2023 ACO Publications

2024 | 2023 | 2022 | 2021 | 2020

Who’s Accountable? Low-Value Care Received by Medicare Beneficiaries Outside of Their Attributed Health Systems 

Date:  August 2023
Source:  Health Affairs
Article

In this national Medicare claims analysis of 40 low-value services, researchers found that most health systems’ attributed beneficiaries received one-third to one-half of low-value services outside of these systems, at a measurable direct cost of $213 million–$1.2 billion during 2017–18. Although most of this use and spending originated from out-of-system specialists, the proportions of low-value care originating from distinct clinician types varied across the low-value services studied. Recipients of low-value care who were older, male, White, rural-residing, or more medically complex; had less continuity of care; or were attributed to a system with lower market share were more likely than other beneficiaries to receive that low-value care outside of their systems. However, the ACO status of a beneficiary’s attributed system (that is, the percentage of that system’s physicians participating in an ACO contract) was not associated with the beneficiary’s likelihood of receiving low-value care out of system. These findings suggest the potential to improve care quality and lower spending for system-attributed beneficiaries by targeting out-of-system low-value care. 

Availability of Medication for Opioid Use Disorder Among Accountable Care Organizations: Evidence from a National Survey 

Date:  August 24, 2023
Source:  Psychiatric Services
Article

This study examined changes in the availability of medication for opioid use disorder (MOUD) among ACOs with Medicare and Medicaid contracts based on responses to the 2018 (N=308 organizations) and 2022 (N=276) National Survey of Accountable Care Organizations (response rate=55% in both years). The percentage of respondents offering at least one MOUD grew from 39% in 2018 to 52% in 2022 (p<0.01). MOUDs were more likely to be available in 2022 among ACOs with (vs. without) in-network substance use treatment facilities (80% vs. 33%, p<0.001). The percentage of 2022 respondents that reported offering MOUD was similar in states with high versus low opioid overdose mortality rates. Despite growing availability of MOUD among ACOs, nearly half reported not offering any MOUD in 2022, and the availability of MOUD did not increase with treatment need. 

Dialysis Costs for a Health System Participating in Value-Based Care 

Date:  August 22, 2023
Source:  American Journal of Managed Care
Article

Unplanned “crash” dialysis starts are associated with worse outcomes and higher costs, a challenging problem for health systems participating in value-based care (VBC). This study examined expenditures and utilization associated with these events at the Cleveland Clinic, a large, integrated health system participating in VBC contracts, including a Medicare ACO. Researchers analyzed beneficiaries who transitioned to dialysis between 2017 and 2020. Crash starts involved initiating inpatient hemodialysis (HD) with a central venous catheter (CVC). Optimal starts were initiated with either home dialysis or outpatient HD without a CVC. Suboptimal starts were initiated with outpatient HD with a CVC or inpatient HD without a CVC.

A total of 495 patients initiated chronic dialysis: 260 crash starts, 130 optimal starts, and 105 suboptimal starts. Median predialysis 12-month cost was $67,059 for crash starts, $17,891 for optimal starts, and $7,633 for suboptimal starts (P < .001). Median postdialysis 12-month cost was $71,992 for crash starts, $55,427 for optimal starts, and $72,032 for suboptimal starts (P = .001). Predialysis inpatient admission per 1000 beneficiaries was 1,236 per 1,000 for crash starts vs 273 per 1,000 for optimal starts and 170 per 1,000 for suboptimal starts (P < .001). Postdialysis inpatient admission for crash starts was 853 per 1,000 vs 291 per 1,000 for optimal starts and 184 per 1,000 for suboptimal starts (P < .001). In a major health system, crash starts demonstrated the highest cost and hospital utilization, a pattern that persisted after dialysis initiation. Developing strategies to promote optimal starts will improve VBC contract performance. 

The Fourth Paradigm of Population Health 

Date:  August 14, 2023
Source:  Population Health Management
Article

As the world emerges from the worst of the COVID-19 pandemic, the field of population health is entering a fourth paradigm. The initial paradigm was the period during which patient-centered medical homes flourished and served to introduce population health into many medical offices. The second, somewhat overlapping, paradigm featured value-based programs gaining broad acceptance by health systems through ACOs and commercial shared savings arrangements, which brought the potential of added revenue, usually without much financial risk, and care coordination across the care continuum was broadly expanded. The third paradigm added downside risk components to insurance contracts. The recent pandemic has accelerated the move into a fourth paradigm by demonstrating how social determinants of health (SDOH) and societal health inequities directly and indirectly negatively impact health. The coming years will focus the attention of health care organizations on the significant impact of these topics on both health outcomes and overall health care-associated costs. 

