2023 ACO Publications
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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 article surveys how ACOs use digital health technology to treat opioid use disorder. ACOs were specifically surveyed on their use of remote mental health therapy and tracking, virtual peer recovery support programs, and digital recovery support for adjuvant cognitive behavior therapy.
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.
So, you want to form a healthcare network – now what?
Healthcare networks are rapidly developing owing to the rising costs of maintaining independent practice while complying with changing rules and regulations. As groups are looking to create a network, a thorough evaluation completed in preparation for participation will assure their new venture greater success. The experiences of current networks, including those associated with accountable care organizations (ACOs), provide a road map for others. Keystone ACO, LLC has more than eight years of network experience in value-based contracting within the Medicare Shared Savings Program. (Keystone Accountable Care Organization, LLC is a Medicare Shared Savings ACO currently participating in the Basic Track E risk track. Information on Keystone ACO can be found at Keystoneaco.org.) This paper presents experiences of management consideration and staffing structures within Keystone ACO. Observations that are both positive and negative, coupled with policy and regulatory statutes, can assist new networks in selecting participants, evaluating opportunities, and providing the staffing resources to create a successful healthcare network. The content of this paper provides examples and thought processes behind building a successful network.
Date: January 2022
Source: Management in Healthcare
Article
Changes in Spending and Quality after ACO Contract Participation for Dually Eligible Beneficiaries with Mental Illness
Date: March 2023
Source: Healthcare
Article
Using Medicare fee-for-service Part A and B claims data from 2009 to 2017 and a difference-in-differences design, this study compared spending and utilization of dually eligible Medicare and Medicaid beneficiaries with mental illness who were and were not attributed to Medicare ACO providers before and after ACO contract entry. Dually eligible beneficiaries with mental illness (N = 5,157,533, 70% depression, 22% bipolar, 27% schizophrenia and other psychotic disorders) had average annual Medicare spending of $17,899. ACO contract participation was generally not associated with spending or utilization changes. However, ACO contract participation was associated with higher rates of follow-up visits after mental health hospitalization: 1.17 and 1.30 percentage points within 7 and 30 days of discharge, respectively (p < 0.001). ACO-attributed beneficiaries with schizophrenia, bipolar, or other psychotic disorders received more ambulatory visits (393.9 per 1000 person-years, p = 0.002), while ACO-attributed beneficiaries with depression experienced fewer emergency department visits (−29.5 per 1000 person-years, p = 0.003) after ACO participation. Dually eligible beneficiaries served by Medicare ACOs did not have lower spending, hospitalizations, or readmissions compared with other beneficiaries. However, ACO participation was associated with timely follow-up after mental health hospitalization, as well as more ambulatory care and fewer ED visits for certain diagnostic groups.
Association of Medicare Beneficiary and Hospital Accountable Care Organization Alignment with Surgical Cost Savings
Date: December 22, 2022
Source: JAMA Health Forum
Article
This study assessed whether greater beneficiary-hospital ACO alignment was associated with lower surgical episode costs using Medicare data from a 20% random sample of beneficiaries. Individuals 18 years of age and older and without kidney failure who had a surgical admission between 2008 and 2015 were included. For each study year, distinction was made between beneficiaries assigned to an ACO and those who were not, as well as between admissions to ACO-participating and nonparticipating hospitals. During the study period, 2,797,337 surgical admissions (6% of which involved ACO-assigned beneficiaries) occurred at 3,427 hospitals (17% ACO participating). Total Medicare payments for 90-day surgical episodes were lowest when ACO-assigned beneficiaries underwent surgery at a hospital participating in the same ACO as the beneficiary ($26,635 [95% CI, $26,426-$26,844]). The highest payments were for unassigned beneficiaries treated at participating hospitals ($27,373 [95% CI, $27,232-$27,514]) or nonparticipating hospitals ($27, 303 [95% CI, $27,291-$27,314]). Assigned beneficiaries treated at hospitals participating in a different ACO and assigned beneficiaries treated at nonparticipating hospitals had similar payments (for participating hospitals, $27,003 [95% CI, $26,739-$27 267] and for nonparticipating hospitals, $26,928 [95% CI, $26,796-$27,059]). A notable factor in the observed differences in surgical episode costs was lower spending on post-acute care services. In this cohort study evaluating hospital and beneficiary ACO alignment and surgical spending, savings were noted for beneficiaries treated at hospitals in the same ACO. Allowing ACOs to encourage or require surgical procedures in their own hospitals could lower Medicare spending on surgery.
