The CMS Innovation Center: Delivering on the Promise of Payment and Delivery Reform

The Potential of Medicare Accountable Care Organizations to Transform the American Health Care Marketplace: Rhetoric and Reality

Cardiovascular disease is the leading cause of death in the United States and accounts for ≈17% of national health expenditures and 30% of Medicare spending.1 Among physician groups and professional societies, cardiologists have been among those leading efforts to create evidence-based guidelines and to measure quality of care. In the post-health reform era, national efforts have expanded beyond quality to include innovative delivery models, such as the patient-centered medical home (PCMH), the medical neighborhood, and accountable care organizations (ACOs). This next generation of care models and the payment strategies that support them incentivize efficiency, patient-centeredness, and care coordination with an emphasis on primary care. We propose strategies for cardiologists to create collaborative opportunities within these new models drawing from examples from around the country within the context of a framework developed by the American College of Physicians.2 Pursuing these approaches or others along similar lines will enable cardiologists to lead and to be active participants in shaping delivery system transformation. These innovative delivery models share similar features. The PCMH is a model of care that emphasizes additional support for primary care providers within a patient-centered team, whereas a medical neighborhood represents a broader collection of primary care doctors, specialists such as cardiologists, hospitals, and other stakeholders within a region that seek to reduce fragmented care by sharing accountability.2,3 The ACO, too, is a broader care delivery arrangement, but in this case, groups of providers are accountable for the quality, cost, and overall care of a particular population, typically defined by the payer. In the Medicare Shared Savings Program (MSSP), an ACO model for Medicare beneficiaries, the ACO can capture shared savings if it reduces its healthcare expenditures and meets certain quality performance standards, nearly half of which are related to cardiovascular disease.4 Within the …

Accountable Care Organization Pathways: Diverse but Ultimately Parallel

New Medicare Models of Care and the LTC Physician

Since the passage of the Affordable Care Act two years ago, patient centered medical homes (PCMH) and accountable care organizations (ACO) have emerged as leading models to address our fragmented, high cost health care system.1 The Center for Medicare and Medicaid Innovation (CMMI) has been allocated $10 billion over a decade to test and spread these and other new models of care and payment, with the aim of providing better health for individuals and populations at lower cost.

Emergency Physicians Seek Their Place in a Pay-for-Value World

BackgroundMany countries have introduced reforms with the aim of primary care transformation (PCT). Common objectives include meeting service delivery challenges associated with ageing populations and health inequalities. To date, there has been little research comparing PCT internationally. Our aim was to examine PCT and new models of primary care by conducting a systematic scoping review of international literature in order to describe major policy changes including key ‘components’, impacts of new models of care, and barriers and facilitators to PCT implementation.MethodsWe undertook a systematic scoping review of international literature on PCT in OECD countries and China (published protocol: https://osf.io/2afym). Ovid [MEDLINE/Embase/Global Health], CINAHL Plus, and Global Index Medicus were searched (01/01/10 to 28/08/21). Two reviewers independently screened the titles and abstracts with data extraction by a single reviewer. A narrative synthesis of findings followed.ResultsA total of 107 studies from 15 countries were included. The most frequently employed component of PCT was the expansion of multidisciplinary teams (MDT) (46% of studies). The most frequently measured outcome was GP views (27%), with < 20% measuring patient views or satisfaction. Only three studies evaluated the effects of PCT on ageing populations and 34 (32%) on health inequalities with ambiguous results. For the latter, PCT involving increased primary care access showed positive impacts whilst no benefits were reported for other components. Analysis of 41 studies citing barriers or facilitators to PCT implementation identified leadership, change, resources, and targets as key themes.ConclusionsCountries identified in this review have used a range of approaches to PCT with marked heterogeneity in methods of evaluation and mixed findings on impacts. Only a minority of studies described the impacts of PCT on ageing populations, health inequalities, or from the patient perspective. The facilitators and barriers identified may be useful in planning and evaluating future developments in PCT.

ACO payment models and the path to accountability.

The CMS Innovation Center was created in section 3021 of the Affordable Care Act (ACA) with the promise to test payment and delivery models expected to reduce costs while improving or maintaining quality of care for Medicare, Medicaid, and Children’s Health Insurance Program (CHIP) beneficiaries. Doug Badger’s analysis of the Center for Medicare and Medicaid Innovation (CMMI), published in Inquiry, described how the CMMI has failed to accomplish its goals and makes a case for reforms. As a practicing clinician in private practice who has followed the implementation of the components of the Affordable Care Act, including the CMMI, his conclusions are not surprising. An examination of the clinically unworkable and recently delayed Radiation Oncology Alternative Payment Model demonstrates serious flaws in current CMMI methods. Government agencies have difficulty directing innovation. Clinicians know that real innovation will arise in unpredictable ways from the ingenious communities, providers, and organizations that deliver the care. Innovation will occur when an atmosphere of transparency forces providers to respond to the demands of patients. The CMMI would do well to redesign its processes. If “value” is the goal of CMS, then America deserves a better “value” from its healthcare agencies.