Analysis of North Carolina Medicaid Claims Data to Simulate a Pediatric Accountable Care Organization 

Date:  August 4, 2023
Source:  JAMA Network Open
Article 

In this cohort study, which included 27,290 children and young adults prospectively attributed to a hypothetical ACO, a small group of individuals with medical complexity accounted for more than half of the total cost of care. More than half of children and young adults sought care outside of the ACO. The study also found that while most children attributed to the hypothetical Medicaid pediatric ACO lived locally with few health care encounters, a small group of children with medical complexity traveled long distances for care and used frequent and costly home-based and outpatient specialty care. Leaked care was substantial for all attributed children, with the cost of leaked care being higher than the total cost of care. These pediatric-specific clinical and utilization profiles have implications for future pediatric ACO design choices related to attribution, accounting for children with high costs, and strategies to address leaked care.

Risk Selection and Care Fragmentation at Medicare Accountable Care Organizations for Patients with Dementia 

Date:  August 2023
Source:  Medical Care
Article 

The aim of this study was to examine differences in ACO enrollment for patients with and without dementia and differences in risk profiles and ambulatory care among patients with dementia by ACO enrollment status. Patients with dementia were less likely to be enrolled in (38.3% vs. 44.6%, P<0.001) and more likely to exit (21.1% vs. 13.7%, P<0.01) ACOs. Among patients with dementia, those enrolled versus not enrolled in ACOs had a more favorable social and health risk profile on 6 of 16 measures (P<0.05). There were no differences in rates of dementia-relevant, primary, or specialty care visits. ACO enrollment was associated with 45.7% higher wellness visit rates (P<0.001), and 13.4% more fragmented primary care (P<0.01) spread across 8.7% more distinct physicians (P<0.05). Medicare ACOs are less likely to enroll and retain patients with dementia than other patients and provide more fragmented primary care without providing additional dementia-relevant ambulatory care visits. 

Building On CMS’s Accountable Care Vision to Improve Care for Medicare Beneficiaries 

Date:  July 31, 2023
Source:  Health Affairs Forefront
Article 

This article describes progress to date in the CMS accountable care strategy and outlines areas that CMS is exploring in 2023 to accelerate the growth of and access to ACOs that can support improved care experience and quality for Medicare beneficiaries, especially those in rural and underserved areas. 

Trade-offs in Locational Choices for Care Coordination Resources in Accountable Care Organizations 

Date:  July 27, 2023
Source:  Health Care Management Review
Article 

Care coordination is central to ACOs, especially in Medicaid where many patients have complex medical and social needs. Little is known about how to best organize care coordination resources in this context, particularly whether to centralize them. This study examined how care coordinators’ location, management, and colocation of both—within ACO headquarters, practice sites, or other organizations—relate to care quality and coordination. Researchers surveyed a sample of practice sites covering all 17 Medicaid ACOs in Massachusetts (n = 225, response rate = 64%). The study assessed how clinical information sharing across settings, care quality improvement, knowledge of social service referral, and cross-resource coordination (i.e., the ability of multiple resources to work well together) relate to where care coordinators were physically located and/or managed. Centralizing care coordinators at ACO headquarters was associated with greater information sharing. Embedding care coordinators in practices was associated with greater care quality improvement. Embedding coordinators at other organizations was associated with less information sharing and care quality improvement. Managing coordinators at practice sites and other organizations was associated with better care quality improvement and cross-resource coordination, respectively. Colocating the two functions showed no significant differences. Choosing care coordinators’ locations may present trade-offs. ACOs may strategically choose embedding care coordinators at practice sites for enhanced care quality versus centralizing them at the ACO to facilitate information sharing. 

Provision of Digital Health Technologies for Opioid Use Disorder Treatment by US Health Care Organizations 

Date:  July 17, 2023
Source:  JAMA Network Open
Article 

This cross-sectional study analyzed responses to the 2022 National Survey of Accountable Care Organizations (NSACO), collected between October 1, 2021, and June 30, 2022, from US organizations with Medicare and Medicaid ACO contracts about the use of digital technologies for opioid use disorder (OUD). Overall, 276 of 505 organizations responded to the NSACO (54.7% response rate), with a total of 304 respondents. Of these, 161 (53.1%) were from a hospital or health system, 74 (24.2%) were from a physician- or medical group-led organization, and 23 (7.8%) were from a safety-net organization. One-third of respondents reported that their organization used at least 1 of the 3 digital health technology categories, including remote mental health therapy and tracking (26.5%), virtual peer recovery support programs (15.1%), and digital recovery support for adjuvant cognitive behavioral therapy (9.0%). In an adjusted analysis, organizations with an addiction medicine specialist or a registry to track mental health were more likely to use at least 1 category of technology compared with otherwise similar organizations lacking these capabilities.  Organizations used patient-facing digital health technologies for OUD as complements to available substance use disorder treatment capabilities rather than as substitutes for unavailable resources. Future studies should examine implementation facilitators to realize the potential of emerging technologies to support organizations facing health care practitioner shortages and other barriers to OUD treatment delivery. 