The Longitudinal Impact of a Multistate Commercial Accountable Care Program on Cost, Use, and Quality
Date: December 2022
Source: Health Affairs
Article
The prevalence of ACOs has grown significantly across Medicare and commercial payers in the past decade, but there are limited insights regarding the effect of ACOs on costs in the commercial population. Researchers used longitudinal administrative claims data over the course of 19 calendar quarters from 2016 to 2021 to assess the ongoing incremental impact of Elevance Health’s commercial ACO program on cost and use across 15 U.S. states. The study also analyzed the program’s impact on spending subcategories (inpatient, outpatient, professional, and pharmacy) and measured differences in quality performance. The program was associated with incremental savings during this period. Incremental savings were greater in the fully insured population relative to the administrative services only population and were due to outpatient and pharmacy savings. ACO providers had superior quality performance measures relative to contracted providers not participating in ACOs.
Growth Of Value-Based Care and Accountable Care Organizations In 2022
Date: December 2, 2022
Source: Health Affairs Forefront
Article
Across all payers, ACO participation has continued, but growth in the number of new ACOs, new ACO contracts, and ACO-covered lives has slowed. By the end of 2022’s first quarter, there were 1,010 known ACOs, with 1,760 public and private ACO contracts, covering more than 32 million lives. Of the 1,760 active ACO contracts, private-sector arrangements continue to represent the largest payer type, with 995 commercial contracts, 625 Medicare contracts, and 139 Medicaid contracts.
Prevalence of Social Risk Factors and Social Needs in a Medicaid Accountable Care Organization (ACO)
Date: November 19, 2022
Source: BMC Health Services Research
Article
This study compared the differential prevalence of social risk factors and social needs in a Medicaid ACO and identified the patient and practice characteristics associated with reporting social needs in a different domain from social risks. The study analyzed patient responses to health-related social needs (HRSN) screening from February 2019 to February 2020. HRSN screening occurred as part of routine primary care and assessed social risk factors in eight domains and social needs by requesting resources in these domains. Participants included adult and pediatric patients from 114 primary care practices. Patient and practice characteristics associated with reporting social needs and concordance to social risks included patient age, sex, race, ethnicity, language, and practice proportion of patients with Medicaid and/or limited English proficiency (LEP). In the study, 27,413 individuals completed 30,703 screenings, including 15,205 (55.5%) caregivers of pediatric patients. Among completed screenings, 13,692 (44.6%) were positive for ≥ 1 social risk factor and 2,944 (9.6%) for ≥ 3 risks; 5,861 (19.1%) were positive for social needs and 4,848 (35.4%) for both. Notably, 1,013 (6.0%) were negative for social risks but positive for social needs. Patients who did not identify as non-Hispanic White or were in higher proportion LEP or Medicaid practices were more likely to report social needs, with or without social risks. Patients who were non-Hispanic Black, Hispanic, preferred non-English languages, or were in higher LEP or Medicaid practices were more likely to report social needs without accompanying social risks. Half of Medicaid ACO patients screened for HRSN reported social risk factors or social needs, with incomplete overlap between groups. Screening for both social risks and social needs can identify more individuals with HRSN and increase opportunities to mitigate negative health outcomes.
Medicaid Population-Based Payment: The Current Landscape, Early Insights, and Considerations for Policymakers
Date: November 2022
Source: Center for Health Care Strategies
Article
Population-based payment (PBP) models, including ACOs, are gaining increasing interest in health care as a way to pursue many goals including: (1) reducing the cost of health care; (2) improving quality; (3) improving patient experience; (4) improving provider experience; and (5) advancing health equity. PBPs are an advanced value-based payment (VBP) approach that delivers a prospective payment to health care providers and holds them financially accountable for quality and cost of care. The report includes: a landscape scan of existing Medicaid PBPs, promising strategies for designing and implementing PBPs in Medicaid, and considerations for state and federal policymakers looking to support PBP programs.
A Global Equity Model (GEM) for the Advancement of Community Health and Health Equity
Date: November 14, 2022
Source: National Academy of Medicine
Article
In the present paper, the authors propose an innovative payment model that realigns incentives across the necessary stakeholders, programs, and payments in metropolitan areas to advance community health and achieve health equity. This paper is organized into a background section and a model proposal section. In the background section, we describe the relevance of existing and emerging payment systems to community health and health equity. In the model proposal section, we propose a global payment model with community health and health equity as its organizing features (hereafter, “the global equity model” or “GEM”). “Global” within this context refers to a form of cost control characterized by setting a cap on the totality of a health system’s revenue across inpatient, emergency department (ED), and outpatient sites of care.
