2024 ACO Publications

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Health Information Technology to Advance Care in Accountable Care Organizations: Implications for Medicare Patients

Date: January-March 2025
Source: Health Care Management Review
Article

While prior research has explored the link between health information technology (HIT) and ACO performance, the challenges of using HIT in ACOs to help manage chronic diseases among Medicare beneficiaries remain less examined. Given the high costs of implementing HIT and the occurrence of multiple chronic conditions (MCC) among elderly individuals, it is important to understand the extent to which HIT capabilities enable chronic disease management among the Medicare population. This study used regression analysis of data from multiple sources for the year 2017, including Leavitt Partners data, the ACO Public Use File published by the Shared Savings Program of the Centers for Medicare & Medicaid Services (CMS), and CMS hospital referral region data. The sample consisted of 470 ACOs. The findings show that health information exchange (HIE)- and HIT-enabled patient engagement reduced unplanned admissions for Medicare patients with MCC. When primary care services were utilized, HIE- and HIT-enabled patient engagement and medication reconciliation further decreased unplanned admissions. This study provides empirical support for HIT’s role in reinforcing the applicability of the chronic care model to improve health outcomes.

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

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

This study investigated variations in Medicare payments for Alzheimer’s disease and related dementia (ADRD) by race, ethnicity, and neighborhood social vulnerability, together with cost variations by beneficiaries’ enrollment in ACOs. Researchers used merged datasets of longitudinal Medicare Beneficiary Summary File (2016–2020), the Social Vulnerability Index (SVI), and the ACO Medicare Shared Savings Program (MSSP) to measure beneficiary-level ACO enrollment at the diagnosis year of ADRD. The study analyzed Medicare payments for patients newly diagnosed with ADRD for the year preceding the diagnosis and for the subsequent 3 years. The dataset included 742,175 Medicare fee-for-service (FFS) beneficiaries aged 65 and older with a new diagnosis of ADRD in 2017 who remained in Medicare FFS from 2016 to 2020. Among those newly diagnosed, Black and Hispanic patients encountered higher total costs compared to White patients, and ADRD patients living in the most vulnerable areas experienced the highest total costs compared to patients living in other regions. These cost differences persisted over 3 years postdiagnosis. Patients enrolled in ACOs incurred lower costs across all racial and ethnic groups and SVI areas. For ADRD patients living in the areas with the highest vulnerability, the cost differences by ACO enrollment of the total Medicare costs ranged from $4,403 to $6,922, and beneficiaries’ savings ranged from $114 to $726 over three years post-ADRD diagnosis by patient’s race and ethnicity. The study concludes that ACOs and emerging CMS Innovation models, such as the Guiding an Improved Dementia Experience (GUIDE) Model, should prioritize strategic resource allocation in socially vulnerable areas while emphasizing culturally competent ADRD care.

Medicare Accountable Care Organization Treatment of Serious Mental Illness: Associations Between Behavioral Health Integration Activities and Outcomes

Date: November 29, 2024
Source: Medical Care
Article

This study examined the association between Medicare ACO behavioral health integration capability and quality and utilization among adults with serious mental illness (SMI).

Researchers surveyed Medicare ACOs (2017-2018 National Survey of ACOs, response rate 69%), and linked responses to 2016-2017 fee-for-service Medicare claims for beneficiaries with SMI. They then examined the cross-sectional association between ACO-reported integration capability (tertiles of a 14-item index) and 7 patient-level quality and utilization outcomes. The study sample included 274,928 beneficiary years (199,910 unique beneficiaries) attributed to 265 Medicare ACOs. ACOs with high behavioral health integration capability (top-tertile) served more dual-eligible beneficiaries (67.8%) than bottom-tertile (63.7%) and middle-tertile ACOs (63.3%). Most beneficiaries received follow-up 30 days after mental health hospitalization and chronic disease monitoring—exceeding national quality benchmarks—but beneficiaries receiving care from top-tertile (vs bottom-tertile) ACOs were modestly less likely to receive follow-up [-2.17 percentage points (pp), P < 0.05], diabetes monitoring (-2.19 pp, P < 0.05), and cardiovascular disease monitoring (-6.07 pp, P < 0.05). Integration capability was not correlated with utilization. The study concluded that ACOs serving adults with substantial physical and mental health needs were more likely to report comprehensive integration capability but were not yet meeting the primary care needs of many adults with SMI.

Participation of Behavioral Health Facilities in Medicare Accountable Care Organizations

Date: November 27, 2024
Source: JAMA Health Forum
Article

Medicare and other payers are increasingly relying on value-based payment (VBP) models to provide coordinated high-quality care while containing costs. Although 1 in 3 Medicare beneficiaries has a behavioral health (BH) condition, integration of BH facilities has not been a focus of many Medicare VBP models. This study describes participation of BH facilities in MSSP ACOs from 2014 to 2022. The study found that ACOs with at least 1 BH facility increased from 93 of 333 (28%) to 214 of 482 (44%) during 2014-2022, with a nearly constant average of 44% since 2019. By 2022, 38% of ACOs included inpatient psychiatric facilities (IPFs), compared with 19% of ACOs that included outpatient BH facilities. Only a small subset (6%) of ACOs included outpatient BH facilities only. That fewer than 1 in 5 ACOs (19%) contracted with an outpatient BH facility is concerning. The authors conclude that including outpatient BH facilities in ACO contracts could be instrumental in coordinating BH and physical care for attributed beneficiaries, especially for ACOs that serve a higher proportion of underserved and rural populations, as outpatient BH facilities may be the only source of specialty BH services in the community.

The Development of the Community Deprivation Index and Its Application to Accountable Care Organizations

Date: November 27, 2024
Source: Health Affairs Scholar
Article

There is strong interest among policymakers to adjust for area-level deprivation when paying providers because such areas have traditionally been underserved. The Medicare Accountable Care Organization Realizing Equity, Access, and Community Health (ACO REACH) model provides higher payments to ACOs serving areas with greater deprivation. The Area Deprivation Index (ADI) is the primary component to measure deprivation for ACO REACH. The ADI is a commonly used deprivation index, but there are concerns about its methodology, primarily its use of non-standardized deprivation factors. Prior research indicates the ADI is mainly determined by home values, which doesn’t allow it to adequately capture deprivation in urban areas. This paper revises and updates the ADI, using American Community Survey data to compute a Census block group deprivation index, the Community Deprivation Index (CDI). The CDI standardizes the deprivation factors to be unit neutral, applies statistical shrinkage to account for the imprecise measurement of the factors, updates several factors, and reweights the factors using the most recently available data. Validation tests suggest the CDI exhibits higher correlations with several health outcome/utilization measures than the ADI. The CDI will better serve policymakers by improving identification of urban areas with higher deprivation.

Behavioral health treatment delivery by social workers in accountable care organizations

Date: November 22, 2024
Source: Social Work in Health Care
Article

Nearly half of traditional Medicare beneficiaries receive care through an ACO. Although the skills of the social work profession align with the goals of ACOs (coordination of service needs across multiple health and social care settings), there is little information on social worker inclusion as behavioral health providers in ACOs. Researchers developed and administered a national survey of organizations (n = 227) with Medicare and Medicaid ACO contracts to provide an estimate of the percentage of ACOs that reported social worker-delivered behavioral health treatment. Approximately half of the respondents reported that social workers delivered mental health treatment, while a third reported that social workers delivered substance use treatment. Organizations that included specialty mental health treatment facilities were more likely to report social worker-delivered mental health and substance use treatment. Organizations that included rural healthcare facilities were less likely to report social worker-delivered substance use treatment. By describing the prevalence and predictors of social worker-delivered behavioral health treatment in ACOs, this study contributes foundational estimates for future research on the role of this important workforce in ACOs.

Accountable Care Organization Changes in Equity of Ambulatory Care Quality by Patient Race and Ethnicity, 2019-2022 

Date: November 21, 2024
Source: Health Affairs Scholar
Article

There is limited information about ACO variation in equity of ambulatory care quality. This study examined whether equity of care changed for racial and ethnic minority patients from 2019 to 2022 and the extent to which equity of care performance varied for 11 ACOs in Massachusetts over time. Researchers analyzed ACO-level changes in equity of care for eight ambulatory care quality measures for Asian, Black, and Hispanic patients, measured as the percentage point difference between each group and the majority non-Hispanic White patient group. Cervical cancer screening (3.54 percentage point change, p<0.001), colorectal cancer screening (3.54 percentage point change, p<0.001), and eye exams for adults with diabetes (3.56 percentage point change, p=0.008) had the largest performance declines. Equity of ambulatory care quality did not significantly change over time. The one exception was for breast cancer screening, where equity declined for Asian patients (3.52 percentage point change, p=0.04). Although equity of care generally did not significantly change over time across ACOs, high variation in equity of care performance between ACOs highlights opportunities to identify and share the strategies that enable physician practices and health care systems to advance equity of care for racial and ethnic minority patients.