Accountable Care Organizations and Use of Surgery Among Patients with Alzheimer Disease and Related Dementias 

Date:  July 12, 2023
Source:  American Journal of Managed Care
Article 

This study examined the effects of ACOs on use of surgery in patients with Alzheimer disease and related dementias (ADRD) for 1 of 6 common surgical procedures (aortic valve replacement [AVR], abdominal aortic aneurysm [AAA] repair, colectomy, carotid artery repair, major joint repair, and prostatectomy). Adjusted odds for use of surgery were lower among patients with ADRD compared with patients without ADRD for all procedures. ACO participation had varying impact on patients with ADRD, with higher odds of AVR and major joint surgery and lower odds of carotid artery repair. Availability of minimally invasive technology increased the likelihood of AVR and AAA repair among patients with ADRD; however, ACO participation reduced these effects. The effect of ACO participation on the likelihood of undergoing surgery did not vary by urgency of the procedure. Overall, the likelihood of undergoing surgery is lower among patients with ADRD and may vary by ACO participation for specific procedures. 

How Benchmarks Affect Participation in Accountable Care Organizations: Prospects for Voluntary Payment Models 

Date:  July 11, 2023
Source:  American Journal of Health Economics
Article 

In voluntary alternative payment models, participation is essential for model viability. This study examined ACO decisions to participate in the Medicare Shared Savings Program (MSSP), leveraging a natural experiment where a 2017 rule change introduced differential shocks to an ACO’s baseline spending and performance-year spending. The net effect was an effective change in benchmarks that varied across ACOs. Dropout was 7 percentage points more likely among ACOs with effective benchmark decreases. While small reductions in the effective benchmark did not affect participation, larger reductions increased dropout by 11 percentage points. ACOs already exceeding their benchmarks were particularly sensitive to effective benchmark reductions, consistent with MSSP’s weak long-term incentives to reduce spending. The results highlight the causal role benchmarks play in ACO participation and the need to consider consequences of participation effects when designing new payment models. 

Impact of Pharmacist Alternative Therapy Interventions in a Pediatric Medicaid Population 

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

Medication access and insurance navigation are difficult because of wide variations in insurance formularies, with some ACOs incorporating pharmacists into their population health teams to assist with access barriers. This study examined the impact of ACO pharmacists and clinical pharmacists in the ambulatory care setting working together, finding such collaborations were associated with ACO cost savings and a reduction in issues caused by insurance prior authorizations. A total of 278 alternative therapy interventions were made with an estimated cost savings of $133,191.43. Primary care clinics (n = 181, 65%) had the most documented interventions. A total of 174 (63%) interventions resulted in the avoidance of a prior authorization.

Using Sacubitril/Valsartan to Decrease Health Care Costs in Population Health Patients 

Date:  June 27, 2023
Source:  American Journal of Cardiology
Article 

This study examined the role of sacubitril/valsartan in decreasing overall health care expenditures in patients with heart failure (HF) enrolled in an ACO.  Researchers used the Health care Economic Efficiency Ratio (HEERO) scoring system, which compares actual costs (utilizing insurance claims) and expected costs (estimated using the Centers for Medicare &Medicaid Services risk score), with scores <1 suggesting economic benefit. A HEERO score was calculated for patients taking sacubitril/valsartan and other HF medications at 3-month intervals up to a year. The study compared the average and total health care expenditure and inpatient days for patients on sacubitril/valsartan, spironolactone, β blocker (BB) along with spironolactone, BB and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker. For patients on sacubitril/valsartan, HEERO scores and inpatient days decreased (decreased health care expenditure) as the number of days of utilization increased (p <0.0001). In total, 270+ days of sacubitril/valsartan decreased health care costs by 22%. This cost reduction was mainly attributed to decreased inpatient days. Sacubitril/valsartan use beyond 270 days resulted in decreased health care expenditure in a population health cohort compared with other HF medications. This economic benefit is achieved through the reduction in hospitalizations. Sacubitril/valsartan is an integral part of value-based care providing high-value, cost-effective care. Payor sources should consider this in subsidizing the cost of the medicine.  

