) reduce preventable, medication-related 30-day all cause hospital readmissions and emergency department (ED) visits for elderly patients, and (2) improve medication-related quality performance for patients with uncontrolled diabetes and hypertension. PharmValCalc forecasts the required PHP full-time equivalents (FTEs), care quality performance goal improvement, and return on investment (ROI). While other pharmacist impact calculators have been developed, PharmValCalc is uniquely designed for the common PHP interventions listed previously. In addition, provider executives verified that the estimated calculator outputs for each outcome (i.e., PHP FTE, care quality goal performance, and ROI) are within acceptable ranges to justify new or expanded PHP interventions in different ACO settings. PharmValCalc is a pragmatic tool for pharmacists and pharmacy leaders in value-based organizations to use when planning the initiation or expansion of PHP interventions with executive-level medical or administrative decision-makers.
Putting Providers At-Risk through Capitation or Shared Savings: How Strong are Incentives for Upcoding and Treatment Changes?
Date: September 1, 2020
Source: The Journal of Mental Health Policy and Economics
Article Link
Alternative payment models, including ACOs and fully capitated models, change incentives for treatment over fee-for-service models and are widely used in a variety of settings. The level of payment may affect the assignment to a payment category, but to date the upcoding literature has been motivated largely by incorporating financial penalties for upcoding rather than by a theoretical model that incorporates the downstream effects of upcoding on service provision requirements. In this study, researchers developed a new theoretical model that is applicable to capitated, case-rate, and shared-savings payment systems and incorporates the downstream effects of upcoding on service provision requirements rather than just the avoidance of penalties. This difference is important, especially for shared-savings models with quality benchmarks.
Researchers tested implications of the theoretical model on changes in severity determination and service use associated with changes in case-rate payments in a publicly funded mental health care system. Modeling provider-assigned severity categories as a function of risk-adjusted capitated payments using conditional logit regressions and counts of service days per month using negative binomial models, the study found that severity determination is only weakly associated with the payment rate, with relatively small upcoding effects, but that level of use shows a greater degree of association. The results are consistent with theoretical predictions where the marginal utility of savings or profit is small, as would be expected from public sector agencies. Upcoding did seem to occur, but at very small levels and may have been mitigated after the county and providers had some experience with the new system. The association between the payment levels and the number of service days in a month, however, was significant in the first period, and potentially at a clinically important level. Providers were not at risk for inpatient services but decreases in use of outpatient services associated with rate decreases may lead to further increases in inpatient use and therefore expenditures over time. Health program directors and policy makers need to be acutely aware of the interplay between provider payments and patient care and eventual health and mental health outcomes. Further research could examine the implications of the theoretical model of upcoding in other payment systems, estimate the power of the tiered-risk systems, and examine their influence on clinical outcomes.
Accountable Care Organizations and Post-Acute Care: A Focus on Preferred SNF Networks
Date: August 2020
Source: Medical Care Research and Review
Article Link
Due to the high magnitude and variation in spending on post-acute care, ACOs are working to transform management of hospital discharges through relationships with preferred skilled nursing facilities (SNFs). Using a mixed-methods design, researchers examined survey data from 366 respondents to the National Survey of ACOs along with 16 semi-structured interviews with ACOs that performed well on cost and quality measures. Survey data revealed that over half of ACOs had no formal relationship with SNFs; however, the majority of ACO interviewees had formed preferred SNF networks. Common elements of networks included a comprehensive focus on care transitions beginning at hospital admission, embedded ACO staff across settings, solutions to support information sharing, and jointly established care protocols. Misaligned incentives, unclear regulations, and a lack of integrated health records remained challenges, yet preferred networks are beginning to transform the ACO post-acute care landscape.
Understanding Medicare ACO Adoption in the Context of Market Factors
Date: August 10, 2020
Source: Population Health Management
Article Link
Medicare ACOs have achieved high-quality performance and recent cost savings, but little is known about how local market conditions influence provider adoption. This study describes physician practice participation in Medicare ACOs at the county level and uses adjusted logistic regression to assess the association between ACO presence and three characteristics hypothesized to influence ACO formation: physician market concentration, Medicare Advantage (MA) penetration, and commercial health insurance market concentration. Analyses are repeated on urban and rural county subgroups to examine geographic differences in ACO adoption. Practice participation in ACOs grew 19% nationally from 5.4% to 6.4% of practices between 2015 to 2017, but participation lagged in the west and rural counties, the latter of which had relatively concentrated physician markets and low MA penetration. After controlling for urban location, population density, and other covariates, ACO presence in a county was independently associated with less concentrated physician markets and moderate MA penetration but not commercial insurance concentration. The evidence suggests that Medicare ACO programs have continued appeal to physician practices, but additional engagement strategies may be needed to expand adoption in rural areas. In addition, greater practice competition and MA experience may facilitate ACO adoption. These insights into the relationship between market conditions and ACO participation have important implications for policy efforts to accelerate Medicare payment transformation.
Accountable Care Organizations Are Associated with Savings Among Medicare Beneficiaries with Frailty
Date: August 31, 2020
Source: Journal of General Internal Medicine
Article Link
The study used a difference-in-differences analysis to compare changes in Medicare spending for older adults with frailty before and after entry to a MSSP ACO with a comparison group of patients in the same hospital-referral region served by providers not participating in ACOs. Using Medicare claims data from 2009 to 2016, the study found that by 2016 the mean differential change was -$253 per person among those enrolled in ACOs. Significant spending reductions also were observed for post-acute care facilities among beneficiaries enrolled in ACOs vs. those not in ACOs.
Outcomes and Cost among Medicare Beneficiaries Hospitalized for Heart Failure Assigned to Accountable Care Organizations
Date: August 2020
Source: American Heart Journal
Article Link
The study examines the impact of ACOs on hospitalized heart failure (HF) patients, a high-cost and high-risk population. Researchers linked Medicare fee-for-service claims from 2013 to 2015 with data from the American Heart Association Get With The Guidelines–HF registry to compare HF care, post-discharge outcomes, and total annual Medicare spending by ACO status at discharge. The study included 45,259 HF patients from 300 hospitals, with 21.1% assigned to an ACO. Patient characteristics were similar between the two groups with a few exceptions. The ACO patients lived in geographic areas with higher median income ($54,400 [IQR $48,600-65,900] vs $52,300 [$45,900-61,200], P < .0001). Compliance with four HF-specific quality measures was modestly higher in the ACO group (80% vs. 76%, P < .0001). In adjusted analysis, ACO status was associated with similar all-cause readmission (HR: 1.03; 99% CI: 0.99, 1.07) but lower risk of 1-year mortality (HR: 0.85; 99% CI: 0.85, 0.90) compared with non-ACO status. Median Medicare spending in the calendar year of hospitalization was similar (ACO $42,737 [IQR $23,011-72,667] vs non-ACO $42,586 [$22,896-72,518], P = 0.06). Among Medicare patients hospitalized for HF, participation in an ACO was associated with similar rates of all-cause readmission and no associated cost reductions compared with non-ACO status. There was a lower risk of 1-year mortality associated with ACO participation, which warrants further evaluation.
MACRA and Accountable Care Organizations: Is It Working?