Financial Characteristics of Critical Access Hospitals (CAHs) Participating in Accountable Care Organizations (ACO)
Date: November 2022
Source: Flex Monitoring Team
Article
Of the 1,299 CAHs included in the sample, 770 (59%) responded to the AHA survey question about ACO participation in 2019. Of these, 388 (50%) reported the hospital or system either leading (n=138) or participating in (n=250) an ACO. Thirty-six CAHs reported previously participating in or leading an ACO but were no longer doing so, and 346 CAHs reported never having led or participated in an ACO. Among hospitals leading an ACO, contracts with Medicare and commercial insurers were most common, followed by Medicare Advantage and lastly Medicaid. Forty-one CAHs reported contracts with only one of the four payers while 73 reported contracts with two, three or all four payers. As compared to CAHs not participating in an ACO or not responding, CAHs that were leading or participating in an ACO had greater net patient revenue and were more likely to be in the Midwest region, not-for-profit, and affiliated with a health system. As compared to CAHs not participating or not responding, CAHs leading or participating in an ACO had higher operating and total margins, fewer days revenue in accounts receivable, greater outpatient revenue as a proportion of total revenue, and a lower Medicare inpatient payer mix.
Designing Accountable Care: Lessons from CMS Accountable Care Organizations
Date: November 10, 2022
Source: The Commonwealth Fund
Article
In July 2022, the Centers for Medicare and Medicaid Services (CMS) announced plans to expand the scale and scope of the ACO program. To inform this effort, the authors synthesized evidence on CMS ACOs to identify factors that have facilitated or hindered success. Evidence has shown ACOs have produced savings while at least maintaining quality of care, but not necessarily improving health disparities.
Looking Ahead to the Next Decade of Accountability for Care Delivery
Date: November 9, 2022
Source: McKinsey & Co.
Article
This report examines the Center for Medicare & Medicaid Innovation’s five strategy objectives and their potential impact on the healthcare landscape: Grow and improve accountable care; advance health equity; support care innovations; improve access by addressing affordability, and partner to achieve care transformation.
To What Extent Are ACO and PCMH Models Advancing the Triple Aim Objective? Implications and Considerations for Primary Care Medical Practices
Date: October-December 2022
Source: Journal of Ambulatory Care Management
Article
ACOs and patient-centered medical homes (PCMHs) have emerged to advance the health care system by achieving the Triple Aim of improving population health, reducing costs, and enhancing the patient experience. This review examines evidence regarding the relationship between these innovative care models and care outcomes, costs, and patient experiences. The 28 articles summarized in this review show that ACO and PCMH models play an important role in achieving the Triple Aim, when compared with conventional care models. However, there can be drawbacks associated with model implementation. The long-term success of these models still merits further investigation.
Performance Results of The Medicare Shared Savings Program In 2021: Continued Uncertainty With Positive Movement
Date: October 20, 2022
Source: Health Affairs Forefront
Article
On August 30, CMS released performance results for the ninth performance year (2021) of the Medicare Shared Savings Program (MSSP). The 2021 data represent the first full year of performance since the start of the COVID-19 pandemic, which continues to impact Medicare spending and cause a high degree of uncertainty in the Medicare program. To that end, CMS maintained programmatic flexibilities, as detailed in our previous article detailing 2020 performance results, throughout the 2021 performance year to help accountable care organizations (ACOs) cope with the unprecedented situation. As such, this year’s results must continue to be interpreted with caution. Key findings from this year’s MSSP performance data analysis include:
- Overall, 475 different organizations participated in the MSSP, which is a 7 percent decrease compared to last year’s 513 and a 12 percent decrease from 2019. This is partially explained by CMS’s COVID-19 flexibilities
- The total number of assigned beneficiaries decreased from 10,614,589 in 2020 to 10,124,325 in 2021.
- The program saw more than $1.6 billion savings in 2021, with similar percentages of ACOs generating net savings (81 percent) and receiving shared savings (58 percent) as 2020.
- ACOs generated approximately $190 net savings per attributed beneficiary, approximately the same as last year.
- Physician group-led ACOs were slightly more likely than hospital-led or jointly led ACOs to realize savings relative to their benchmark and to receive bonus payments.
- Of the 12 ACOs with the majority of their beneficiaries in dual enrollment, all but one of these ACOs produced shared savings.
- More than 41 percent of ACOs were in two-sided risk, up from 37 percent last year and 33 percent in 2019, and two-sided ACOs tended to have higher shared savings rates and slightly better mean quality scores.