Variation in Risk‐Standardized Acute Admission Rates Among Patients with Heart Failure in Accountable Care Organizations: Implications for Quality Measurement  

Date:  June 22, 2023
Source:  Journal of the American Heart Association
Article 

This study examined variation across Medicare Shared Savings Program ACOs in admission rates for patients with heart failure (HF). Researchers identified Medicare fee‐for‐service beneficiaries with HF who were assigned to an ACO in 2017 and survived ≥30 days into 2018 and calculated risk‐standardized acute admission rates across ACOs, assigned ACOs to 1 of 3 performance categories, and examined associations between ACO characteristics and performance categories. Among 1,232,222 beneficiaries with HF, 283,795 (mean age, 81 years; 54% women; 86% White; 78% urban) were assigned to 1 of 467 MSSP ACOs. Across ACOs, the median risk‐standardized acute admission rate was 87 admissions per 100 people, ranging from 61 (minimum) to 109 (maximum) admissions per 100 beneficiaries. Compared to the overall average, 13% of ACOs performed better on risk‐standardized acute admission rates, 72% were no different, and 14% performed worse. Most ACOs with better performance had fewer Black beneficiaries and were not hospital affiliated. Most ACOs that performed worse than average were large, located in the Northeast, had a hospital affiliation, and had a lower proportion of primary care providers.  

Reimagining “Covered Lives” as Communities: Communitarian Ethics for ACOs  

Date:  June 16, 2023
Source:  American Journal of Accountable Care
Article 

U.S. health care has long sought to balance the health needs of individuals and communities, and efforts in bioethics aim to address tension between individual autonomy and the common good. In population health management, ACOs are designed to create efficiencies by integrating and coordinating provider networks for defined patient populations often based on geography and physician practice patterns. From an ethical perspective, a lack of patient engagement in ACOs is problematic in that population health becomes something that happens to them, instead of the patients taking a participatory role in their health. Previous ethical frameworks have analyzed autonomy at the level of the individual, leading to ethically questionable conclusions around constraining patient autonomy to protect the common good. An approach based on responsive communitarian ethics, in which autonomy is conceived at the community level, is better suited to address the common good. One way forward is to reconceive “covered lives” in ACOs as patient communities capable of engaging in moral dialogue about population health priorities.  

Less Is More: Quality Measurement in Primary Care  

Date:  June 15, 2023
Source:  Health Affairs Forefront
Article 

In this article, leaders of a nationwide network of accountable care organizations (ACOs) composed of independent primary care practices and health centers across 45 states, with more than 15,000 clinicians and 2 million patients, encourage CMS to reconsider elements of the “Preliminary Adult and Pediatric Universal Foundation Measures.” First, CMS should sharpen the classification of “Foundational Core” to differentiate measures that are proven and appropriate for universal implementation now, as distinct from candidate metrics that are not yet proven for widespread implementation but represent priority domains for research and development. Foundational Core measures should:

Building Research Capacity in Primary Care Practices That Serve Predominantly Racial and Ethnic Minority Populations  

Date:  June 6, 2023
Source:  American Journal of Managed Care
Article 

This commentary reports on lessons learned over 2 years (2020-2022) from conducting primary care research to address health inequities through a novel alliance of an ACO consisting of independent practices, a health plan, and several academic researchers, with the support of a private foundation. The process of collaborating on research was mutually beneficial for a network of independent practices and a group of academic researchers.

Assessment of the Massachusetts Flexible Services Program to Address Food and Housing Insecurity in a Medicaid Accountable Care Organization  

Date:  June 2, 2023
Source: JAMA Health Forum
Article 

This study examined barriers and facilitators of the Massachusetts Flexible Services program, a 3-year pilot to address food insecurity and housing insecurity by connecting Medicaid ACO enrollees to community resources. This mixed-methods qualitative evaluation study included two Mass General Brigham (MGB) hospitals and affiliated community health centers. Of 67,098 Medicaid ACO enrollees from March 2020 to July 2021, 38,442 (57.3%) completed at least one social needs screening; 10,730 (16.0%) screened positive for food insecurity, and 7,401 (11.0%) screened positive for housing insecurity. There were 658 (1.6%) adults and 173 (0.7%) children enrolled in Flex. Most Flex enrollees (584 [88.8%] adults; 143 [82.7%] children) received the intended nutrition or housing services. Implementation challenges identified by staff interviewed included administrative burden, coordination with community organizations, data-sharing and information-sharing, and COVID-19 factors (e.g., reduced clinical visits). Implementation facilitators included administrative funding for enrollment staff, bidirectional communication with community partners, adaptive strategies to identify eligible patients, and raising clinician awareness of Flex. In Flex enrollee interviews, those receiving nutrition services reported increased healthy eating and food security; they also reported higher program satisfaction than Flex enrollees receiving housing services. Enrollees who received nutrition services that allowed for selecting food based on preferences reported higher satisfaction than those not able to select food. The findings indicate that Medicaid and health system programs that address social needs may benefit from providing funding for administrative costs, developing bidirectional data-sharing platforms, and tailoring support to patient preferences.  