Date: August 18, 2020
Source: Journal of Ambulatory Care Management
Article Link
The study examined how the Medicare Access and CHIP Reauthorization Act (MACRA) has impacted health care delivery and ACO goals. ACOs have supported improved quality of care through reduction in readmission rates, improved care coordination, and cost savings. MACRA was predicted to further decrease Medicare spending on physician and hospital services. ACOs have had a positive impact on improving health care delivery and have played a significant role in providing exceptional quality of care while also managing to increase cost savings.
We Know Health Is Not Elective: Impacts of COVID-19
Date: August 17, 2020
Source: Population Health Management
Article Link
Several months into the impact of the global COVID-19 pandemic, the authors use the framework of “radical uncertainty” and regional health care data, including from a Pennsylvania-based ACO, to understand current and future health and economic impacts from the pandemic. Four key areas of discussion included are: (1) How did structural health care inequality manifest itself during the closure of all elective surgeries and visits?; (2) How can we really calculate the so-called untold burden that resulted from the closure, with a special emphasis on primary care?; (3) The Pennsylvania experience – using observations from the population of one major delivery ecosystem (Jefferson Health), a major accountable care organization (Delaware Valley ACO), and statewide data from Pennsylvania; and (4) What should be the priorities and focus of the delivery system of the future given the dramatic financial and clinical disruption of COVID-19?
Health Expenditures and Quality Health Services: The Efficiency Analysis of Differential Risk Structures of Medicare Accountable Care Organizations (ACOs)
Date: July 28, 2020
Source: North American Actuarial Journal
Article Link
This study examines various Medicare ACO models, focusing on the level of financial risk assumed, and determines their potential cost reductions. The results indicate that in minimizing health expenditures given quality services, or maximizing quality services given health expenditures, one-sided ACOs are more efficient than two-sided ACOs. Noting that the Centers for Medicare & Medicaid Services has pushed ACOs to assume greater financial risks, the study concludes it may be inadvisable to mandate the transition of ACOs from one-sided to two-sided risk. The study also found that Medicare ACOs should be able to reduce expenditures significantly through efficiency improvement without switching to two-sided tracks. Another finding is that the benchmark expenditures for a significant number of Medicare ACOs are below the efficient expenditures and should be adjusted upward.
Association Between Specialist Compensation and Accountable Care Organization Performance
Date: July 27, 2020
Source: Health Services Research
Article Link
The study examined whether Medicare Shared Savings Program ACOs using cost reduction measures in specialist compensation demonstrated better performance. Researchers used national, cross‐sectional survey data on ACOs (2013‐2015) linked to public‐use data on ACO performance (2014‐2016). The study compared characteristics of ACOs that did and did not report use of cost reduction measures in specialist compensation and determined the association between using this approach and ACO savings, outpatient spending, and specialist visit rates. Of 160 ACOs surveyed, 26 percent reported using cost reduction measures to help determine specialist compensation. ACOs using cost reduction in specialist compensation were more often physician‐led (68.3 vs 49.6 percent) and served higher‐risk patients (mean Hierarchical Condition Category score 1.09 vs 1.05). These ACOs had similar savings per beneficiary year (adjusted difference $82.6 [95% CI −77.9, 243.1]), outpatient spending per beneficiary year (−24.0 [95% CI −248.9, 200.8]), and specialist visits per 1,000 beneficiary years (369.7 [95% CI −9.3, 748.7]). Incentivizing specialists on cost reduction was not associated with ACO savings in the short term. Further work is needed to determine the most effective approach to engage specialists in ACO efforts.
Nurse Practitioner Involvement in Medicare Accountable Care Organizations: Association With Quality of Care
Date: July 26, 2020
Source: American Journal of Medical Quality
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The study examined care quality outcomes associated with nurse practitioner (NP) involvement in ACOs via a cross-sectional study of 521 Medicare Shared Savings Program ACOs during 2014-2016. Data included ACO provider/beneficiary files, Medicare claims, and ACO performance data with a focus on Medicare beneficiaries with diabetes, chronic obstructive pulmonary disease, or heart failure. ACO care quality measures were stratified by NP involvement and adjusted for patient, provider, and ACO factors. NP involvement was highest in larger ACOs, states that allow NPs full scope of practice, and rural areas. Greater involvement was associated with fewer readmissions and higher scores on measures of preventive care but not chronic disease and medication management. Greater NP involvement in ACOs was associated with improvement in some care quality measures.
Savings or Selection? Initial Spending Reductions in the Medicare Shared Savings Program and Considerations for Reform
Date: July 22, 2020
Source: The Milbank Quarterly
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Turnover in ACO physicians and patient panels has raised concerns that Medicare Shared Savings Program (MSSP) ACOs may be earning shared‐savings bonuses by selecting lower‐risk patients or providers with lower‐risk panels. The study included three sets of analyses of Medicare claims data. First, researchers estimated overall MSSP savings through 2015 using a difference‐in‐differences approach and methods that eliminated selection bias from ACO program exit or changes in the practices or physicians included in ACO contracts. They then checked for residual risk selection at the patient level. Second, they re-estimated savings with methods that address undetected risk selection but could introduce bias from other sources. Third, they tested for changes in provider composition or provider billing that may have contributed to bonuses, even if they were eliminated as sources of bias in the evaluation analyses. MSSP participation was associated with modest and increasing annual gross savings in the 2012‐2013 entry cohorts of ACOs that reached $139 to $302 per patient by 2015. Savings in the 2014 entry cohort were small and not statistically significant. Robustness checks revealed no evidence of residual risk selection. Alternative methods to address risk selection produced results that were substantively consistent with the primary analysis but varied somewhat and were more sensitive to adjustment for patient characteristics, suggesting the introduction of bias from within‐patient changes in time‐varying characteristics. The study found no evidence of ACO manipulation of provider composition or billing to inflate savings.
Utilization by Long-Term Nursing Home Residents Under Accountable Care Organizations
Date: July 18, 2020
Source: The Journal of the American Medical Directors Association
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The study examined the association between ACO attribution status and utilization and Medicare spending among long-term Medicare nursing home residents residing in areas with ≥5% ACO penetration. ACO attribution and covariates used in propensity matching were measured in 2013 and outcomes were measured in 2014, including hospitalization (total and ambulatory care sensitive conditions), outpatient emergency department visits, and Medicare spending. Nearly one-quarter (23.3%) of nursing home residents who survived into 2014 (n = 522,085, 76.1% of 2013 residents) were attributed to an ACO in 2013 in areas with ≥5% ACO penetration. After propensity score matching, ACO-attributed residents had significantly ( P < .001) lower hospitalization rates per 1,000 (total: 402.9 vs 419.9; ambulatory care sensitive conditions: 64.4 vs 71.4) and fewer outpatient ED visits (29.9 vs 33.3 per 100) but no difference in total spending ($14,071 vs $14,293 per resident, P = .058). Between 2013 and 2014, a sizeable proportion of residents’ attribution status switched (14.6%), either into or out of an ACO. ACO nursing home residents had fewer hospitalizations and ED visits, but did not have significantly lower total Medicare spending. Among residents, attribution was not stable year over year.