Federally Qualified Health Centers and Performance of Medicare Accountable Care Organizations

Date: November 18, 2024
Source: JAMA Open Network
Article

Federally qualified health centers (FQHCs) have increasingly participated in MSSP ACOs. Although FQHCs may strengthen ACOs’ ability to provide affordable care to diverse Medicare beneficiaries, evidence on ACOs’ performance by FQHC participation is limited. This study compared beneficiary characteristics, utilization, expenditure, and quality between ACOs with and without FQHC participation. Using MSSP public use files, this cross-sectional study compared performance of ACOs that always had FQHC participation with ACOs that never had FQHC participation from January 1, 2016, to December 31, 2022, supplemented with staggered difference-in-differences analyses of ACOs’ first-time inclusion of FQHCs on performance measures. Among 752 ACOs in the descriptive analysis, 140 ACOs always had at least 1 FQHC participant, while 612 ACOs never had FQHC participants. In this repeated cross-sectional study, MSSP ACOs with FQHC participation served more socioeconomically disadvantaged Medicare beneficiaries than those without FQHC participation. The inclusion of first FQHCs was associated with increased rates of several preventive services without increasing costs. Participation of safety net practices appeared to improve access to ACOs among beneficiaries from underserved communities.

Attributing Ischemic Heart Disease Patients to Physicians: An Assessment of Claims-based Accountable Care Organization Attribution Methods

Date: November 11, 2024
Source: Circulation
Article

ACOs often assess provider care quality by using attribution algorithms to determine the provider most responsible for a patient’s care. However, patients with ischemic heart disease (IHD) may receive care from more than one physician, and secondary prevention for IHD is often provided by both primary care physicians (PCPs) and cardiologists. This study assessed the performance of two commonly used claims-based ACO attribution methods for identifying the provider responsible for managing IHD-related outpatient care for patients in the year following incident acute myocardial infarction (AMI). The study used retrospective analysis of Medicare claims data for 491,391 AMI patients who survived for at least 1 year. Assignment of responsibility was made to the physician who saw the patient for the 1) plurality of PCP visits (PCP-method) or 2) plurality of PCP or cardiologist visits (PCP-Cardiologist method). For each method, researchers assessed a) the proportion of patients that could be attributed to a physician, and b) how often the attributed physician and non-attributed physicians provided IHD care. The study found that the PCP-method attributed 352,261 patients (72%) and the PCP-Cardiologist method attributed 396,618 patients (81%) to a physician. The PCP-method attributed physician did not see the patient for an IHD visit in 38% of cases and did not provide the plurality of IHD visits in 67% of cases. The PCP-cardiologist method attributed physician did not see the patient for an IHD visit in 30% of cases and did not provide the plurality of IHD visits in 35% of cases. Overall, the proportion of IHD visits provided by other, non-attributed physicians was 69% for the PCP-method and 39% for the PCP-Cardiologist method. The study concluded that commonly used ACO attribution methods to identify a single physician responsible for a patient’s IHD care results in a significant number of patients being unattributed. Attribution methods that focus on visit frequency alone often attribute patients to physicians that do not provide any IHD care or less than a plurality of IHD care. Multi-attribution methods which attribute patients to more than one physician and consider both visit frequency and clinical context could result in a more appropriate appraisal and distribution of the responsibility of IHD care.

Opportunities To Enhance Design and Implementation of ACO REACH’s Core Payment Model Design Elements

Date: November 7, 2024
Source: Health Affairs Forefront
Article

ACO REACH, the largest CMS Innovation Center model, included 2.6 million beneficiaries in 2024. ACO Reach is a more advanced alternative payment model than the permanent ACO Medicare Shared Savings Program. Experts have noted that ACO REACH is a major step forward in incorporating multiple equity design and implementation elements directly into an advanced value-based payment (VBP) model. Given the significant policy implications REACH has for the future of VBP in Medicare broadly, this article focuses on recommendations to improve REACH’s core payment model design components, informed by literature review and conversations with REACH participants and other expert stakeholders about successes, challenges, and opportunities for improvement.

Pediatric Practices’ Experiences with Massachusetts’ Medicaid Accountable Care Organizations

Date: November 5, 2024
Source: Academic Pediatrics
Article

This study examined the experience of Medicaid ACOs that include pediatric practices, including their motivations and experiences working together. The mixed-methods study is set within the first two years of the Massachusetts Medicaid ACO Program, which created 17 Medicaid ACOs across the Commonwealth in 2018. The study combines qualitative interviews from organizational leaders across three Medicaid ACOs with pediatric representation (N=28; purposive sample; 2018) with a 44-item primary care practice leader survey (N=225 after 64% response rate; statewide stratified random sample of primary care practices; 2019). Interviews gathered information about organizational motivations and experiences with becoming a Medicaid ACO; the survey asked five domains of questions describing the experience of pediatric- and adult-focused primary care practices in joining Medicaid ACOs (e.g., how much practices solved problems jointly with the ACO). Leaders of Medicaid ACOs with pediatric representation expressed a desire to voice pediatric concerns regarding state Medicaid payment policy and to integrate social services as part of routine medical care. Relative to the experience of adult-focused primary care practice leaders, pediatric-focused practices reported less collaboration and standardization within their Medicaid ACOs.

Accountable Care Organizations and HPV Vaccine Uptake: A Multilevel Analysis

Date: October 24, 2024
Source: American Journal of Managed Care
Article

This study examined associations between ACO membership and human papillomavirus (HPV) vaccination and variation in HPV vaccination across ACO providers. Researchers analyzed records of commercially insured children and adolescents aged 11 to 14 years using Connecticut’s All-Payer Claims Database from January 2012 to December 2017. A total of 23,911 adolescents receiving care from 933 ACO-attributable providers and 923 non–ACO-attributable providers were included. The mean rate of HPV vaccine initiation was 53% overall (51% among boys, 55% among girls). Among those who initiated the vaccine, the mean rate of HPV vaccine completion was 69% (67% among boys, 70% among girls). Adolescents receiving care from ACOs were significantly more likely to initiate and complete HPV vaccination than were adolescents receiving care in non-ACO settings. Variation in HPV vaccine uptake attributable to providers within ACOs dwarfed variation attributable to ACOs, indicating that vaccine uptake was more dependent on the provider irrespective of the ACO with which they were affiliated. Efforts to improve HPV vaccination rates may require provider-focused interventions regardless of the overall performance of their health care system or provider organization.

Differences in Utilization of Preventive Services for Primary Care Clinicians Participating in MIPS and ACO

Date: October 22, 2024
Source: Quality Management in Health Care
Article

To improve quality and lower costs, CMS implemented the Quality Payment Program (QPP) for clinicians in 2017. Under the Medicare QPP, most eligible clinicians participate in one of the payment models:Advanced Alternative Payment Models (A-APMs) through eligible APMs like ACOs or (b) the Merit-based Incentive Payment System (MIPS). This study evaluated the differences in the utilization of preventive services by primary care clinicians participating in MIPS and ACOs. Since preventive services like immunization and certain cancer screening are mandatory reporting measures for ACOs and voluntary measures for MIPS, the treatment group for this study is ACO clinicians and the comparison group is non-ACO MIPS clinicians. Researchers obtained the rates of influenza immunization, pneumonia vaccination, tobacco use cessation intervention, depression screening, colorectal cancer screening, breast cancer screening, and wellness visits per 10,000 Medicare beneficiaries from Medicare Provider Utilization and Payment Public Use File (2012-2018).  The study included  508,144 total observations (ACO = 25.78% and MIPS = 74.22%) from 72,592 unique primary care clinicians. Compared to MIPS clinicians, ACO clinicians had significantly higher rates of pneumonia vaccination but lower rates of colorectal cancer screening. Similarly, clinicians in ACO shared savings-only models had significantly higher rates of pneumonia vaccination, depression screening, and wellness visits compared to MIPS clinicians. There were no differences between ACO and MIPS clinicians on the utilization of breast cancer screening procedures and tobacco use cessation interventions. The researchers concluded that ACO clinicians may have prioritized relatively low-cost services such as pneumonia vaccination, depression screening, and wellness visits to improve their performance under QPP. Policymakers may need to alter incentives in performance-based payment programs to ensure that clinicians are improving all types of quality measures, including cancer screening.