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

Date:  June 2023
Source:  Medical Care
Article 

This study examined the relationship between ACO attribution and nurse practitioner (NP) care delivery during skilled nursing facility (SNF) visits, finding that greater participation by NPs in care delivery in SNFs was associated with a reduced risk of patient readmission to hospitals. The study included a sample of 527,329 fee-for-service Medicare beneficiaries with one or more SNF stays between 2012 and 2017. Researchers used logistic regression to measure the association between patient ACO attribution and evaluation and management care delivered by NPs in addition to the relationship between evaluation and management (E&M) services delivered by NPs and hospital readmissions. ACO beneficiaries were 1.26 percentage points more likely to receive one or more E&M services delivered by an NP during their SNF visits. ACO-attributed beneficiaries receiving most of their E&M services from NPs during their SNF visits were at a lower risk of readmission than ACO-attributed beneficiaries receiving no NP E&M care (5.9% vs. 7.1%; P <0.001).  

Accountable Care Organizations, Skilled Nursing Facilities, and Nurse Practitioners: Moving from Broad Themes to Actionable Care Redesign 

Date:  June 2023
Source:  Medical Care
Article 

This commentary article highlights the need for adaptive staffing models that leverage the skills of a clinically diverse workforce, including nurse practitioners. Moving forward, closer examination of the specific combinations of clinical and institutional care that lead to positive outcomes  is needed, as well as leveraging pockets of success to drive the system toward new clinical staffing configurations and care models.  

Benchmarking Changes and Selective Participation in The Medicare Shared Savings Program 

Date:  May 2023
Source:  Health Affairs
Article 

In 2017, the Medicare Shared Savings Program (MSSP) began incorporating regional spending into ACO benchmarks, thus favoring the participation of ACOs and practices with lower baseline spending than their region. To characterize providers’ responses to these incentives, researchers isolated changes in spending due to changes in the mix of ACOs and practices participating in the MSSP. In contrast to earlier participation patterns, the composition of the MSSP after 2017 increasingly shifted to providers with lower preexisting levels of spending relative to their region, consistent with a selection response. Changes occurred through the entry of new ACOs with lower baseline spending, the exit of higher-spending ACOs, and the reconfiguration of participant lists favoring lower-spending practices within continuing ACOs. These participation patterns varied meaningfully by ACO type. Although compositional changes could not be definitively tied to benchmarking changes, the disproportionate participation of providers with lower baseline spending implies substantial costs and the need for ACO benchmarking reforms. 

Integration on the Frontlines of Medicaid Accountable Care Organizations and Associations with Perceived Care Quality, Health Equity, and Satisfaction

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

Amid enthusiasm about ACOs in Medicaid, little is known about the primary care practices participating in Medicaid ACOs. Researchers used a survey of administrators within a random sample (stratified by ACO) of 225 practices joining Massachusetts Medicaid ACOs (64% response rate; 225 responses). The study measured the integration of processes with distinct entities: consulting clinicians, eye specialists for diabetes care, mental/behavioral care providers, and long-term and social services agencies. Using multivariable regression, researchers examined organizational correlates of integration and assessed integration’s relationships with care quality improvement, health equity, and satisfaction with the ACO. Integration varied across practices. Clinical integration was positively associated with perceived care quality improvement; social service integration was positively associated with addressing equity; and mental/behavioral and long-term service integration were positively associated with ACO satisfaction (all p < .05).  

Using Advanced Payments in Population-Based Models to Address Equity

Date:  May 25, 2023
Source:  Health Affairs Forefront
Article 

In January 2024, new advance investment payments will be available to new, inexperienced, and low-revenue Medicare Shared Savings Program ACOs. Upfront payments can support complex budgeting and investment dynamics at many organizations, particularly in the early phases of participation. Upfront payments can also offset the uncertainty and delayed nature of receiving funds after the fact (oftentimes more than one year after initiating participation) in retrospective financial reconciliation. Guidance about use of funds is critical for setting an explicit intention to address equity in payment models and preventing participating organizations from reallocating them to other purposes. This article describes features of forthcoming advance investment payments and highlights equity-oriented upfront payments as an encouraging development in population-based models—one worth careful consideration from policymakers, payers, and health care delivery organizations seeking to drive accountable care for population health.  

Tacking Upwind: Reducing Spending Among High-risk Commercially Insured Patients  

Date:  May 15, 2023
Source:  American Journal of Managed Care
Article 

The study examined a commercial ACO population and assessed the impact of an integrated care management program on medical spending and clinical event rates. Using medical spending claims and other enrollment data, the study assessed the demographic and clinical characteristics, medical spending, and clinical event rates of patients in the ACO and its high-risk care management program. The study then examined the impact of the program using a staggered difference-in-difference design with individual-level fixed effects and compared outcomes of those who had entered the program with those of similar patients who had not entered. The commercially insured ACO population was healthy on average but included several hundred high-risk patients (n = 487). After adjustment, patients within the ACO’s integrated care management program for high-risk patients had lower monthly medical spending (by $1,361 per person per month) as well as lower emergency department visit and hospitalization rates compared with similar patients who had yet to start the program. Although commercial ACO populations might be healthy on average, some individuals might benefit from programs for high-risk patients. Identifying this subset of patients could be critical for reducing spending. 