Effective Care Management by Next Generation Accountable Care Organizations
Date: July 14, 2020
Source: The American Journal of Managed Care
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This large-scale, multisite study demonstrated that a standardized complex care management program can consistently reduce utilization and spending for high-risk Medicare populations distributed across diverse geographies. The study estimated the utilization and spending impact of a standardized complex care management program implemented at five Next Generation ACOs (NGACOs). In 2016 and 2017, high-risk Medicare beneficiaries aligned to five geographically diverse NGACOs were identified using predictive analytics for enrollment in a standardized complex care management program. Researchers estimated the program’s impact on all-cause inpatient admissions, emergency department visits, and total medical expenditures (TME) relative to a matched cohort of nonparticipants. Researchers also studied the effects of intervention fidelity on program impact. Participation in the care management program was associated with a 21% reduction in all-cause inpatient admissions (P = .03) and a 22% reduction in TME (P = .02) six months after program completion. Relative spending reductions were 2.1 times greater for high-fidelity interventions compared with overall program participation (P < .001). Centrally staffed complex care management programs can reduce costs and improve outcomes for high-risk Medicare beneficiaries. Integrating predictive risk stratification, evidence-based intervention design, and performance monitoring can ensure consistent outcomes.
Assessing the Short‐Term Association Between Rural Hospitals’ Participation in Accountable Care Organizations and Changes in Utilization and Financial Performance
Date: July 13, 2020
Source: The Journal of Rural Health
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The study examined the association between rural hospitals’ participation in an ACO and their performance on utilization and financial measures. From an initial group of 643 rural hospitals that participated in an ACO for at least one year during the 2011 to 2018 study period and 1,541 rural hospitals that did not participate in an ACO, researchers created a sample of propensity score‐matched hospitals of 525 ACO‐participating and 525 comparable non‐ACO hospitals. Rural hospitals’ participation in an ACO was not associated with changes in hospital utilization or financial measures. Moreover, there was no association between these performance metrics and whether another within‐county hospital participated in an ACO. A secondary analysis limited to critical access hospitals provided some evidence that inpatient utilization increases in the second year of ACO participation, though the increases are not significant in year 3 and beyond. In conclusion, the study found no evidence that rural hospitals experience substantive changes in outpatient visits, inpatient utilization, or operating margin in the years immediately after joining an ACO.
Accountable Care Organizations and Patient-Centered Medical Homes: Health Expenditures and Health Services
Date: July 1, 2020
Source: The American Journal of Accountable Care
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The study compared total health expenditures and health services utilization of patients receiving care in a stand-alone ACO (ACO only), stand-alone patient-centered medical home (PCMH only), hybrid (ACO + PCMH), and standard (neither ACO nor PCMH) facilities. Using 2016 Medical Expenditure Panel Survey data, researchers identified patients 18 years and older who received care at a facility designated as ACO, PCMH, hybrid, or standard. Researchers identified 3,431 patients who received care in facilities designated as ACO (n = 1096), PCMH (n = 355), hybrid (n = 1,219), or standard (n = 761). Unadjusted yearly total health expenditure was significantly higher in the standard care group vs. hybrid ($9,850 vs $8,432; P < .0001), standard vs ACO ($9,850 vs. $8,399; P < .0001), and standard vs PCMH ($9,850 vs. $7,580; P < .0001). Additionally, unadjusted total health expenditure was significantly lower in the PCMH group compared with the ACO, hybrid, and standard care groups. After adjustment, total health expenditure was significantly lower in the ACO (β = –0.12; P = .0189) and PCMH (β = –0.25; P = .0005) groups compared with hybrid but significantly higher in standard care (β = 0.16; P = .0049) compared with hybrid. In conclusion, care received in ACO and PCMH facilities was associated with lower total health care costs compared with standard care. However, hybrid models were associated with slightly higher total health care costs compared with stand-alone models.
Savings or Selection? Initial Spending Reductions in the Medicare Shared Savings Program and Considerations for Reform
Date: July 22, 2020
Source: The Milbank Quarterly
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Participation in the original MSSP program was associated with modest savings and not with favorable risk selection. These findings suggest an opportunity to build on early progress. Understanding the effect of new opportunities and incentives for risk selection in the revamped MSSP will be important for guiding future program reforms. MSSP participation was associated with modest and increasing annual gross savings in the 2012‐2013 entry cohorts of ACOs that reached $139 to $302 per patient by 2015. Savings in the 2014 entry cohort were small and not statistically significant. Robustness checks revealed no evidence of residual risk selection. Alternative methods to address risk selection produced results that were substantively consistent with our primary analysis but varied somewhat and were more sensitive to adjustment for patient characteristics, suggesting the introduction of bias from within‐patient changes in time‐varying characteristics. We found no evidence of ACO manipulation of provider composition or billing to inflate savings. Finally, larger savings for physician group ACOs were robust to consideration of differential changes in organizational structure among non‐ACO providers (eg, from consolidation).
Serious Illness Conversations: A Case Management Quality Improvement Project
Date: July/August 2020
Source: Professional Case Management
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This project developed, implemented, and evaluated an educational program and serious illness protocol for a case management team of nurses and social workers working in an ACO’s primary care clinics. The goals were to: (1) use a protocol to identify patients with a serious illness; (2) elicit patients’ goals and preferences for serious illness care; and (3) document in the electronic medical record the patients’ elicited values and goals using a structured documentation template. Twenty case management staff participated in a 4-hour face-to-face educational program. Participants completed a pre- and post-test survey of knowledge; self-rated their confidence in conducting serious illness conversations; and evaluated the educational program. All participants reported that the format to deliver the program was effective, the content of the program was directly relevant to their clinical practice, and they would change their practice because of learning/understanding the program content. Case managers correctly identified 92% of patients who met the established serious illness identification criteria. In 91.8% of cases, case managers conducted a conversation in adherence to the protocol. In 76% of the cases, documentation about the conversation was completed in accordance with the protocol. Key implications include:
- Case managers may lack formal or informal education about engaging in conversations with patients living with a serious illness regarding their goals of care and advanced care planning.
- Establishing a protocol for case managers to follow is essential, including identifying patients appropriate for a serious conversation, conducting the conversation, and documenting information from the conversation in the electronic medical record.
- Conducting serious illness conversations with appropriately identified patients is expected to result in the establishment of a plan of care consistent with patient preferences.
Accountable Care Organizations’ Increase in Nonphysician Practitioners May Signal Shift for Health Care Workforce
Date: June 2020
Source: Health Affairs
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This study analyzed how the clinician composition of Medicare Shared Savings Program (MSSP) ACOs changed between 2013 and 2018 and the implications of this change for value-based care and larger trends in the health care workforce. The number of MSSP ACOs rose from 220 in 2013 to 548 in 2018. As program participation grew, the number of assignment-eligible clinicians within ACOs increased as well, from an average of 263 clinicians per ACO in 2013 to 653 in 2018. Although increases occurred for primary care physicians (from an average of 141 to 251) and medical specialists (from an average of 76 to 157), the increase for nonphysician practitioners (from an average of 47 to 245) was the largest. These differential increases changed the ACO workforce composition over time. The average proportion of nonphysician practitioners in ACOs grew from 18.1 percent to 38.7 percent, with a commensurate decline in the average share of primary care physicians from 60.0 percent to 42.2 percent. As value-based care models grow in prevalence, their evolving clinician composition may affect workforce patterns in the broader health care delivery system.