Patient Assignment and Quality Performance: A Misaligned System

Date: October 2024
Source: American Journal of Managed Care
Article

This study examined the congruence between patient assignment and established patients and the association with Healthcare Effectiveness Data and Information Set (HEDIS) quality performance. The study setting was a fully integrated health care delivery system in Phoenix, Arizona. The study population includes Medicaid patients who received primary care services or were assigned to a primary care physician (PCP) at the study setting by 5 Medicaid managed care organizations (MCOs). Researchers identified four possible relationships between the established patients (2 primary care visits) and the assigned patients (assigned by the MCO to the study setting): true-positive, false-positive, true-negative, and false-negative classifications. A total of 100,030 Medicaid enrollees (adults and children) were established and/or assigned to the study setting from five separate payers. Only 15% were congruently established and assigned to the physician (true-positive). The vast majority of assigned patients were not treated by the assigned PCP, yet better patient outcomes were seen with an established patient. As the health system rapidly adopts value-based payments, more rigorous methodologies are essential to identify physician-patient relationships. Physicians need to receive accurate and timely information regarding their patient panel to effectively manage patient care, a precursor to being held accountable for care delivered.

Physician Payment Reform in Medicare: Putting the Pieces Together

Date: October 9, 2024
Source: Health Affairs Forefront
Article

This article explores the possible role of alternative payment models (APMs) in advancing physician payment reform. The author examines the design of two pieces of physician payment reform that are more related than they may seem and directly interact with broader population-based payment reforms: the APM bonus and primary care payment reform. An overarching theme is that appreciating how various pieces need to be crafted to fit together is crucial to elucidating a way forward that effectively achieves policy objectives.

Identifying and Addressing Health-Related Social Needs: A Medicaid Member Perspective

Date: October 8, 2024
Source: BMC Health Services Research
Article

This study examines patient perspectives about screening and referral for health-related social needs (HRSNs). The main study objectives were to explore how Massachusetts Medicaid (MassHealth) members engage with their health care clinicians to discuss HRSNs, to identify common needs discussed, and to describe whether members feel these needs are being addressed by health care clinicians and staff. In this qualitative study of Medicaid members, some reportedly felt comfortable freely discussing all of their clinical and social needs with their health care clinicians, while others noted feelings of apprehension. Several members recalled being asked about their HRSNs in various clinical or community settings, while others did not. The majority of members reported  having an unmet HRSN, including housing, nutrition, financial, or transportation issues, and many barriers to addressing these HRSNs were discussed. Finally, many members cited a preference for discussing HRSNs with community-based care coordinators and social workers at the community partner organizations rather than with their health care clinicians. Community-based care coordinators were lauded as essential facilitators in making the connection to necessary resources to help address HRSNs. The results highlight an opportunity to increase the effectiveness of HRSN screening and referral practices within the health care setting through relationship building between Medicaid members and diverse interdisciplinary care teams that include staff such as community health workers. Continued investment in cross-sector partnerships, screening workflows, and patient-clinician relationships may contribute to establishing an environment in which members can comfortably discuss HRSNs and connect with needed services to improve their health.

Expanding Permanent Pathways in Medicare for Accountable Care

Date: September 30, 2024
Source: Health Affairs Forefront
Article

In 2021, CMS set a goal to have 100 percent of beneficiaries with traditional Medicare in accountable care by 2030, where they have longitudinal care relationships with providers responsible for managing the quality and total cost of their care. High-quality, advanced primary care forms the foundation of a high-performing health care system and most accountable care relationships. The two main pathways for delivering accountable care to traditional Medicare beneficiaries have been through CMS ACO initiatives and the CMS Innovation Center advanced primary care model tests. Since 2022, CMS ACO initiatives have been guided by the objectives of alignment, growth, and equity to meet the 2030 accountable care goals. The Medicare Shared Savings Program, CMS’s permanent ACO program, currently includes more than 608,000 clinicians, in 480 ACOs, serving nearly 11 million beneficiaries. The program has produced consistent net savings over the past six years while delivering high-quality care, which provides additional opportunities for people with traditional Medicare to receive the benefits of coordinated care, including avoidable health care use. This article provides an update on Innovation Center efforts to align policies and advance accountable care.

Supporting Federally Qualified Health Center Participation in Value-Based Payment to Improve Quality and Achieve Savings

Date: September 2024
Source: Milbank Memorial Fund
Article

By 2030, CMS seeks to have 100% of traditional Medicare beneficiaries and “the vast majority” of Medicaid beneficiaries in accountable care arrangements where providers are paid based on quality care, health outcomes, and costs. However, federally qualified health centers (FQHCs), which provide care to 1 in 11 people in the United States, have largely been left out of value-based contracts. Medicaid managed care organizations, which operate these programs for most state Medicaid agencies, have presented several barriers to participation, and the complexity of FQHC payment policy creates additional challenges. This report outlines these barriers and highlights FQHC networks that are having success with value-based payment. The authors offer guidelines on designing successful value-based payment contracts for FQHCs and recommend action steps for CMS, state Medicaid agencies, and FQHCs that will enable more of these safety-net providers to participate in value-based care—and realize savings as well as improved quality for patients.

Medicaid Accountable Care Organizations and Disparities in Pediatric Asthma Care

Date: September 30, 2024
Source: JAMA Pediatrics
Article

Nearly 6 million U.S. children have asthma, and over one-third of U.S. children are insured by Medicaid. Although 23 state Medicaid programs have experimented with ACOs, little is known about ACO effects on longstanding insurance-based disparities in pediatric asthma care and outcomes. This study examined associations between Massachusetts Medicaid ACO implementation in March 2018 and changes in care quality and use for children with asthma.

Using data from the Massachusetts All Payer Claims Database from January 1, 2014, to December 31, 2020, researchers determined child-years with asthma and used difference-in-differences estimates to compare asthma quality of care and emergency department (ED) or hospital use for child-years with Medicaid vs. private insurance for 3-year periods before and after ACO implementation for children aged 2 to 17 years. Among 376,509 child-year observations, 268,338 (71.27%) were insured by Medicaid and 73,633 (19.56%) had persistent asthma. There was no significant change in rates of routine asthma visits for Medicaid-insured child-years vs. privately insured child-years post-ACO implementation. There was an increase in the proportion with asthma medication ratio (AMR) greater than 0.5 for Medicaid-insured child-years vs. privately insured in the postimplementation period, with absolute declines in both groups postimplementation. There was an increase in any ED or hospital use for Medicaid-insured child-years vs. privately insured postimplementation, an 8% increase from the preperiod Medicaid use rate. Introduction of Massachusetts Medicaid ACOs was associated with persistent insurance-based disparities in routine asthma visit rates; a narrowing in disparities in appropriate AMR rates due to reductions in appropriate rates among those with private insurance; and worsening disparities in any ED or hospital use for Medicaid-insured children with asthma compared to children with private insurance.

Accounting for Children in Accountable Care Organizations

Date: September 30, 2024
Source: JAMA Pediatrics
Article

ACOs, which aim to improve quality and reduce cost through population health management and value-based payment arrangements, are one of the most widespread U.S. health care reform models. Although ACO development and innovation have mainly focused on older adults insured by Medicare, 14 states have now implemented Medicaid ACOs that serve both adults and children. As ACOs continue to expand, there is a growing need to understand how these care and payment models can best promote child health and account for children’s distinct health care needs, particularly for the nearly 40% of US children insured by Medicaid and those enrolled in mixed-age (non–pediatric-focused) ACOs.

Improvement Science and Value-Based Payment Models

Date: September 20, 2024
Source: Health Affairs Forefront
Article

This article explores a novel approach to building value-based payment models that emphasize continuous revision during implementation. Inspired by quality improvement models that have improved delivery system performance, the authors propose that iterative model development in payment may allow for a more flexible understanding of population-level risk, financial incentives that in turn promote better care delivery processes, and rapid iteration of delivery system activities to overcome inertia. The authors examine how the ACO Realizing Equity, Access, and Community Health (REACH) model might be revised under such an approach.