Advancing Health Equity Through the CMS Innovation Center: First Year Progress and What’s to Come  

Date:  May 11, 2023
Source:  Health Affairs Forefront
Article  

In 2022, the CMS Innovation Center launched a new health equity initiative, proposing to: 1) develop new models and revise existing models to promote and incentivize equitable care; 2) increase participation of safety-net providers; 3) increase collection and analysis of equity data; and 4) monitor and evaluate models for health equity impact. This article provides a one-year look back at what the Innovation Center has accomplished and describes additional areas of focus moving forward. 

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

Date: February 2023
Source: Journal of Health Politics, Policy and Law
Article

ACOs were envisioned as a way to address both healthcare cost growth and uneven quality in U.S. health care. In the decade since their launch, ACOs have grown into one of Medicare’s flagship payment reform programs, with millions of beneficiaries receiving care from hundreds of ACOs. While great expectations surrounded ACOs’ introduction into Medicare, their impacts to date have been modest. ACOs have achieved some savings and improvements in measured quality, but disagreement persists over the meaning of those results: Do ACOs represent important, incremental steps forward on the path toward a more efficient, high-quality health care system? Or do their modest achievements signal a failure of large-scale progress despite the substantial investments of resources? ACOs have proven to be politically resilient, largely sidestepping the controversies and partisan polarization that have led to the demise of other Affordable Care Act provisions. But the same features that have enabled ACOs to evade backlash have constrained their impacts and effectiveness. After a decade, ACOs’ long-term influence on Medicare and the U.S. health care system remains uncertain. 

Value-Based Care and a Path to Achieve Comprehensive Care in the Safety-Net 

Date:  February 28, 2023
Source:  Health Affairs Forefront
Article

This article examines how safety-net providers can and do succeed in value-based payment (VBP) models, including ACOs, with the support of multi-stakeholder alignment and conducive policy environments. Safety-net representation in value-based payment (VBP) models remains relatively limited compared to growth for other types of providers. This disparity is due in part to misaligned funding streams, lack of capital investments, and unsustainable payment design features. However, recent reforms including those from ACO REACH and the expansion of Medicaid flexibilities through Section 1115 waivers have increased opportunities for safety-net providers to participate in VBP arrangements, especially as ongoing equity efforts in the VBP policy landscape continue to target safety-net providers. Drawing on a focused literature review and interviews with safety-net organizations, payers, funders, and federal and state policymakers, the authors illustrate how VBP can help strengthen care delivery and how additional reforms can encourage broader participation.

Accountable Care In 2023: Evolving Terminology, Current State, And Priorities

Date: February 24, 2023
Source: Health Affairs Forefront
Article

This article reviews what “accountable care” means, and how its evolving definition provides insights into its opportunities and challenges and provides an overview of where accountable care models are across payers in 2023. The article also identifies some of the key issues facing policymakers and the health care industry for translating the promise of accountable care into greater realized success in improving health care experiences, affordability, and outcomes for all.

Skilled Nursing Facility 3-Day Waiver: Analysis of Use in ACOs 2014 to 2019

Date:  February 17, 2023
Source:  Centers for Medicare & Medicaid Services
Article

A new CMS analysis describes trends in use and outcomes associated with Medicare waiving the 3-day hospital stay requirement before discharge to a skilled nursing facility (SNF). The 3-day waiver for certain ACOs allows providers to admit patients to certain SNFs directly from the community or after only one to two days in a hospital. The analysis found shorter SNF lengths of stay and higher rates of discharge-to-home for waiver stays as well as lower or similar rates of adverse outcomes relative to non-waiver stays. The analysis also found that very few SNF stays were SNF waiver stays and direct waiver admissions were most common, particularly for beneficiaries who needed rehabilitation following an injury but not hospitalization.

ACO Benchmarks Based on Area Deprivation Index Mask Inequities

Date: February 17, 2023
Source:  Health Affairs Forefront
Article

This article focuses on how the Area Deprivation Index (ADI) is being used in Medicare ACO ACO initiatives to target support for organizations caring for disadvantaged and marginalized groups. Targeting support is important but complicated because of the great variety of communities across the country, including differences in cost of living and population density. The ADI has been a useful tool for many research efforts, and it offers several advantages including accessibility, timeliness, and ease of use. Nonetheless, the first applications of ADI within Medicare payment policy have significant limitations that need to be addressed to ensure that Medicare is successful in its efforts to achieve health equity.