Improving Medication Adherence in an ACO Primary Care Office with a Pharmacist-Led Clinic: A Report From the ACORN SEED
Date: June 24, 2020
Source: Journal of Pharmacy Practice
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This study assessed the effects of a pharmacist-led Medication therapy management (MTM) clinic in an ACO-affiliated primary care office on adherence to renin-angiotensin system (RAS) antagonists, diabetic medications, and/or statin medications reported via HEDIS Medicare Star Ratings. In this retrospective cohort study, data were collected via chart review of pharmacist-led MTM patient interviews and follow-ups between October 2015 and April 2017. Eligible patients were Humana HMO Medicare beneficiaries, with at least one chronic disease state, for which they were treated with a RAS antagonist, statin, or diabetic medication. A total of 102 patients were referred to the MTM clinic. Out of these, 32 had a follow-up visit, resulting in a total of 25 interventions. One year prior to MTM clinic implementation, most star ratings were consistently 3 (out of 5) for RAS antagonists, diabetic medications, and statins. Postintervention, ratings increased to 4 or 5 across these categories. Implementing a pharmacist-led MTM clinic in the ACO primary care setting was associated with improved Medicare Star Ratings in patients with chronic conditions.
The Effect of an Accountable Care Organization on Dental Care for Children with Disabilities
Date: June 9, 2020
Source: Public Health Dentistry
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This study examined the effect of a state policy change that moved some children with disabilities into a Medicaid‐serving pediatric ACO on dental service use. The researchers hypothesized that ACOs’ emphasis on prevention, care coordination, and reduction in emergency department use would extend to dental services. Using Ohio Medicaid administrative claims data for 2011-2016, researchers examined dental service use by Medicaid‐eligible children with disabilities before and after enrolling in an ACO compared with similar children enrolled in non‐ACO managed care plans. Dental utilization is relatively low among Medicaid‐eligible children with disabilities. The study found that preventive dental visits increased 3.1 percentage points (P < 0.05) from a baseline in the control group of 33.9 percent among ACO‐enrolled children, especially adolescent children, compared to similar children who were not in an ACO, representing an 11 percent increase in the rate of preventive dental visits. However, overall dental utilization did not increase for children with disabilities who were part of the ACO compared to similar children who were not in the ACO. Access to dental care is a continuing challenge for children covered by Medicaid. ACOs that serve Medicaid children are well positioned to include dental services and could play an important role in improving access to dental care and increasing dental utilization.
ACO Status Associated with Reports of Meals on Wheels in Hospitals in 2017
Date: May 2020
Source: Journal of Health Care for the Poor and Underserved
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Hospitals’ approaches to increased value may include taking part in payment programs, such as those relating to ACOs, and addressing social determinants of health, including food insecurity. This cross-sectional study used 2017 American Hospital Association Annual Survey and Area Health Resource File data to examine hospitals that are in ACOs and offer Meals on Wheels. Of 3,992 hospitals in 2017, 27.4% took part in ACOs only, 8.4% took part in Meals on Wheels only, and 11.2% took part in both. In adjusted models, hospitals in ACOs had 1.94 higher odds of having Meals on Wheels programs compared with hospitals not in ACOs (95% CI 1.58–2.38). Some hospital strategies to increase value may extend beyond traditional medical care to social services.
Using Practice Facilitation to Improve Depression Management in Rural Pediatric Primary Care Practices
Date: May/June 2020
Source: Pediatric Quality and Safety
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Researchers developed an evidence-based, quality improvement project designed to help pediatricians increase screening and initial management of depression in the primary care setting. They recruited four practices from a pediatric ACO in rural Ohio as part of a larger quality improvement portfolio that used a practice facilitation model to support practices with data collection and project management. Practitioners received training on quality improvement, depression screening, and a depression management plan (referred to as the depression management bundle). Practices completed plan-do-study-act cycles to improve performance. Screening increased from 0% to 81% within 6 months. All four practices measured documentation of the depression management bundle for patients diagnosed with depression. Composite data from these practices showed an increase in documentation from 59% to 86% by month 6. This study provides preliminary support for the use of practice facilitation combined with skills training to increase screening and improve documentation of depression management in rural primary care practices, where specialty mental health resources may be limited. Further research is needed to determine if this approach can be successfully disseminated and if patient outcomes improved.
Accountable Care Organizations Are Increasingly Led by Physician Groups Rather Than Hospital Systems
Date: May14, 2020
Source: American Journal of Managed Care
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Hospitals and health systems sponsored most new ACOs from 2010 to 2015 and influenced policy priorities and strategies designed to drive ACO adoption. In recent years, however, most new ACOs have been sponsored by physician groups. This shift means that policies need to be developed with the characteristic strengths and weaknesses of physician-led ACOs in mind. Using data from the Leavitt Partners ACO database, researchers analyzed the types of providers becoming ACOs over time to look at their numbers and market potential. In 2018, physician group-led ACOs represented approximately 45% of all ACOs, hospital-led ACOs accounted for approximately 25%, and joint-led ACOs represented 30%. Because the market potential for further growth of physician group-led ACOs is much stronger than for hospital- or health system-led ACOs, policymakers need to create programs and policies that facilitate physician-led ACOs’ success by helping them develop the capacity to take on risk, finance investments in high-value healthcare, and partner with other organizations to provide the full spectrum of care.
Proportion of Racial Minority Patients and Patients With Low Socioeconomic Status Cared for by Physician Groups After Joining Accountable Care Organizations
Date: May 8, 2020
Source: JAMA Network Open
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The incentive structure of Medicare Shared Savings Program (MSSP) ACOs may lead to participating physician groups selecting fewer vulnerable patients. To test for changes in the percentage of racial minority patients and patients with low socioeconomic status cared for by physician groups after joining ACOs, researchers examined a retrospective cohort of a 15% random sample of Medicare fee-for-service beneficiaries attributed to physician groups from 2010 to 2016. MSSP participation was determined using ACO files. Using linear probability models, the researchers conducted difference-in-differences analyses based on the year a physician group joined an ACO to estimate changes in vulnerable patients within ACO-participating groups compared with nonparticipating groups. Study measures included whether the patient was black, was dually enrolled in Medicare and Medicaid, and poverty and unemployment rates of the patient’s zip code. In a cohort of 76,717 physician groups caring for 7,307,130 patients, 16.1% of groups caring for 27.8% of patients participated in an MSSP ACO. Using 2010 characteristics, patients attributed to ACOs from 2012 to 2016, compared with those who were not, were less likely to be black (8.0% [n = 81,698] vs 9.3% [n = 270,924]) or dually enrolled in Medicare and Medicaid (12.8% [n = 130,957] vs 18.2% [n = 528,685]), and lived in zip codes with lower poverty rates (13.8% vs 15.5%); unemployment rates were similar (8.0% vs 8.5%). In the difference-in-differences analysis, there was no statistically significant change associated with ACO participation in the proportions of vulnerable patients attributed to ACO-participating physician groups compared with nonparticipating groups.