What Value Do Teaching Hospitals Provide Commercial Beneficiaries When in an ACO?

Date: September 2024
Source: American Journal of Managed Care
Article

This study augments the ACO literature by examining cross-payer teaching hospital differences by comparing cost, utilization, and clinical outcomes in 2019 to 2021 among commercial beneficiaries, rather than Medicare beneficiaries, treated by providers participating in Medicare ACOs with and without an affiliated major teaching hospital. Compared with per-beneficiary rates at nonteaching ACOs, major teaching ACOs had lower mortality rates by up to 2.2 percentage points depending on the patient age group, $283 lower inpatient spending, and lower emergency department utilization in inpatient and outpatient settings, as well as $146 higher overall outpatient spending. Upward trends in mortality and beneficiary risk scores across both ACO types show disruption to health outcomes during COVID-19. These results provide evidence that ACOs with major teaching hospitals may be more likely to achieve the value-based goals of ACOs. Means to accomplish those goals may include avoiding higher-intensity care and supporting access to lower-cost alternatives where clinically appropriate, such as reducing inpatient and emergency department stays by delivering timely, high-quality outpatient care.

Massachusetts Medicaid ACO Program May Have Improved Care Use and Quality for Pregnant and Postpartum Enrollees

Date: September, 2024
Source: Health Affairs
Article

This study leveraged a natural experiment in Massachusetts to evaluate the effects of Medicaid ACOs on quality-of-care-sensitive measures and care use across the prenatal, delivery, and postpartum periods. Using all-payer claims data on Medicaid-covered live deliveries in Massachusetts, researchers used a difference-in-differences approach to compare measures before (the first quarter of 2016 through the fourth quarter of 2017) and after (the third quarter of 2018 through the fourth quarter of 2020) Medicaid ACO implementation among ACO and non- ACO patients. After three years of implementation, the Medicaid ACO was associated with
statistically significant increases in the probability of a timely postpartum visit, postpartum depression screening, and number of all-cause office visits in the prenatal and postpartum periods, with no changes in severe maternal morbidity, preterm birth, postpartum glucose screening, or prenatal or postpartum emergency department visits. Changes in cesarean deliveries were inconclusive. Results suggest that implementing Medicaid ACOs in the thirty- eight states without them could improve maternal health care outpatient engagement, but alone it may be insufficient to improve maternal health outcomes.

Senior-Focused Primary Care Organizations Increase Access for Medicare Advantage Members, Especially Underserved Groups

Date: September, 2024
Source: Health Affairs
Article

In this study, using data from Humana Medicare Advantage (MA) plans, researchers examined whether “senior-focused” primary care organizations supported predominantly by risk-based payments in contracts with MA plans are associated with better care and improved equity compared with other primary care organizations receiving other forms of payment in MA. Analyses of data from 462,872 MA beneficiaries in 2021 showed that senior-focused primary care organizations served more Black and dually eligible beneficiaries than other primary care organizations serving MA beneficiaries, and regression-adjusted analysis showed that senior-focused primary care patients received 17 percent more primary care visits. Differences were largest among Black and dual-eligible beneficiaries. These findings suggest that risk-bearing organizations in MA are responding to current payment dynamics and providing enhanced care and access to patients, particularly historically underserved populations.

Enhancing Annual Wellness Visits: A Pharmacy-Driven Quality Improvement Approach with Multidisciplinary Collaboration

Date: August 23, 2024
Source: Journal of Ambulatory Care Management
Article

Annual wellness visits (AWVs) guide appropriate patient care through lifestyle modifications, medication intervention, or social assistance. This study examined the impact of a quality improvement program to target Medicare beneficiaries as part of an ACO. Key stakeholders collectively implemented a process consisting of two cohorts: AWVs completed with the support of the pharmacy team or directly by providers. A standardized workflow for the pharmacy cohort involved the clinical pharmacists and pharmacy extenders, allowing a layered learning experience. The AWV completion rate was optimized with the interventions of the pharmacy team.

Improving Participation in Value-Based Care—The CMS Innovation Center’s Data-Sharing Strategy Initiative

Date: August 21, 2024
Source: Health Affairs Forefront
Article

This article outlines the CMS Innovation Center’s data-sharing strategy to support development and testing of innovative health care payment and service delivery models. Accurate and comprehensive data can support model operations, including payment, enable the evaluation of model performance, and can be an important resource for model participants trying to transform care delivery. Additionally, one of the CMS Innovation Center’s goals is to test ways to better share data, with the aim of incorporating these lessons into other CMS programs, thereby improving the infrastructure of value-based programs. Given the role and importance of data to the work we do and to our model participants, we are advancing our data-sharing strategy with a primary goal of identifying additional data-sharing needs across CMS Innovation Center models that ensures proper security, risk management, and privacy obligations are employed in tandem with sharing goals. The data-sharing strategy can also provide a framework that may be useful for other payers, reducing the burden of participating in value-based care overall by facilitating multipayer alignment.

Effects of Medicaid Accountable Care Organizations on Children’s Access to and Utilization of Health Services

Date: August 8, 2024
Source: Health Services Research
Article

This study used difference-in-differences models comparing ACO and non-ACO states from 2018 through 2021. Access measures are indicators for preventive and sick care sources, unmet healthcare needs, and having a personal doctor or nurse. Utilization measures are preventive and dental care, mental healthcare, specialist visits, emergency department visits, and hospital admissions. Medicaid ACO implementation was associated with an increase in children’s likelihood of having a personal doctor or nurse by about 4 percentage-points concentrated among states that implemented ACOs in 2018. Medicaid ACOs were also associated with an increase in specialist care use and decline in emergency visits by about 5 percentage-points (the latter being concentrated among states that implemented ACOs in 2020). There were no discernable or robust associations with other pediatric outcomes.

Closing The Gap in Value-Based Care: Lessons from Provider-Led ACO Experience

Date: August 6, 2024
Source: Health Affairs Forefront
Article

Drawing from experience at an ACO participating in the Direct Contracting and ACO REACH Models, the authors analyze some of the major remaining barriers to widespread value-based care (VBC) adoption. Addressing these barriers will bring more providers and patients into VBC arrangements and accelerate movement toward the quadruple aim of better health outcomes, improved patient experience, provider well-being, and lower costs. We propose four pillars for the next evolution of VBC to close the gap: full risk-sharing options for ACOs, upfront capitated payments, financial predictability, and sustainable payment formulas.

Meeting The Needs of Socially Vulnerable Patients: Views of ACO Leaders On Moving from Intent To Action

Date: August 2024
Source: Health Affairs
Article

The Centers for Medicare and Medicaid Services has placed growing emphasis on social drivers of health, but little is known about how ACOs aim to meet the needs of vulnerable patients. During September–December 2022, researchers interviewed leaders of 49 ACOs participating in the Medicare Shared Savings Program (MSSP). Participants were asked about strategies to identify socially vulnerable patients, programs that addressed their needs, and Medicare reforms that could support their efforts. Seven themes emerged: ACOs were in the early stages of collecting social needs data; leaders were frustrated by an incomplete ability to act on such data; ACOs tended to stratify patients by medical, rather than social, risk; some ACOs have introduced pilot programs to address challenges, including social isolation and drug costs; programs were often payer agnostic; rural ACOs faced unique challenges; and Medicare reforms related to reimbursement, logistical support, quality metrics, and patient benefits could support ACO efforts. These findings suggest that the MSSP alone has not been sufficient to promote consistent investment in social needs provision at most ACOs. Policy makers may want to consider more direct support and incentives for health care organizations, or greater investment in non–health care sectors, to help socially vulnerable patients.

ACO Leakage Among Gynecologic Cancer Patients: Incidence, Predictors, and Impact on Annual Medicare Expenditure

Date: August 2024
Source: Gynecologic Oncology
Article

This study examined patterns of ACO leakage—the receipt of care by ACO-assigned patients from institutions outside the ACO network—among patients with gynecologic cancer. ACO leakage was estimated as rates of patients seeking care external to their ACO assignment. Overall incidence of ACO leakage was 28.1%, with highest leakage for outpatient care and uterine cancer patients. ACO leakage risk was 56% higher among Black patients compared to White patients, and 77% more for patients in higher quintiles of median household income compared to lower quintiles. Leakage decreased by 3% and 8% with each unit increase in ACO size and number of subspecialists, respectively. Healthcare costs were 19.5% higher for leakage patients. Overall, ACO leakage rates among gynecologic cancer patients was modest, with some regional and temporal variation, higher leakage for certain subgroups and substantially higher Medicare spending in inpatient and outpatient settings for patients with ACO leakage. These findings identify targets for further investigations and strategies to encourage oncologists to participate in ACOs and prevent increased health care costs associated with use of non-ACO providers.