Examining Network Entry Decisions in Healthcare: Network and Organizational Characteristics

Date:  February 10, 2023
Source:  Decision Sciences
Article

The motivation behind the formation of ACOs is to improve the quality of care while reducing healthcare costs. Despite these commendable goals, hospitals’ participation in ACOs remains low; the most significant barrier being the risk associated with joining. This study explores factors that facilitate hospitals’ ACO entry decisions by applying resource dependence theory to explain that competition network characteristics, organizational network characteristics, and internal organizational characteristics mitigate hospitals’ financial risk and are therefore critical to ACO participation.

Primary Care Sub-Capitation in Medicaid: Improving Care Delivery in the Safety Net

Date:  February 7, 2023
Source:  Journal of General Internal Medicine
Article

This article examines Massachusetts’ request to implement primary care sub-capitation for its Medicaid ACO program via a Section 1115 Demonstration waiver. Under the proposal, distinct from most other current capitated payment arrangements in Medicaid, ACOs would receive a prospective, risk-adjusted, per member per month (PMPM) payment for primary care services and would be required to pay primary care providers a similarly risk-adjusted PMPM via a sub-capitated arrangement, without subsequent reconciliation to utilization, a feature that would be unique to the MassHealth program. Although practices would continue to submit claims to capture risk and measure quality, claims included in the sub-capitation program would no longer be used for fee-for-service style reimbursement. Sub-capitation alone though may not properly reward and capture the level of effort taken by practices that have integrated more services directly into the primary care experience. To encourage further primary care integration, the proposed sub-capitation program also includes three attainable “tiers” of primary care practice, with enhanced funding alongside increasing care delivery expectations at each successive tier. All practices participating in the ACO program would be required to meet a baseline set of expectations at the first tier, with the higher second and third tiers featuring increased actuarially based payments given for practices meeting the requirements of that respective tier. Higher tiers would be expected to provide enhanced team-based primary care and staffing, including particular focus on specific populations, including behavioral health, substance use disorder, and pediatric members. changes in readmission or mortality after controlling for other factors. Policies that shorten LOS may not have adverse effects on outcomes for people living with dementia. 

Impact of a Clinician Incentive Program on Quality Measures Performance in a Medicare Shared Savings Accountable Care Organization 

Date: January/February 2023
Source: American Journal of Medical Quality
Article

Financial incentives are often used to encourage and reward clinicians for achieving specific outcomes; however, there is limited data on their effectiveness. This study evaluates the impact of New York Quality Care’s Clinician Incentive Program on improving quality measure performance over four years. Clinicians, including primary care physicians and specialists, actively opted-in to an incentive program where their quality performance was evaluated and rewarded biannually. Using Medicare Shared Savings Program data extracted for quality measures (2016–2019), this study analyzed quality measure performance between clinicians who opted-in to the program compared to those who did not. Additional analysis was performed comparing primary care clinician and specialist performance. The analysis revealed that clinicians in the incentive program significantly outperformed (P < 0.05) clinicians who chose not to join the program in six of the seven quality measures. In addition, the program helped facilitate discussions with clinicians more broadly in population health efforts. 

Risk Adjustment and Promoting Health Equity in Population-Based Payment: Concepts and Evidence 

Date: January 2023
Source: Health Affairs
Article

The objective of risk adjustment is not to predict spending accurately but to support the social goals of a payment system, which include equity. Setting population-based payments at accurate predictions risks entrenching spending levels that are insufficient to mitigate the impact of social determinants on health care use and effectiveness. Instead, to advance equity, payments must be set above current levels of spending for historically disadvantaged groups. In analyses intended to guide such reallocations, this study found that current risk adjustment for the community-dwelling Medicare population overpredicts annual spending for Black and Hispanic beneficiaries by $376–$1,264. The risk-adjusted spending for these populations is lower than spending for White beneficiaries despite the former populations’ worse risk-adjusted health and functional status. Thus, continued movement from fee-for-service to population-based payment models that omit race and ethnicity from risk adjustment (as current models do) should result in sizable resource reallocations and incentives that support efforts to address racial and ethnic disparities in care. The study found smaller overpredictions for less-educated beneficiaries and communities with higher proportions of residents who are Black, Hispanic, or less educated, suggesting that additional payment adjustments that depart from predictive accuracy are needed to support health equity. These findings also suggest that adding social risk factors as predictors to spending models used for risk adjustment may be counterproductive or accomplish little. 

