Abstract
Accountable care organizations (ACOs) aim to control health expenditures while improving quality of care. Primary care has been emphasized as a means to reduce spending, but little is known about the implications of using specialists for achieving this ACO objective. To examine the association between ACO-beneficiary office visits conducted by specialists and the cost and utilization outcomes of those visits. This cross-sectional study obtained data on 620 distinct ACOs from the Centers for Medicare & Medicaid Services Shared Savings Program Accountable Care Organizations Public-Use Files from April 1, 2012, to September 30, 2017. Generalized estimating equation models were used for analysis of ACOs, adjusting for ACO-beneficiary health status, Medicare enrollment groups, ACO size, and proportion of participating specialists. Specialist encounter proportion, the percentage of office visits provided by a specialist, was categorized into 7 discrete groups: less than 35%, 35% to less than 40%, 40% to less than 45% (reference group), 45% to less than 50%, 50% to less than 55%, 55% to less than 60%, and 60% or greater. The primary outcome was total expenditures (given in US dollars) per assigned beneficiary person-year. The secondary outcomes were total numbers of emergency department visits, hospital discharges, skilled nursing facility discharges, and magnetic resonance imaging orders. In total, the data set included 1836 ACO-year (number of participation years per ACO) observations for 620 distinct ACOs. Those ACOs with a specialist encounter proportion of 40% to less than 45% had $1129 (95% CI, $445-$1814) lower per-beneficiary person-year spending than did ACOs in the lowest specialist encounter proportion group and had $752 (95% CI, $115-$1389) lower per-beneficiary person-year spending compared with ACOs in the highest specialist encounter proportion group. Monotonic decreases in emergency department visits, hospital discharges, and skilled nursing facility discharges were observed with increasing specialist encounter proportion. Conversely, monotonic increases in magnetic resonance imaging volume discharges were observed with increasing specialist encounter proportion. These findings suggest that an ACO's ability to reduce spending may require sufficient involvement in care processes from specialists, who seem to complement the intrinsic primary care approach in ACOs.
Highlights
The Medicare Shared Savings Program (MSSP) accountable care organization (ACO) is a health care payment and delivery model intended to incentivize a consortium of health care practitioners who control spending by cooperating, communicating, and coordinating patient care across multiple clinical settings.[1]
Monotonic decreases in emergency department visits, hospital discharges, and skilled nursing facility discharges were observed with increasing specialist encounter proportion
The ACOs with the lowest specialist encounter proportions had means of 41.0% fewer beneficiaries, 33.9% lower specialist participation, a 10.0% higher proportion of person-years for beneficiaries with a disability, and a 5.2% higher proportion of person-years for beneficiaries with a dual-eligible status compared with ACOs with high specialist encounter proportions
Summary
The Medicare Shared Savings Program (MSSP) accountable care organization (ACO) is a health care payment and delivery model intended to incentivize a consortium of health care practitioners who control spending by cooperating, communicating, and coordinating patient care across multiple clinical settings.[1]. In April 2017, more than 500 Medicare ACOs provided care to nearly 10 million people.[2] The putative success of the MSSP ACOs depended largely on successfully incentivizing strong organizational leadership and expanding the responsibilities of primary care physicians (PCPs) to coordinate care,[3,4] approaches believed to be necessary to slow the growth of spending.[5] With the broad implementation of the ACO payment model, studies have reported modest improvements in reducing expenditures and enhancing quality of care.[6,7] Given that most health expenditures are associated with care for a small proportion of patients with complex clinical conditions,[8] specialists may play an important role in containing costs for patients with high-resource needs.[9] Specialists can support judicious service use, when aligned with ACO incentives, across the ACO patient population.[10] The MSSP does not require specialist membership for ACO formation,[11] but previous studies suggest that the integration of specialists in an ACO may be financially advantageous.[12,13]
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