Telehealth Infrastructure, Accountable Care Organization, and Medicare Payment for Patients with Alzheimer’s Disease and Related Dementia Living in Socially Vulnerable Areas

Date: August 2024
Source: Telemedicine and e-Health
Article

This study examined whether telehealth for care coordination and ACO enrollment for residents in the most disadvantaged areas, particularly those with Alzheimer’s disease and related dementia (ADRD) were associated with reduced Medicare costs. The study used the merged data set of 2020 Medicare inpatient claims data, the Medicare Beneficiary Summary File, the Medicare Shared Savings Program ACO, the CMS Social Vulnerability Index (SVI), and the American Hospital Annual Survey. The study focused on community-dwelling Medicare fee-for-service beneficiaries aged 65 years and up. The study found that Medicare fee-for-service beneficiaries residing in SVI Q4 (i.e., the most vulnerable areas) reported significantly higher total Medicare costs and were least likely to be treated in hospitals that provided telehealth post-discharge services or have ACO affiliation. Meanwhile, the proportion of the population with ADRD was the highest in SVI Q4 compared with other SVI levels. The results suggest that the combination of telehealth post-discharge and ACO financial incentives that promote care coordination is promising to reduce the Medicare cost burden among patients with ADRD living in socially vulnerable areas.

Gaps in the Coordination of Care for People Living with Dementia

Date: July 29, 2024
Source: Journal of the American Geriatrics Society
Article

One-third of people living with dementia (PLWD) have highly fragmented care (i.e., care spread across many ambulatory providers without a dominant provider). It is unclear whether PLWD with fragmented care and their caregivers perceive gaps in communication among the providers involved and whether any such gaps are perceived as benign inconveniences or as clinically meaningful, leading to adverse events. Researchers sought to determine the frequency of perceived gaps in communication (coordination) among providers and the frequency of self-reported adverse events attributed to poor coordination. In the context of a Medicare ACO in New York in 2022–2023, the study examined PLWD who were attributed to the ACO, had fragmented care in the past year by claims (reversed Bice-Boxerman Index ≥0.86), and were in a pragmatic clinical trial on care management. Using an existing survey instrument to determine perceptions of care coordination and perceptions of four adverse events (repeat tests, drug–drug interactions, emergency department visits, and hospital admissions), ACO care managers collected data by telephone, using clinical judgment to determine whether each survey respondent was the patient or a caregiver. Of 167 eligible PLWD, surveys were completed for 97 (58.1%). Of those, 88 (90.7%) reported having >1 ambulatory visit and >1 ambulatory provider and were thus at risk for gaps in care coordination and included in the analysis. Of those, 23 respondents were patients (26.1%) and 64 were caregivers (72.7%), with one respondent’s role missing. Overall, 57% of respondents reported a problem (or “gap”) in the coordination of care and, separately, 18% reported an adverse event that they attributed to poor care coordination. Gaps in coordination of care for PLWD are reported to be very common and often perceived as hazardous.

Enhancing Annual Wellness Visits: A Pharmacy-Driven Quality Improvement Approach with Multidisciplinary Collaboration

Date: July 22,2024
Source: The Journal of Ambulatory Care Management
Article

Annual wellness visits (AWVs) guide appropriate patient care through lifestyle modifications, medication intervention, or social assistance. We launched a quality improvement program to target Medicare beneficiaries as part of an ACO. Key stakeholders collectively implemented a process consisting of two cohorts: AWVs completed with the support of the pharmacy team or directly by providers. A standardized workflow for the pharmacy cohort involved the clinical pharmacists and pharmacy extenders, allowing a layered learning experience. The AWV completion rate was optimized with the interventions of the pharmacy team.

How Adoption of New Pharmaceuticals Can Impact U.S. Health System Reimbursement under Alternative Payment Models: An Economic Model Measuring the Impact of Sotagliflozin among Patients with Heart Failure and Diabetes

Date: July 11, 2024
Source: Journal of Managed Care & Specialty Pharmacy
Article

This study assessed the financial impact of provider health systems’ use of sotagliflozin to treat patients hospitalized with heart failure (HF) under common alternative payment model (APM) financing arrangements, including ACOs. Sotagliflozin use reduced the frequency of patient hospital readmissions and emergency department visits, leading providers to receive large value-based bonus payments under these APMs. Study results demonstrate that using sotagliflozin to treat patients hospitalized with HF and comorbid diabetes mellitus leads to positive financial impacts on health systems under APMs. These results help health care providers and payers make informed decisions on formulary management of new treatments in HF and encourage future endeavors examining the financial implications of adopting new health technologies within the framework of APM reimbursement.

The Effect of Next Generation Accountable Care Organizations on Medicare Expenditures

Date: July 2024
Source: Health Affairs
Article

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

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

Date: July 2024
Source: Health Affairs
Article

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

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

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

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

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

Date: July 2024
Source: Health Affairs
Article

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

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

Date: July 2024
Source: Psychiatric Services
Article

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

A Pilot Project Implementing a Team-Based Approach for Remote Physiologic Monitoring in an Accountable Care Organization

Date: June 18, 2024
Source: American Journal of Health-System Pharmacy
Article

Chronic conditions such as hypertension, heart failure, and chronic obstructive pulmonary disease (COPD) have a significant impact on health care spending and hospital readmission. In response to the increasing burden of chronic diseases, CMS has implemented programs such as chronic care management (CCM) for patients with two or more chronic disease states. Such programs increase interactions between healthcare teams and patients. The overarching goal is to provide patient-centered care and improve outcomes for high-risk patients in complicated cases. Technological advances enabled significant growth in non–face-to-face services. Phone calls have been replaced with telehealth in some instances, and now advanced home monitoring is supported through remote physiologic monitoring (RPM) Common Procedural Terminology (CPT) codes. RPM includes measurements such as blood pressure, heart rate, pulse oximetry, and body weight. There was a major expansion of telehealth and related services during the COVID-19 pandemic. Reports show a 555% increase in RPM use between February 2020 and September 2021.4 During this time, RPM CPT codes were increasingly utilized by primary care providers and cardiologists to treat patients with hypertension and diabetes. RPM offers more clinical data and the potential to overcome the limitations of adjusting therapy based on a single clinic measurement.

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

Date: June 14 2024
Source: Journal of Dental Hygiene
Article

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

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

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

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

Physicians in ACOs Report Greater Documentation Burden

Date: May 31, 2024
Source: The American Journal of Managed Care
Article

This study analyzed the relationship between value-based payment (VBP) program participation and documentation burden among office-based physicians in 2019 and 2021. Researchers used cross-sectional data from the National Electronic Health Records Survey to measure VBP program participation and reported electronic health record (EHR) documentation burden. In adjusted analyses, participation in any VBP program was associated with 10.5% greater probability of reporting more than 1 hour per day of after-hours documentation time (P = .01), which corresponded to an estimated additional 11 minutes per day (P = .03). Program-specific estimates illustrated that ACO participation drove the aggregate relationship, with ACO participants reporting greater after-hours documentation time (18 additional minutes per day; P < .001), more difficulty documenting (30.6% more likely; P < .001), and more inappropriateness of time spent documenting (21.7% more likely; P < .001).  Office-based physicians participating in ACOs report greater documentation burden across several measures; the same is not true for other VBP programs. Although many ACOs relax documentation requirements for reimbursement, documentation for quality reporting and risk adjustment may lead to a net increase in burden, especially for physicians exposed to numerous programs and payers.

Bridging the Evidence and Practice Gap in Chronic Kidney Disease: A System Thinking Approach to Population Health

Date: May 27, 2024
Source: Population Health Management
Article

Chronic kidney disease (CKD) is common, costly, and life-limiting, requiring dialysis and transplantation in advanced stages. Although effective guideline-based therapy exists, the asymptomatic nature of CKD, combined with low health literacy, adverse social determinants of health, unmet behavioral health needs, and primary care providers’ (PCP) limited understanding of CKD, results in defects in screening and diagnosis. In this article, the authors define how they classified defects in care and report the current numbers of patients exposed to these defects, both nationally and in their health system ACO. They describe use of the health system’s three-pillar leadership model (believing, belonging, and building) to empower providers to transform CKD care. Believing entailed engaging individuals to believe defects in CKD care could be eliminated and were a collective responsibility. Belonging fostered the creation of learning communities that broke down silos and encouraged open communication and collaboration between PCPs and nephrologists. Building involved constructing a fractal management infrastructure with transparent reporting and shared accountability. The result is proactive and relational CKD care organized around the patient’s needs in University Hospitals Systems of Excellence, which combine multiple domains of expertise to promote best practice guidelines and integrate care throughout the system.