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

Date: January 2023
Source: Journal of Rural Health
Article

This study examined the associations of ACO characteristics with the likelihood of participation in 2-sided risk tracks in the Medicare Shared Savings Program (MSSP). Researchers used CMS ACO Public Use Files and Provider-Level Research Identifiable Files to trace ACOs’ MSSP participation between 2012 and 2020 and measure ACO characteristics, including size, rurality of the service area, affiliation with supporting organizations, program experience, and performance.  Among the 624 MSSP ACOs that started between 2012 and 2017, 26 participated in 2-sided risk tracks in their initial contracts and 95 switched to 2-sided risk tracks subsequently. ACO characteristics were not significantly associated with the probability of participating in 2-sided risk tracks in initial contracts. ACO size, affiliation with supporting organizations, and performance were positively associated with the likelihood of switching to 2-sided risk. Rural ACOs were less likely to switch to 2-sided risk than their urban counterparts. Small and rural ACOs are less prepared to transition into 2-sided risk swiftly. 

What Should Antiracist Payment Reform Look Like? 

Date: January 2023
Source: AMA Journal of Ethics
Article

Racism reduces eligibility for health insurance and access to high-quality care for people of color in the United States, and current payment structures exacerbate the resulting de facto racial segregation. Payers and health plans do not adequately support and incentivize clinicians and health care delivery organizations to meet the health needs of minoritized communities. This article describes foundational work needed to create an antiracist culture of equity; the Roadmap to Advance Health Equity; and specific, actionable antiracist payment reform strategies, including increasing access to and the scope of health insurance coverage, antiracism accountability in managed-care contracts, support for the safety-net system, strengthened nonprofit hospital tax status requirements, and payment incentives to advance health equity. Antiracist payment reforms have great potential to desegregate health care systems and to ensure that everyone has a fair opportunity to receive good health services and optimize their health. 

Associations Between Physician Practice Models and Health Information Exchange 

Date: January 11, 2023
Source: American Journal of Managed Care
Article

This study examined the interaction between emerging physician practice models and the use of health information exchange (HIE), as well as barriers to HIE adoption among physicians who were not utilizing HIE. The study used survey data came from a 2019-2021 statewide census of all physicians in Arizona collected at the time of license renewal (n = 3,312, or 17.9% of all practicing physicians). Compared with physicians in traditional care delivery models, physicians in ACOs, clinically integrated networks, or integrated delivery networks had significantly higher odds of using HIE to share both patient care summaries (P < .01) and laboratory results (P < .05 for ACOs), although associations varied across provider and practice characteristics. ACO providers not using HIE were more likely to cite a lack of connectivity and lack of information as HIE barriers. 

Working With ACOs To Address Social Determinants of Health 

Date: January 10, 2023
Source: Health Affairs Forefront
Article

Social, behavioral, and economic factors are important determinants of health and health outcomes. Many health care organizations are beginning to assess the social risks of their patients and facilitate interventions to address health-related social needs. Organizations participating in payment models where they are responsible for managing the total cost of care for assigned or enrolled populations, such as ACOs, may be particularly interested in integrating medical and social services. In this article, the authors discuss key lessons learned from ACO managers tasked with advancing their organizations’ efforts to integrate medical and social care, including: collecting data on patients’ social needs is essential but costly; health system investments are needed to build effective partnerships with community-based organizations; many community-based organizations lack funding to meet the increasing demand from health care organizations; and more direct payment for social care is needed to accelerate the integration of health and social services. 

Risk Adjustment: It’s Time for Reform 

Date: January 9, 2023
Source: Health Affairs Forefront
Article

A growing range of policy discussions correctly assert that the current Centers for Medicare and Medicaid Services’ (CMS) risk-adjustment system needs modernization, reflecting its long history and evolution. While refined over time, the same CMS-Hierarchical Condition Categories (HCC) risk-adjustment model has been used for nearly 20 years. The same essential model is employed in Medicare Advantage (MA) and applied to nearly all of CMS’s longitudinal value-based payment models, including both the Medicare Shared Savings Program and the Innovation Center’s ACOs, including the ACO Realizing Equity, Access, and Community Health (REACH) Model. This article outlines approaches to reforming risk adjustment to advance health equity goals. 

A Pharmacy Liaison-Patient Navigation Intervention to Reduce Inpatient and Emergency Department Utilization Among Primary Care Patients in a Medicaid Accountable Care Organization 

Date: January 9, 2023
Source: JAMA Network Open
Article

This study examined whether more frequent screening for health-related social needs and patient navigation embedded in pharmacy care were associated with reduced hospital admissions and emergency department (ED) visits among primary care patients in a Medicaid ACO compared with usual pharmacy care. In this nonrandomized controlled trial of 364 adults, patients in the enhanced pharmacy care group did not have a lower likelihood of any hospital admissions or ED visits vs the usual pharmacy care group over 12 months. These findings suggest that enhancing pharmacy services for patients with high levels of health care utilization does not lead to reduced health care utilization.