Gastroenterology in a New Era of Accountability: Part 3. Accountable Care Organizations

Accountable Care Organizations and the Allergist: Challenges and Opportunities

Determine the relationship between quality of an accountable care organization (ACO) and its long-term reduction in healthcare costs. We conducted a cost minimization analysis. Using Centers for Medicare and Medicaid cost and quality data, we calculated weighted composite quality scores for each ACO and organization-level cost savings. We used Markov modeling to compute the probability that an ACO transitioned between different quality levels in successive years. Considering a health-systems perspective with costs discounted at 3 percent, we conducted 10,000 Monte Carlo simulations to project long-term cost savings by quality level over a 10-year period. We compared the change in per-member expenditures of Pioneer (early-adopters) ACOs versus Medicare Shared Savings Program (MSSP) ACOs to assess the impact of coordination of care, the main mechanism for cost savings. Overall, Pioneer ACOs saved USD 641.24 per beneficiary and MSSP ACOs saved USD 535.59 per beneficiary. By quality level: (a) high quality organizations saved the most money (Pioneer: USD 459; MSSP: USD 816); (b) medium quality saved some money (Pioneer: USD 222; MSSP: USD 105); and (c) low quality suffered financial losses (Pioneer: USD -40; MSSP: USD -386). Within the existing fee-for-service healthcare model, ACOs are a mechanism for decreasing costs by improving quality of care. Higher quality organizations incorporate greater levels of coordination of care, which is associated with greater cost savings. Pioneer ACOs have the highest level of integration of services; hence, they save the most money.

To explain key challenges to evaluating Center for Medicare and Medicaid Innovation (CMMI) accountable care organization (ACO) models and ways to address those challenges. We enumerate the challenges, beginning with the conception of the alternative payment model and extending through the decision to scale up the model should the initial evaluation suggest that the model is successful. The challenges include churn at the provider and ACO levels, beneficiary leakage and spillover, participation in prior payment models, and determinants of shared savings and penalties. We explain challenges posed in evaluations of voluntary ACO models vs models in which ACOs are randomly assigned to the treatment group. We also note the relationship between the design used in an evaluation and subsequent plans for scaling up successful models. The optimal research design is inextricably tied to the plans for scaling up a successful model. Decisions regarding churn, leakage, spillover, and participating in past payment models can alter the estimated effects of the intervention on participants in the model. If CMMI intends to offer the model to a larger, but similar, group of volunteers, then the estimated treatment effect based on voluntary participants may be the most policy-relevant parameter. However, if the scaled-up population has different characteristics than the evaluation sample, perhaps due to mandatory participation, then the evaluator will need to employ pseudo-randomization appropriate for observational data.

SGR Out, MACRA In: Medicare's Move Toward Merit-Based Pay

Evidence from initial cohorts of accountable care organizations (ACOs) participating in the Medicare Shared Savings Program (MSSP) found modest reductions in health care spending. Little is known about whether these effects have changed over time. To determine long-term changes in spending for MSSP ACO participants. Using 2010 to 2019 traditional Medicare data, difference-in-differences analyses were performed to compare spending changes for patients attributed to ACOs relative to changes for patients at non-ACO organizations. Outcomes included total Medicare spending and spending by category. Three- and 6-year effects and estimated differential changes overall and by ACO characteristics were calculated, including size (small defined as <10 000 patients), rurality, and whether an ACO included a hospital (hospital-associated ACO) or not (physician-group ACO). Attribution to a medical group or clinic in an ACO during the first 2 years of ACO tenure. Total annual per-patient Medicare spending. The sample included 41 973 272 Medicare patient-years. Baseline characteristics for 2 719 406 ACO patients and 5 523 652 control patients were similar (average age, 72 years; 58% female; and 82% to 84% White) prior to ACO formation in 2010 and 2011, and unadjusted annual per-patient spending was slightly lower in the ACO group vs control group ($12 147 vs $12 318; difference, -$171 [95% CI, -$223 to -$118]) in the 2 years prior to ACO formation. ACO formation was associated with a mean differential reduction of $142 (95% CI, -$193 to -$92) in annual per-patient spending over 3 years and $294 (95% CI, -$347 to -$241) over 6 years. Spending reductions associated with ACO formation increased over time: compared with control patients, ACO patients experienced a mean reduction of $234 (95% CI, -$298 to -$171) in year 3 and $584 (95% CI, -$680 to -$489) in year 6. Physician-group and small ACOs generated larger spending reductions. Spending changes resulted in $4.1 billion to $8.1 billion in savings to Medicare between 2012 and 2019. During the MSSP's first decade, ACOs generated meaningful reductions in spending, with larger effects over time.