Telehealth Infrastructure, Accountable Care Organization, and Medicare Payment for Patients with Alzheimer’s Disease and Related Dementia Living in Socially Vulnerable Areas

Date: May 16, 2024
Source: Telemedicine and e Health
Article

Structural social determinants of health have an accumulated negative impact on physical and mental health. Evidence is needed to understand whether emerging health information technology and innovative payment models can help address such structural social determinants for patients with complex health needs, such as Alzheimer’s disease and related dementias (ADRD). This study aimed to test whether telehealth for care coordination and ACO enrollment for residents in the most disadvantaged areas, particularly those with ADRD, was associated with reduced Medicare payment. The study used the merged data set of 2020 Medicare inpatient claims data, the Medicare Beneficiary Summary File, the Medicare Shared Savings Program, the Social Vulnerability Index (SVI), and the American Hospital Annual Survey. The study focused on community-dwelling Medicare fee-for-service beneficiaries aged 65 years and older.

Medicare fee-for-service beneficiaries residing in SVI Q4 (i.e., the most vulnerable areas) had significantly higher total Medicare costs and were least likely to be treated in hospitals providing telehealth post-discharge services or affiliated with an ACO. The proportion of the population with ADRD was highest in SVI Q4 compared with other SVI levels. Adjusted results showed that hospital telehealth post-discharge infrastructure, patient ACO affiliation, SVI Q4, and ADRD were significantly associated with higher Medicare payments. However, coefficients of interaction terms among these factors were significantly negative. For example, the average interaction effect of telehealth post-discharge and ACO, SVI Q4, and ADRD on Medicare payment was −$1,766.2 (95% confidence interval: −$2,576.4 to −$976). The results suggest that the combination of telehealth post-discharge and ACO financial incentives that promote care coordination shows promise in reducing Medicare costs among patients with ADRD living in socially vulnerable areas.

Defragmentation of Care in Complex Patients with ESKD Improves Clinical Outcomes

Date: May 13, 2024
Source: The American Journal of Managed Care
Article

This study examined the partnership between a kidney care organization and an integrated health system within a large ACO to improve care coordination for patients with end-stage kidney disease (ESKD). First, researchers compared rates of hospitalizations and emergency department visits between patients enrolled in the Shared Patient Care Coordination (SPCC) program and other patients of the integrated health system with ESKD who did not participate in SPCC. Second, rates of clinical indicators—central venous catheter (CVC) use, home dialysis, advance care planning, and missed dialysis treatments—were benchmarked vs normative data taken by bootstrap sampling of the kidney care organization’s patient population. Overall, dialysis patients participating in the SPCC program had a 15% lower rate of hospital admissions than those not participating (P = .02). Additionally, the bootstrap analysis showed that by the second year, dialysis patients in the program had favorable rates (above the 95th percentile) of CVC use, dialysis treatment absenteeism, and completion of advance care plans.

Tame The Private Equity Beast by Shifting Its Focus to Value-Based Care

Date: May 8, 2024
Source: Health Affairs Forefront
Article

This article provides an overview of the negative impact of private equity (PE) investment in health care and how PE firms could be encouraged to invest in entities—such as independent primary care groups and ACOs—that need additional capital to make the transition to value-based care.

The Role of Medicaid Accountable Care Organizations in Maternal Health

Date: May 7, 2024
Source: Health Affairs Forefront
Article

Using document review, reports of relevant research, and interviews with key informants from Massachusetts Medicaid ACOs, including ACO managers and maternity care clinicians, researchers identified the role of Massachusetts Medicaid ACOs in maternal health and maternal health equity. The authors concluded that Medicaid ACOs may be able to impact quality and coordination of care by influencing maternity care delivered prenatally or during the birth hospitalization, connecting patients being seen by a maternity care clinician to behavioral health care if needed, and connecting patients back to primary care postpartum. Medicaid ACOs can also potentially impact community-level determinants of maternal health by screening for health-related social needs and creating smoother connections to community-based social services, or directly providing or reimbursing for other enhanced services that are not typically included in perinatal care or covered by Medicaid.

Can ACOs Flex While Supporting Specialty Care? 

Date: May 1, 2024
Source: Health Affairs Forefront
Article

This article summarizes why CMS should expand eligibility for the ACO Primary Care Flex Model (ACO PC Flex Model) to all MSSP ACOs, not just low-revenue ACOs. Under the model, monthly prospective primary care payments to MSSP ACOs will replace fee-for-service payments to primary care providers. The MSSP ACOs will, in turn, be responsible for distributing payments to primary care participants. The authors contend that limiting the model to low-revenue ACOs will create market distortions by advantaging one provider type over another and urge CMS to expand the ACO PC Flex Model to all ACOs regardless of their revenue status or structure. 

Impact of Pharmacist Transitions of Care on 30-Day Readmissions Within a Primary Care-Based Accountable Care Organization 

Date: May 1, 2024
Source: The Senior Care Pharmacist
Article

Previous studies in the ambulatory care setting have shown inconsistent results related to pharmacist telephonic transitions of care (TOC) encounters and reduction in 30-day readmission rates. This study analyzed the impact of clinical pharmacy telephonic TOC encounters on readmission rates within a primary care-based ACO. The primary outcome of this study was all-cause 30-day readmission rate. Secondary outcomes included 30-day readmission rate for targeted disease states, time to readmission, and readmission reason the same as previous discharge reason. For subjects who received a telephonic TOC encounter, pharmacist intervention type and provider acceptance of intervention(s) were described. For the final analysis, 154 encounters were included, 83 encounters in the telephonic TOC encounter group, and 71 did not receive a telephonic TOC encounter. The 30-day readmission rates were similar among those who received a telephonic TOC encounter and those who did not: the difference was not significant (15.7% vs. 28.2%; P = 0.059). There was also no statistical difference in the secondary outcomes. Even so, the results of this study suggest that performing a pharmacist telephonic TOC encounter in a primary care-based ACO setting has the potential to reduce 30-day readmission rates and further research appears to be warranted in this important area of practice. 

Accountable Care Organizations, Mental Health, and Aging in the New Era of Digital Health 

Date: April 26, 2024
Source: Public Policy & Aging Report
Article

The health care costs of those with mental illness are estimated to be 60%–75% higher than for those without. In 2019, the United States had $18 billion in medical spending for older adults with mental health disorders. Although older patients with mental health disorders have greater health care needs, they often receive poorer quality of care and have worse clinical outcomes. A population health approach that involves coordinated care and an integrated system, supported by public health system and community organizations, is essential to improving the triple aim of improving quality, increasing efficiency, and aligning expenditures with population health. 

Association Between Physician–Hospital Integration and Inpatient Care Delivery in Accountable Care Organizations: An Instrumental Variable Analysis 

Date: April 23, 2024
Source: Health Services Research
Article

Using an instrumental variable approach, the study compared inpatient care delivery between patients of ACOs demonstrating high versus low integration. Researchers measured physician–hospital integration within ACOs by the proportion of primary care physicians in an ACO who billed for outpatient services with a place-of-service code indicating employment or practice ownership by a hospital. The study sample comprised non-elderly adults who had continuous insurance coverage and were attributed to one of the 15 ACOs. Outcomes of interest included total medical expenditure during an episode of inpatient care, length of stay (LOS) of the index hospitalization, and 30-day readmission. An inpatient episode was defined as 30, 45, and 60 days from the admission date. The study examined 33,535 admissions from patients served by the 15 ACOs. Average medical expenditure within 30 days of admission was $24,601, within 45 days was $26,447, and within 60 days was $28,043. Average LOS was 3.5 days, and 5.4% of patients were readmitted within 30 days. Physician–hospital integration was associated with a 10.6% reduction in 30-day expenditure (95% CI, −15.1% to −5.9%). Corresponding estimates for 45 and 60 days were − 9.7% (95%CI, −14.2% to −4.9%) and − 9.6% (95%CI, −14.3% to −4.7%). Integration was associated with a 15.7% decrease in LOS (95%CI, −22.6% to −8.2%) but unrelated to 30-day readmission rate. 