Outcomes and Cost among Medicare Beneficiaries Hospitalized for Heart Failure Assigned to Accountable Care Organizations
Date: May 8, 2020
Source: American Heart Journal
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The study examined the impact of ACOs on hospitalized heart failure (HF) patients by linking Medicare fee-for-service claims from 2013 to 2015 with data from the American Heart Association Get With The Guidelines HF registry to compare HF care, post-discharge outcomes, and total annual Medicare spending by ACO status at discharge. The study included 45,259 HF patients from 300 hospitals, with 21.1% assigned to an ACO. Patient characteristics were similar between the two groups with a few exceptions. For example, ACO patients lived in geographic areas with higher median income ($54,400 [IQR $48,600-65,900] vs. $52,300 [$45,900-61,200], p<.0001). Compliance with four HF-specific quality measures was modestly higher in the ACO group (80% vs. 76%, p<.0001). In adjusted analysis, ACO status was associated with similar all-cause readmission (HR: 1.03; 99% CI: 0.99, 1.07) but lower risk of 1-year mortality (HR: 0.85; 99% CI: 0.85, 0.90) compared with non-ACO status. Median Medicare spending in the calendar year of hospitalization was similar (ACO $42,737 [IQR $23,011-72,667] vs. non-ACO $42,586 [$22,896-72,518], p=0.06). Among Medicare patients hospitalized for HF, participation in an ACO was associated with similar rates of all-cause readmission and no associated cost reductions compared with non-ACO status. There was a lower risk of 1-year mortality associated with ACO participation, which warrants further evaluation.
Use of Health Care Services Among Children With Disabilities Enrolled in an Accountable Care Organization
Date: May 2020
Source: Patient-Centered Outcomes Research Institute Final Research Report
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The study assessed care coordination provided by an ACO and measured effects on the health outcomes and experiences of children with disabilities and their caregivers compared with a traditional health delivery model. Researchers used a policy change that moved Medicaid-eligible children with disabilities from a fee-for-service system into a large pediatric ACO via enrollment in managed care plans in Ohio to design the study. Using Medicaid claims data, the study examined patterns of health care services use and compared the group of children enrolled in the ACO (n = 17,356) with a natural control group of similar children enrolled in non-ACO managed care plans (n = 47,026). The average marginal effect of joining an ACO on adolescent well-child visits was 5.1 percentage points higher in the ACO region as compared with the non-ACO region of the state during the period after managed care implementation. Emergency department use increased by 1.6 percentage points in the ACO region over the control group. The study found no difference in primary care visits, hospital utilization, or follow-up to outpatient providers after hospitalization. The study found greater rates of access to 3 of the 6 classes of medications by ACO enrollees (antidepressants, anticonvulsants, and antianxiety medications) and a lower use rate of medications for attention-deficit/hyperactivity disorder (ADHD). The probability of follow-up after initial use of ADHD medication increased by 7.2 percentage points in the ACO region. In contrast to trends in the comparison group, access to home health services after ACO implementation declined by 2.7 percentage points, representing a 40% relative decline over the rate in the non-ACO population. Overall, caregivers did not perceive that becoming part of an ACO increased their access to care coordination services. Caregivers identified needs that were less about medical care and more related to social services. Becoming part of an ACO did not appear to have any negative impacts on quality as indicated by most indicators of health services use.
Effect of a Medicaid Accountable Care Collaborative on 30-Day Hospital Readmission Rates
Date: April 29, 2020
Source: Population Health Management
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Hospital readmission within 30 days is undesirable and costly. Most programs and studies have focused on the Medicare population and readmission prevention through discharge planning; less is understood about how Medicaid might reduce readmissions to improve outcomes and control program costs. The objective of this study was to estimate the relationship between the Colorado Medicaid Accountable Care Collaborative (ACC) and 30-day hospital readmission rates. A difference-in-differences design was used to compare 30-day readmissions before and after Medicaid members were enrolled in the ACC program using two different control groups: Medicaid members not enrolled and commercially insured. The authors used Probit regressions at the hospital level, controlling for patient characteristics, and clustered errors at the provider level. The study sample included Colorado adults aged 19 to 64 with a qualifying hospital discharge. Analysis data included Medicaid and commercial payer administrative claims data (2009-2015) from Colorado’s All-Payer Claims Database. The ACC program significantly reduced 30-day readmissions among Colorado Medicaid patients. Participation in the ACC program reduced the probability of a 30-day readmission by 1.4% (P < 0.001), with the largest effect among maternity and delivery patients. Because the majority of Medicaid members are female, even after Medicaid expansion, and Medicaid covers a disproportionate share of complex births, maternity and delivery readmissions are a fruitful area for reducing Medicaid expenditures.
Accountable Care Organizations and Preventable Hospitalizations Among Patients With Depression
Date: April 23, 2020
Source: American Journal of Preventive Medicine
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This study examined variation of potentially preventable hospitalizations for chronic conditions with coexisting depression in adults by hospital ACO affiliation and care coordination strategies by race/ethnicity. Researchers used data for 11 states from 2015 State Inpatient Databases to identify potentially preventable hospitalizations for chronic conditions with coexisting depression by race/ethnicity; the 2015 American Hospital Association (AHA) Annual Survey to identify hospital ACO affiliation; and the AHA Survey of Care Systems and Payment (collected from January to August 2016) to identify hospital ACO affiliation and hospital-based care coordination strategies, such as telephonic outreach, and chronic care management. Preventable hospitalizations were significantly lower among ACO-affiliated hospitals than unaffiliated hospitals. Lower preventable hospitalization rates were observed among white, African American, Native American, and Hispanic patients. Effective care coordination strategies varied by patients’ race. Results also showed variation of the adoption of specific care coordination strategies among ACO-affiliated hospitals. Analysis further indicated effective care coordination strategies varied by patients’ race. ACOs and specifically designed care coordination strategies can potentially improve preventable hospitalization rates and racial disparities among patients with depression. Findings support the integration of mental and physical health services and provide insights for Centers for Medicare & Medicaid Services risk adjustment efforts across race/ethnicity and socioeconomic status.
The Impacts of Accountable Care Organizations on Patient Experience, Health Outcomes and Costs: A Rapid Review
Date: April 22, 2020
Source: Journal of Health Services Research & Policy
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The study sought (1) to identify the impacts of ACOs on improving the quadruple aim goals of improving patient experience of care, enhancing population health outcomes, reducing per capita cost of health care and ensuring positive provider experiences and (2) to determine how and why such impacts have been achieved through ACOs. Researchers used a rapid review approach, searching Health Systems Evidence (for systematic reviews) and PubMed (for reviews and studies). The authors identified one recent systematic review and 59 primary studies that addressed the first objective (n = 54), the second objective (n = 4) or both objectives (n = 1). The reviewed studies suggest that ACOs reduce costs without reducing quality. Key findings related to objective 1 include: (1) there are positive trends across the quadruple-aim outcomes for ACOs compared to Medicare fee-for-service or group physician fee-for-service models; (2) ACOs produced modest cost savings, which are largely attributable to savings in outpatient expenses among the most medically complex patients and reductions in the delivery of low-value services; (3) ACO models met the majority of quality measures and perform better than their fee-for-service counterparts; and (4) there is relatively little evidence about the impact of ACOs on provider experience. Qualitative studies related to objective 2 highlighted mechanisms that were important for enabling ACOs, including supplemental staff to enhance coordination and accountable care organization-wide electronic health records.