The Impact of Medicaid Accountable Care Organizations on Health Care Utilization, Quality Measures, Health Outcomes and Costs from 2012 to 2023: A Scoping Review 

Date: April 15, 2024
Source: Medical Care Research and Review
Article

Most of the evidence regarding the success of ACOs is from the Medicare program. This review evaluates the impacts of ACOs within the Medicaid population. Researchers identified 32 relevant studies published between 2012 and 2023 that analyzed the association of Medicaid ACOs and health care utilization (n = 21), quality measures (n = 18), health outcomes (n = 10), and cost reduction (n = 3). The results of the review regarding the effectiveness of Medicaid ACOs were mixed. Significant improvements included increased primary care visits, reduced admissions, and reduced inpatient stays. Cost reductions were reported in a few studies, and savings were largely dependent on length of attribution and years elapsed after ACO implementation. Adopting the ACO model for the Medicaid population brings some different challenges from those with the Medicare population, which may limit its success, particularly given differences in state Medicaid programs. 

Medicare Transitional Care Management Program and Changes in Timely Postdischarge Follow-Up 

Date: April 12, 2024
Source: JAMA Health Forum
Article

In 2013, Medicare implemented payments for transitional care management (TCM) services, which provide increased reimbursement to clinicians providing ambulatory care to patients after discharge from medical facilities to the community. This study examined whether the introduction of TCM payments was associated with an increase in timely postdischarge follow-up. This cross-sectional interrupted time-series study assessed quarterly postdischarge visit rates before (2010-2012) and after (2013-2019) TCM implementation using a 100% sample of Medicare fee-for-service beneficiaries discharged to the community after a hospital or skilled nursing facility stay. Timely postdischarge follow-up was defined as receipt of a primary care ambulatory visit within 14 days of discharge. Secondary outcomes included receipt of a TCM visit and specialty care follow-up. The study found timely primary care follow-up increased from 31.5% in 2010 to 38.8% in 2019 (absolute increase 7.3%), whereas specialist follow-up increased from 27.6% to 30.8% (absolute increase 3.2%). By 2019, 11.3% of eligible patients received TCM services. Patients attributed to ACOs had higher rates of receipt of both timely primary care follow-up and TCM visits, which increased through the study period. By 2019, patients attributed to ACOs had an absolute 5.2% greater rate of TCM visits and an absolute 5.2% greater rate of timely primary care follow-up. Receipt of timely follow-up increased for all demographic groups; however, Black, Hispanic, and Medicaid dual-eligible patients and patients residing in urban areas and counties with high-level social deprivation were less likely to receive follow-up during the study period. These disparities widened for Black patients and patients who were Medicaid dual-eligible. These findings indicate that Medicare’s introduction of payments for TCM services was associated with a persistent increase in the rate of timely postdischarge primary care but did not narrow demographic or socioeconomic disparities. Most beneficiaries did not receive timely primary care follow-up. 

Accountable Care Organization Initiatives to Improve the Cost and Outcomes of Specialty Care 

Date: April 2, 2024
Source: American Journal of Managed Care
Article

This study assessed initiatives to manage the cost and outcomes of specialty care in organizations that participate in Medicare ACOs using cross-sectional analysis of 2023 ACO survey data from 101 respondents representing 174 ACOs participating in the Medicare Shared Savings Program or the Realizing Equity, Access, and Community Health ACO model in 2023. Improving specialist alignment was a high priority for 62% of the 101 respondents and a medium priority for 34%. Only 11% reported that employed specialists were highly aligned and 7% reported that contracted specialists were highly aligned. A subset of ACOs reported major efforts to engage specialists in quality improvement projects (38%) and to convene specialists to develop evidence-based care pathways (30%). They also reported supporting primary care physicians through providing specialist directories (44%), specialist e-consults (23%), and sharing specialist cost data (20%). The most common challenges reported were the influence of fee-for-service payment on specialist behavior (58%), lack of data to evaluate specialist performance (53%), and insufficient bandwidth or ACO resources to address specialist alignment (49%). 

The CMS Innovation Center’s Strategy to Support Person-Centered, Value-Based Specialty Care: 2024 Update 

Date: April 2, 2024
Source: Health Affairs Forefront
Article

In this article, CMS Innovation Center leaders provide an update on their progress on a comprehensive specialty strategy to test models and innovations that support access to high-quality, integrated specialty care across the patient journey. The specialty integration strategy includes four elements: Enhancing specialty care performance data transparency; maintaining momentum on acute episode payment models and condition-based models; creating financial incentives within primary care for specialist engagement; and creating financial incentives for specialists to affiliate with population-based models and move to value-based care. 

High-Need Beneficiary Enrollment Patterns in Medicare Advantage and Traditional Medicare 

Date: April 2024
Source: American Journal of Managed Care
Article

This study examined the extent to which high-need beneficiaries enrolled in Medicare Advantage (MA) or traditional Medicare (TM) ACOs relative to TM non-ACOs. Using Medicare claims and MA encounter data, researchers identified three groups of high-need beneficiaries: (1) individuals younger than 65 years with a disability or end-stage kidney disease; (2) frail individuals, and (3) older individuals with major complex or multiple noncomplex chronic conditions.  The study found that in 2019 high-need beneficiaries accounted for 18 million or 32% of enrollees in TM and MA, an increase of approximately 1 million since 2016, driven by growth in MA. A larger share of beneficiaries in TM ACOs was high need (38%) compared with MA (24%). Although the total count of high-need beneficiaries in TM remained stable from 2016 to 2019, ACOs saw an increase of almost 1.5 million high-need beneficiaries (39% increase), and TM non-ACOs saw a decrease of 1.9 million (23% decrease). Researchers found that high-need beneficiaries were more likely to be in TM non-ACOs than in MA through 2019. However, an increasing number of these beneficiaries are enrolling in MA or aligned with a TM ACO.

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

Date: March 27, 2024
Source: Psychiatric Services
Article

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

Alternative Payment Models and Patient-Reported Quality of Preparation for Discharge: A Retrospective Longitudinal Study 

Date: March 22, 2024
Source: Journal of Patient Experience
Article

This study assessed whether patient-reported preparation for posthospital care was associated with reduced readmissions and whether alternative payment model (APM) participation was associated with improved preparation for posthospital care. Researchers used mixed-effects regression on retrospective (2013–2017) observational data for 2,685 U.S. hospitals. They measured patient-reported preparation for posthospital care using the 3-Item Care Transition Measure and readmission using 30-day all-cause risk-adjusted readmissions from Hospital Compare. Participation in ACOs, Medical Homes, and Medicare’s Bundled Payments for Care Improvement program was obtained from Medicare, the American Hospital Association’s Annual Survey, and Leavitt Partner’s ACO database. We found that APMs are not associated with improved preparation for posthospital care, even though it was associated with reduced readmissions (Marginal Effect: −0.012 percentage points). This may be because hospitals are not investing in patient engagement. This study has limited insight into causality and reduced generalizability among smaller, rural, and non-teaching hospitals. 

ACO Clinicians Have Higher Medicare Part B Medical Services Payments Than MIPS Clinicians Under the Quality Payment Program 

Date: March 21, 2024
Source: Inquiry
Article

The Quality Payment Program (QPP) is a Medicare value-based payment program with 2 tracks: Advanced Alternative Payment Models (A-APMs), including two-sided risk ACOs and Merit-based Incentive Payment System (MIPS). In 2020, A-APM eligible ACO clinicians received an additional 5% positive and MIPS clinicians received up to 5% negative or 2% positive performance-based adjustments to their Medicare Part B medical services payments. It is unclear whether the different payment adjustments have differential impacts on total medical services payments for ACO and MIPS participants. The study compared Medicare Part B medical services payments received by primary care clinicians participating in ACO and MIPS programs using Medicare Provider Utilization and Payment Public Use Files from 2014 to 2018 using difference-in-differences regressions. The study included 254,395 observations from 50, 879 unique clinicians (ACO = 37.86%; MIPS = 62.14%). Regression results suggest that ACO clinicians have significantly higher Medicare Part B medical services payments ($1003.88; 95% CI: [579.08, 1428.69]) when compared to MIPS clinicians. The findings suggest that ACO clinicians had a greater increase in medical services payments when compared to MIPS clinicians following QPP participation. Increased payments for Medicare Part B medical services among ACO clinicians may be driven partly by higher payment adjustment rates for ACO clinicians for Part B medical services. However, increased Part B medical services payments could also reflect clinicians switching to increased outpatient services to prevent potentially costly inpatient services. Policymakers should examine both aspects when evaluating QPP effectiveness. 