Quality Improvement and Clinical Innovation: Trial of an e-Consult System in an Outpatient Tertiary Care Neurology Practice for Patients in an Accountable Care Organization Model
Date: April 14, 2020
Source: Neurology
Article Link
The study examined whether an e-consultation model was effective in reducing costs and encouraging faster access to neurological care for patients in an ACO model. Access to neurological consultation is often limited by provider availability and the distance patients live from the neurology practice. Schedulers at the UT Southwestern outpatient neurology practice referred all new consults made during February 2017 to a single neurologist for e-consultation. Following neurologist evaluation, one of four decisions ensued. Decision A: brief opinion rendered based on documentation alone. Decision B: if documentation is insufficient, neurologist will call patient and determine whether patient needs to be seen, or if not, provide recommendations. Decision C: based on either records review or phone call, the patient is scheduled with reviewing neurologist. Decision D: the patient is scheduled in specialty clinic. The study found 24 patients were suitable for e-consultation. Average age was 66 years. Six patients were referred for cognitive issues, five for movements disorders (4 for tremors) and three each for epilepsy and headaches. Seventeen patients (70%) required specialty clinic consultation (Option D), while 6 patients’ issues were resolved with a patient phone call (Option B). In no patient was e-consultation completed only by review of records. These outcomes were due to the complexity of the underlying patient population. The authors concluded that e-consultation may not be suitable in a patient population with complex neurological issues.
One Size Will Not Fit All: Factors That Drive Strategy in Accountable Care Organizations
Date: April 6, 2020
Source: The American Journal of Accountable Care
Article Link
Although ACOs all possess a set of core features that define the payment model, differences across payer types and patient populations mean that no single strategy will be effective for all types of ACOs. Provider organizations would be best served by considering and participating in ACOs after they have considered these differences and their implications for care delivery initiatives that can support ACO success. In this article, the authors leverage their perspective as physician leaders in an integrated delivery system that participates in multiple ACOs and discuss three factors—clinical complexity of ACO populations, social complexity of ACO populations, and ACO network configuration—to advance the discourse about payment model strategy and performance.
Implementation of Pharmacist-Driven Comprehensive Medication Management as Part of an Interdisciplinary Team in Primary Care Physicians’ Offices
Date: April 3, 2020
Source: The American Journal of Accountable Care
Article Link
This study describes the initial implementation of pharmacist-driven comprehensive medication management into an interdisciplinary care team at an ACO’s primary care offices for ambulatory patients, including the workflow of the clinical pharmacist, typical activities performed, and recommendations. The findings indicated positive provider and patient satisfaction. Areas of opportunity were identified to improve provider acceptance rate of pharmacists’ recommendations and enhance pharmacist-provider relationships.
Spending Variation Among ACOs in the Medicare Shared Savings Program
Date: March 31, 2020
Source: American Journal of Managed Care
Article Link
The study analyzed spending differences across Medicare Shared Savings Program ACOs to help identify cost savings opportunities. Using a cross-sectional analysis of Medicare claims, researchers stratified ACOs into quartiles based on the deviation between each ACO’s risk-adjusted spending and average risk-adjusted fee-for-service spending in the same market (hospital referral region). Researchers compared spending between top- and bottom-quartile ACOs on each of seven major service categories and 10 clinical condition groups to identify areas of potential savings and then simulated spending reductions if ACOs with high adjusted spending reduced spending to the levels of lower-spending ACOs. In 2016, geographically adjusted and risk-adjusted total per-beneficiary spending for the highest-spending quartile of ACOs was 14% higher than for ACOs in the lowest quartile. Variation between high- and low-spending ACOs was greatest, at 27%, in the use of skilled nursing facilities—a service category where ACOs have reduced spending by the greatest percentage. Inpatient care was the largest driver of absolute dollar differences in spending, however, accounting for 37% of the total spread. If spending in ACOs above median adjusted spending were brought down to the median, savings would be 3% to 4%. By extending the variations literature to focus on ACOs, the study illustrated that meaningful further savings opportunities exist both within and across markets.
Transforming Medicare’s Payment Systems: Progress Shaped by the ACA
Date: March 2020
Source: Health Affairs
Article Link
Alternative payment models (APM) run by Medicare have generally produced modest savings and quality improvements. However, popular APMs, including ACO and bundled payment models, have high drop-out rates, which may indicate a problem managing downside risk. The authors reviewed 40 APMs operated by the Centers for Medicare & Medicaid Services, including the Medicare Shared Savings Program, Bundled Payments for Care Improvement, the Comprehensive Care for Joint Replacement model, and the Comprehensive Primary Care Plus initiative. The review found that population- and episode-based payment models—largely ACO and bundled payment programs—generated some savings on average, with ACO models having the greatest impact overall.
High Real-World Medication Adherence and Durable Clinical Benefit in Medicare Patients Treated with 5 Alpha-Reductase Inhibitors for Benign Prostatic Hyperplasia
Date: March 13, 2020
Source: Journal of Urology
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Although clinical trials demonstrate 5 alpha-reductase inhibitors (5ARIs) are efficacious treatments for benign prostatic hyperplasia (BPH), 5ARIs have low reported medication adherence outside of clinical trials. This study evaluated real-world drug adherence and clinical outcomes in Medicare ACO patients with lower urinary tract symptoms from BPH managed with 5ARI therapy. Using medical and pharmacy claims from Partners Healthcare Medicare ACO enrollees (January 2009 – July 2018), researchers found that among 3,107 men initiating 5ARI therapy for BPH and filling at least two prescriptions, 74.9% had high medication adherence over the first year. Patients with low adherence had 29% higher hazards of undergoing surgical intervention after adjusting for age, BPH severity, the presence of hematuria, bladder stones, and type of 5ARIs. Among Medicare patients, 5ARI treatment adherence was high and associated with lower hazards of surgical intervention. 5ARI therapy may be more feasible for older men with BPH than previously reported and demonstrates modest clinical benefit.
Clinicians’ Attitudes and System Capacity Regarding Transitional Care Practices Within a Health System: Survey Results From the Partners-PCORI Transitions Study
Date: March 13, 2020
Source: Journal of Patient Safety
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To prepare for implementation of a multifaceted care transitions intervention within an ACO, researchers sought to better understand contextual factors among providers involved in care transitions in inpatient and outpatient settings. As part of the Partners-Patient-Centered Outcomes Research Institute (PCORI) Transitions Study, researchers purposefully sampled inpatient and outpatient providers within the ACO. Survey questions focused on training and feedback on transitional tasks and opinions on the quality of care transitions. Among 387 providers surveyed, 220 responded (response rate = 57%) from 15 outpatient practices and 26 inpatient units. A large proportion of respondents reported having never received training (50%) or feedback (68%) on key transitional care activities, and most (58%) reported insufficient time to complete these tasks. 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. 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.
Addressing Medicare Shared Savings Program Vulnerabilities
Date: March 5, 2020
Source: Medicare Payment Advisory Commission (MedPAC) Staff Presentation
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Savings achieved in the Medicare Shared Savings Program to date could be vulnerable if ACOs can engage in patient selection that is not reflected in ACO benchmarks and leads to unwarranted shared savings payments, according to a MedPAC staff analysis. This could result from having low-cost patients enter the ACO without changing the benchmark or having high-cost patients exit the ACO without changing the benchmark. While MedPAC has not seen evidence of pervasive patient selection to date, MedPAC is concerned about the incentives as ACO experience matures. Selection is problematic because it can inaccurately improve an ACO’s performance year spending relative to its baseline years. Selection can occur by adding clinicians that disproportionately have low-cost patients or by removing clinicians that disproportionately have high-cost patients. Selection can also occur via beneficiary assignment to ACO clinicians by keeping low-cost patients and losing high-cost patients.
The Role of Specialists in Alternative Payment Models and Accountable Care Organizations
Date: March 5, 2020
Source: Medicare Payment Advisory Commission (MedPAC) Presentation
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A MedPAC analysis examined two questions: First, do specialists have opportunities to participate in APMs and ACOs? Second, are ACOs with specialists more likely to reduce volume and spending than other ACOs? On the first question, the analysis found that specialists account for the majority of physicians participating in Medicare ACOs, but that each ACO determines the role of specialists and other physicians; for example, whether they are involved in ACO leadership or receive a portion of shared savings. And MedPAC lacks detailed information about these arrangements. On the second question, thus far, the limited evidence from the literature suggests that specialists are less likely to reduce volume and spending.
The Financial Impact of Genetic Diseases in a Pediatric Accountable Care Organization
Date: February 28, 2020
Source: Frontiers in Public Health
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To understand the financial impact of genetic disease on a pediatric ACO, researchers analyzed 2014 medical claims from Partners for Kids, an ACO in partnership with Nationwide Children’s Hospital in Columbus, OH. Using insurance claims for 258,399 children, researchers assigned patients to categories based on the strength of genetic basis of disease. The study identified 22.7% of patients as having a disease with a “strong genetic basis” (e.g., single gene diseases, chromosomal abnormalities). Total ACO paid claims in 2014 were $379 million, with $161 million (42.5%) attributable to these patients. Another 23.3% of patients had a disease with a suspected genetic component or predisposition, such as asthma or type 1 diabetes, accounting for an additional 28.6% of 2014 costs. Patients in the first category also were more likely to experience at least one hospitalization compared to patients without genetic disease. Nearly half (42.5%) of healthcare paid claims cost in 2014 for this study population were accounted for by patients with single-gene diseases or chromosomal abnormalities, indicating a need for ACOs to plan for effective care strategies and capitation models for children with genetic disease.
Telehealth: Advances in Alternative Payment Models
Date: February 26, 2020
Source: Telemedicine and e-Health
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The study examined the association among alternative payment models (APMs), market competition, and telehealth provisions in the hospital setting. Researchers used 2018 U.S. census data to analyze data from 4,257 nonfederal short-term acute care hospitals across 1,874 counties with at least one hospital. Regarding APMs, researchers found that hospital participation in ACOs and participation in a bundled payment risk arrangement are significantly associated with the provision of telehealth services. From the market perspective, competitive advantage was found to be statistically associated with hospitals providing telehealth services. In addition, other hospital characteristics, such as ownership, part of a system, part of a network, and major teaching affiliation, also have impact on the provision of telehealth.
Out-Of-Network Primary Care Is Associated With Higher Per Beneficiary Spending In Medicare ACOs
Date: February 2020
Source: Health Affairs
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The study examined the association between out-of-network care and per beneficiary spending in ACOs using national Medicare data for 2012-15. While there was no association between out-of-network specialty care and ACO spending, each percentage-point increase in receipt of out-of-network primary care was associated with an increase of $10.79 in quarterly total ACO spending per beneficiary. When researchers broke down total spending by place of service, they found that out-of-network primary care was associated with higher spending in outpatient, skilled nursing facility and emergency department settings but not inpatient settings. Decreasing the percentage of primary care delivered out-of-network across all Medicare ACOs by just one-tenth of a percentage point could save the Medicare system $45 million a year, the study found. The findings suggest an opportunity for the Medicare program to realize substantial savings if policy makers developed explicit incentives for beneficiaries to seek more of their primary care within ACO networks.
Upstream With A Small Paddle: How ACOs Are Working Against The Current To Meet Patients’ Social Needs
Date: February 2020
Source: Health Affairs
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Despite interest in addressing social determinants of health to improve patient outcomes, little progress has been made in integrating social services with medical care. This study aimed to understand how health care providers with strong motivation (for example, operating under new payment models) and commitment (for example, early adopters) fared at addressing patients’ social needs. Researchers collected qualitative data from 22 ACOs that were early adopters and were working on initiatives to address social needs, including such common needs as transportation, housing, and food. However, even these ACOs faced significant difficulties in integrating social services with medical care. First, the ACOs were frequently “flying blind,” lacking data on both their patients’ social needs and the capabilities of potential community partners. Additionally, partnerships between ACOs and community-based organizations were critical but were only in the early stages of development. Innovation was constrained by ACOs’ difficulties in determining how best to approach return on investment, given shorter funding cycles and longer time horizons to see returns on social determinants investments. Policies that could facilitate the integration of social determinants include providing sustainable funding, implementing local and regional networking initiatives to facilitate partnership development, and developing standardized data on community-based organizations’ services and quality to aid providers that seek partners.
Health Care Spending And Use Among People Experiencing Unstable Housing In The Era Of Accountable Care Organizations
Date: February 2020
Source: Health Affairs
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Researchers used Medicaid claims data to analyze spending and use among 402 people who were continuously enrolled in the Boston Health Care for the Homeless Program (BHCHP) from 2013 through 2015, compared to spending and use among 18,638 people who were continuously enrolled in Massachusetts Medicaid with no evidence of experiencing homelessness. The BHCHP population averaged $18,764 per person per year in spending—2.5 times more than spending among the comparison Medicaid population ($7,561). In unadjusted analyses this difference was explained by greater spending in the BHCHP population on outpatient care, including emergency department care, as well as on inpatient care and prescription drugs. After adjustment for covariates and multiple hypothesis testing, the difference was largely driven by outpatient spending. Differences were sensitive to adjustments for risk score, which suggests that housing instability and health risk are meaningfully correlated. These findings from a precursor to the Massachusetts Medicaid ACO program may help improve the design of alternative payment models for vulnerable populations. The results show that total Medicaid spending for people experiencing episodes of homelessness can average over $4,300 per person per year more than spending for Medicaid enrollees with no evidence of experiencing homelessness—even after risk is adjusted for. Thus, budgets for provider organizations that care for similar unstably housed populations may need to be further adjusted to allow the organizations to care for such populations in a sustainable manner.
Quantifying Health Systems’ Investment In Social Determinants Of Health, By Sector, 2017-19
Date: February 2020
Source: Health Affairs
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The study examined the degree to which U.S. health systems are directly investing in community programs to address social determinants of health as opposed to screening and referral. Researchers searched for all public announcements of new programs involving direct financial investments in social determinants of health by U.S. health systems from January 1, 2017, to November 30, 2019, and identified 78 unique programs involving 57 health systems that collectively included 917 hospitals. The programs involved at least $2.5 billion of health system funds, of which $1.6 billion in 52 programs was specifically committed to housing-focused interventions. Additional focus areas were employment (28 programs, $1.1 billion), education (14 programs, $476.4 million), food security (25 programs, $294.2 million), social and community context (13 programs, $253.1 million), and transportation (six programs, $32 million). All of the 57 health systems investing in community programs were nonprofits. Compared with non-investing systems, systems making investments were significantly larger, more likely to include at least one major teaching hospital (86% vs. 32%), and more likely to participate in an ACO (86% vs. 52 percent).