Accountable Care Organization Leader Perspectives on the Medicare Shared Savings Program: A Qualitative Study 

Date: March 15, 2024
Source: JAMA Health Forum
Article

In this qualitative study, interviews were conducted with leaders of 49 ACOs of differing sizes, leadership structures, and geographies from MSSP between September 29 and December 29, 2022. Participants were asked about their clinical and care management efforts; how they engaged frontline clinicians; the process by which they distributed shared savings and added or removed practices; and other factors that they believed influenced their success or failure in the program. Of the 49 ACOs interviewed, 34 were hospital-associated ACOs (69%), 35 were medium or large (>10 000 attributed beneficiaries) (71%), and 17 were rural (35%). The ACOs had a mean (SD) tenure of 8.1 (2.1) years in MSSP. Five major themes emerged: (1) ACO leaders reported a focus on annual wellness visits, coding practices, and care transitions; (2) leaders used both relationship-based and metrics-based strategies to promote clinician engagement; (3) ACOs generally distributed half or more of shared savings to participating practices; (4) ACO recruitment and retention efforts were increasingly influenced by market competition; and (5) some hospital-associated ACOs faced misaligned incentives. 

Update On the Medicare Value-Based Care Strategy: Alignment, Growth, Equity 

Date: March 14, 2024
Source: Health Affairs Forefront
Article

In July 2022, in Health Affairs Forefront, the Centers for Medicare and Medicaid Services (CMS) articulated our overall Medicare value-based care strategy of alignment, growth, and equity. Since then, CMS has promulgated several final rules for both traditional Medicare and Medicare Advantage (MA), announced new alternative payment models, and is considering future potential policies with multipayer alignment, growth of accountable care, and promotion of equity in mind. The selection of these objectives—alignment, growth, and equity—is deliberate to maximize care transformation and improve care for the people we serve. CMS is also focused on the growth of accountable care. CMS has defined accountable care as when a person-centered care team takes responsibility for improving quality of care, care coordination, and health outcomes for a defined group of individuals to reduce care fragmentation and avoid unnecessary costs for individuals and the health system. One of the primary ways that accountable care is delivered is through ACOs. Because accountable care has been shown in several contexts to deliver more person-centered care, reduce the cost of care, and promote delivery of high-quality care, CMS has established the goal of having 100 percent of traditional Medicare beneficiaries and the vast majority of Medicaid beneficiaries in an accountable care relationship with their providers by 2030. 

Where Are All the Specialists? Current Challenges of Integrating Specialty Care Into Population-Based Total Cost of Care Payment Models 

Date: March 12, 2024
Source: Annals of Internal Medicine
Article

The Center for Medicare & Medicaid Innovation Center (CMMI) has set the goal for 100% of traditional Medicare beneficiaries to be part of an accountable care relationship by 2030. Lack of meaningful financial incentives, intolerable or unpredictable risk, infrastructure costs, patient engagement, voluntary participation, and operational complexity have been noted by the provider and health care delivery community as barriers to participation or reasons for exiting programs. In addition, most piloted and implemented population-based total cost of care (PB-TCOC) payment models have focused on the role of the primary care physician being the accountability (that is, attributable) leader of a patient’s multifaceted care team as well as acting as the mayor of the “medical neighborhood,” leaving the role of specialty care physicians undefined. Successful provider specialist integration into PB-TCOC models includes meaningful participation of specialists in achieving whole-person, high-value care where all providers are financially motivated to participate; there is unambiguous prospective attribution and clearly defined accountability for each participating party throughout the care journey or episode; there is a known care attribution transition accountability plan; there is actionable, transparent, and timely data available with appropriate data development and basic analytic costs covered; and there is advanced payment to the accountable person or entity for management of the care episode that is part of a longitudinal care plan. Payment models should be created to address the 7 challenges raised here if specialists are to be incented to join TCOC models that achieve CMMI’s goal. 

Aligning Accountable Care Models with The Goal of Improving Population Health 

Date: March 11, 2024
Source: Health Affairs Forefront
Article

Policy makers and health care leaders understand that despite spending twice as much per capita on health care, the US leads amongst high-income countries in early mortality. Within the US, health disparities are widening and pervasive, with variations in life expectancy present across neighborhoods, counties, and states and across racial and socioeconomic populations. The authors argue that a complete transition to global payment models, such as those employed by ACOs, combined with a shift to population health-focused performance measures should be used to encourage health care organizations to play a leadership role in improving health and eliminating health inequities within the US population. We take this stance for three reasons. First, life expectancy is powerfully influenced by modifiable clinical and behavioral risk factors that are already the direct responsibility of primary care. Second, providers can improve these if they have the tools, incentives, and flexibility needed to do so. Third, if sufficiently motivated to improve health, we suggest (with some evidence) that providers can and will reach out to collaborate across sectors to work upstream to improve the vital conditions essential to health and well-being in the communities they serve and advocate for the policy changes required to do so. 

Delivering on the Promise of Accountable and Value-Based Care 

Date: March 7, 2024
Source: The American Journal of Accountable Care
Article

Although ACOs have been touted as a solution to the problems experienced every day in doctors’ offices across the country, doubt about ACOs still exists. That may be because some see value-based care as too good to be true or feel we are too far into a fee-for-service model and there is no easy way to transition. But I’ve seen firsthand how physicians can adapt and embrace the model—and when they do, practices change for the better, and most importantly, patients see improvements in their health, life, and relationships, both with their health care providers and in their own personal lives.

Measuring Value in Healthcare: Lessons from Accountable Care Organizations 

Date: March 1, 2024
Source: Health Affairs Scholar
Article

ACOs were created to promote healthcare value by improving health outcomes while curbing healthcare expenditures. Although a decade has passed, the value of care delivered by ACOs is yet to be fully understood. We proposed a novel measure of healthcare value using data envelopment analysis and examined its association with ACO organizational characteristics and social determinants of health (SDOH). We observed that the value of care delivered by ACOs stagnated in recent years, which may be partially attributed to challenges in care continuity and coordination across providers. ACOs that were solely led by physicians and included more participating entities exhibited lower value, highlighting the role of coordination across ACO networks. Furthermore, SDOH factors, such as economic well-being, healthy food consumption, and access to health resources, were significant predictors of ACO value. Our findings suggest a “skinny in scale, broad in scope” approach for ACOs to improve the value of care. Healthcare policy should also incentivize ACOs to work with local communities and enhance care coordination of vulnerable patient populations across siloed and disparate care delivery systems. 

Patient-Reported Outcome-Based Performance Measures in Alternative Payment Models: Current Use, Implementation Barriers, and Principles to Succeed 

Date: February 2024
Source: Value in Health
Article

Patient-reported outcome-based performance measures (PRO-PMs) offer a way to collect patient-centered information and aggregate the collected data into a reliable and valid measure of performance at the entity level (e.g., clinician, hospital, and ACO); yet they have been potentially underused within the promising avenue of alternative payment models. Researchers identified 54 instances of active PRO-PM usage across CMS programs as well as five principles to prioritize as part of greater PRO-PM development and incorporation within alternative payment models: (1) clinical salience, (2) adequate sample size, (3) meaningful range of performance among measured entities and the ability to detect performance change in a reasonable timeframe, (4) equity focus, and (5) appropriate risk adjustment. A phased and iterative PRO-PM implementation strategy that overcomes identified barriers should be considered to ensure provider and stakeholder engagement and ultimately inform and improve healthcare-related decision making by allowing reliable outcome comparisons across entities. 

Accountable Care Organizations and Specialists: Opportunities for Neurologists 

Date: February 2024
Source:  Neurology: Clinical Practice
Article

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

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

Date: February 2024
Source:  Health Affairs
Article

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

Building for Value: A Foundational Structure to Support Population Health 

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

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

A Path to Risk: Critical Elements of a Structured Approach 

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

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

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

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

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

Practice Site Heterogeneity Within and Between Medicaid Accountable Care Organizations 

Date: January 20, 2024
Source:  Healthcare
Article

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

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

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

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

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

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

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

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

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

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