Integrated, Accountable Care For Medicaid Expansion Enrollees: A Comparative Evaluation of Hennepin Health
Date: February 2020
Source: Medical Care Research and Review
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Hennepin Health, a Medicaid ACO, began serving early expansion enrollees (very low-income childless adults) in 2012. The ACO uses an integrated care model to address social and behavioral needs. Researchers compared health care utilization in Hennepin Health with other Medicaid managed care in the same area from 2012 to 2014, controlling for demographics, chronic conditions, and enrollment patterns. Homelessness and substance use were higher in Hennepin Health. Overall adjusted results showed Hennepin Health had 52% more emergency department visits and 11% more primary care visits than comparators. Over time, modeling a 6-month exposure to Hennepin Health, emergency department and primary care visits decreased and dental visits increased; hospitalizations decreased insignificantly but increased among comparators. Subgroup analysis of high utilizers showed lower hospitalizations in Hennepin Health. Integrated, accountable care under Medicaid expansion showed some desirable trends and subgroup benefits but overall did not reduce acute health care utilization versus other managed care.
Association of Discharge Disposition with Outcomes
Date: February 25, 2020
Source: Population Health Management
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Understanding the relationships between discharge disposition, readmissions, and cost of care is an important strategy for ACOs trying to achieve shared savings. This study examined whether there is an association between the discharge dispositions of home with home health (HH) compared to skilled nursing facility (SNF) and the readmission rate and cost of care for Medicare ACO patients discharged from the hospital. Researchers studied the variables associated with readmission rates and cost of care, including discharge disposition and risk score for 1,151 patients attributed to an ACO. In multivariate logistic regression analysis, variables associated with increased risk for 30-day readmission were the Hierarchical Condition Category risk score and the discharge setting. Discharges to SNF were almost 5 times more likely to be readmitted to the hospital at 30 days compared to patients discharged to the HH setting. The cost of care is lower for the HH discharge disposition, with an $8,678 per patient difference between the cost of care for patients discharged to HH and SNF levels of care. The findings suggest that employing a transitional care planning approach that prioritizes discharging patients to the least restrictive next site of care, shifting patients from SNF disposition to HH as appropriate, is an effective strategy to improve readmission rates and cost of care.
Association Between Outpatient Rehabilitation Therapy and Total Cost of Care for a Frail Elderly Population in a Medicare Accountable Care Organization
Date: February 17, 2020
Source: Population Health Management
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Frailty is a debilitating and increasingly costly condition among Medicare beneficiaries, accounting for nearly $7.6 billion in Medicare spending in 2016. Understanding the burden of frailty and how to manage this population efficiently is of key importance in an ACO. Using an operational, claims-derived definition of frailty, researchers explored the association between therapy and total cost of care for the frail elderly population. Claims data were reviewed for nearly 94,000 beneficiaries to identify the burden of frailty along with the association with therapy utilization. Nearly 10% of patients in the study populations were found to meet the operational definition of frailty. When the frail population is segmented into those who receive outpatient rehabilitation therapy and those who do not, outpatient rehabilitation therapy is associated with decreased cost at 13–32 therapy units delivered. Outside of this dose range, outpatient rehabilitation therapy was not associated with statistically significant improvements in total cost of care for this population. Results suggest that from the standpoint of population health management, utilization of outpatient rehabilitation services may be helpful to decrease costs in several domains. When that cost reduction is compared to therapy units delivered, it is demonstrated that outpatient rehabilitation therapy is associated with lower costs at a certain quantity of therapy. This study has implications for population health management of a frail elderly cohort as well as for managing preferred partnerships with therapy providers, given the wide array of therapy patterns delivered.
Low-Value Care and Clinician Engagement in a Large Medicare Shared Savings Program ACO: A Survey of Frontline Clinicians
Date: January 2020
Source: Journal of General Internal Medicine
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The study assessed ACO engagement of clinicians and whether engagement was associated with clinicians’ reported difficulty implementing recommendations against providing low-value care. Researchers surveyed 1,289 clinicians in the Physician Organization of Michigan ACO, including general physicians (18%), internal medicine specialists (16%), surgeons (10%), other physician specialists (27%), and advanced practice providers (29%). The response rate was 34%. The 2018 survey asked about clinicians’ participation in ACO decision-making, awareness of ACO incentives, perceived influence on practice, and perceived quality improvement. According to the survey, few clinicians participated in the decision to join the ACO (3%), and few clinicians were aware of ACO incentives, including knowing the ACO was accountable for both spending and quality (23%), successfully lowered spending (9%), or faced upside risk only (3%). Few clinicians agreed (moderately or strongly) that the ACO changed compensation (20%), practice (19%), feedback (15%), improved care coordination (17%), or inappropriate care (13%). Clinicians reported difficulty following recommendations against low-value care 18% of the time and reported patients had difficulty accepting recommendations 36% of the time. Increased awareness of ACO incentives and was associated with decreased difficulty (− 2.3 percentage points) in implementing recommendations against delivering low-value care. The study authors concluded that clinicians participating in a large Medicare ACO were broadly unaware of and unengaged with ACO objectives and activities. Whether low clinician engagement limits ACO efforts to reduce low-value care warrants further study.
Using Nurse Care Managers Trained in the Serious Illness Conversation Guide to Increase Goals-of-Care Conversations in an Accountable Care Organization
Date: January 2020
Source: Journal of Palliative Medicine
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The study assessed efforts to increase the number of serious illness conversations occurring in an ACO using a script delivered telephonically by nurse care managers. Working with nurses previously trained in the basics of geriatric assessment and goals-of-care conversations, researchers used a quality improvement framework to modify the Ariadne Laboratories Serious Illness Conversation Guide to a six-question script. The target population was a subset of ACO patients who were high health care utilizers. After testing and modifying the script, researchers imbedded the script in the initial nursing assessment in the electronic health record, which prompts nurses to ask the questions every three months to track changes in patient goals of care over time. The study found that documentation of goals-of-care conversations increased from 33% of patients during the first month of the intervention to 86% at the end of the first year. Additionally, nurse care managers reported that clinical outcomes were improved by these conversations.
Effect of Accountable Care Organizations on Emergency Medicine Payment and Care Redesign: A Qualitative Study
Date: January 2020
Source: Annals of Emergency Medicine
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This qualitative study examined how ACOs have impacted emergency care redesign and payment. Researchers conducted 22 interviews with emergency department (ED) and ACO leaders responsible for strategy, care redesign, and payment across seven ACOs participating in the Medicare Shared Savings Program. Sites varied in region and maturity with respect to population health initiatives. Nearly all sites were focused on reducing low-value ED visits, expanding alternate venues for acute unscheduled care, and redesigning care to reduce ED admission rates through expanded care coordination, including programs targeting high-risk populations such as older adults and frequent ED users, telehealth, and expanded use of direct transfer to skilled nursing facilities from the ED. However, the study found no significant reform of payment for emergency medical care within the ACOs. Nearly all informants expressed concern about reduced ED reimbursement, given ACO efforts to reduce ED utilization and increase clinician participation in alternative payment contracts. No participants expressed a clear vision for reforming payment for ED services. Researchers concluded that care redesign within ACOs has focused on outpatient access and alternatives to hospitalization. However, there has been little influence on emergency medicine payment, which remains fee for service. Evidence-based policy solutions are urgently needed to inform the adoption of value-based payment for acute unscheduled care.