Accountable Care Organization Contracts Research Articles

All-payer value-based contracting in organizations with Medicare ACOs.

To measure the prevalence of non-Medicare value-based contracting and participation in contracts with downside risk among organizations participating in the Medicare Shared Savings Program (MSSP). Cross-sectional analysis of 2022 accountable care organization (ACO) survey. The author analyzed surveys from 100 organizations participating in the MSSP that reported the number of covered lives they have in value-based contracts in traditional Medicare (ACOs), Medicare Advantage (MA), commercial payers, Medicaid managed care organizations, Medicaid, and direct-to-employer arrangements. We analyzed the distribution of covered lives across shared-savings, shared-risk, and full-risk contracts and analyzed changes between 2018 and 2022. Respondents reported 15.5 million covered lives in value-based contracts. All respondents have Medicare ACO contracts, and roughly 75% reported value-based contracts with commercial and MA plans. Approximately one-third reported such contracts with Medicaid managed care plans. Seventy percent of covered lives in respondents' Medicare ACO contracts included downside risk for losses compared with 51% of lives in commercial plans and 45% in MA plans. Compared with a similar 2018 survey, the proportion of respondents in value-based MA contracts doubled, and the proportion in commercial contracts rose by half. Organizations that participate in Medicare ACO models have substantially increased their participation in value-based contracts with other payers. They reported a higher proportion of Medicare ACO covered lives in downside risk arrangements than in commercial or MA contracts.

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

Digital health technologies may expand organizational capacity to treat opioid use disorder (OUD). However, it remains unclear whether these technologies serve as substitutes for or complements to traditional substance use disorder (SUD) treatment resources in health care organizations. To characterize the use of patient-facing digital health technologies for OUD by US organizations with accountable care organization (ACO) contracts. This cross-sectional study analyzed responses to the 2022 National Survey of Accountable Care Organizations (NSACO), collected between October 1, 2021, and June 30, 2022, from US organizations with Medicare and Medicaid ACO contracts. Data analysis was performed between December 15, 2022, and January 6, 2023. Treatment resources for SUD (eg, an addiction medicine specialist, sufficient staff to treat SUD, medications for OUD, a specialty SUD treatment facility, a registry to identify patients with OUD, or a registry to track mental health for patients with OUD) and organizational characteristics (eg, organization type, Medicaid ACO contract). The main outcomes included survey-reported use of 3 categories of digital health technologies for OUD: remote mental health therapy and tracking, virtual peer recovery support programs, and digital recovery support for adjuvant cognitive behavior therapy (CBT). Statistical analysis was conducted using descriptive statistics and multivariable logistic regression models. Overall, 276 of 505 organizations responded to the NSACO (54.7% response rate), with a total of 304 respondents. Of these, 161 (53.1%) were from a hospital or health system, 74 (24.2%) were from a physician- or medical group-led organization, and 23 (7.8%) were from a safety-net organization. One-third of respondents (101 [33.5%]) reported that their organization used at least 1 of the 3 digital health technology categories, including remote mental health therapy and tracking (80 [26.5%]), virtual peer recovery support programs (46 [15.1%]), and digital recovery support for adjuvant CBT (27 [9.0%]). In an adjusted analysis, organizations with an addiction medicine specialist (average marginal effect [SE], 32.3 [4.7] percentage points; P < .001) or a registry to track mental health (average marginal effect [SE], 27.2 [3.8] percentage points; P < .001) were more likely to use at least 1 category of technology compared with otherwise similar organizations lacking these capabilities. In this cross-sectional study of 276 organizations with ACO contracts, organizations used patient-facing digital health technologies for OUD as complements to available SUD treatment capabilities rather than as substitutes for unavailable resources. Future studies should examine implementation facilitators to realize the potential of emerging technologies to support organizations facing health care practitioner shortages and other barriers to OUD treatment delivery.

Population turnover and leakage in commercial ACOs.

Commercial accountable care organization (ACO) contracts attempt to mitigate spending growth, but past evaluations have been limited to continuously enrolled ACO members in health maintenance organization (HMO) plans, excluding many members. The objective of this study was to examine the magnitude of turnover and leakage within a commercial ACO. A historical cohort study using detailed information from multiple commercial ACO contracts within a large health care system between 2015 and 2019. Individuals insured through 1 of the 3 largest commercial ACO contracts during the study period, 2015-2019, were included. We examined patterns of entry and exit and the characteristics that predicted remaining in the ACO compared with leaving the ACO. We also examined predictors of the amount of care delivered in the ACO compared with outside the ACO. Among the 453,573 commercially insured individuals in the ACO, approximately half left the ACO within the initial 24 months after entry. Approximately one-third of spending was for care occurring outside the ACO. Patients who remained in the ACO differed from those who left earlier, including being older, having a non-HMO plan, having lower predicted spending at entry, and having more medical spending for care performed within the ACO during the initial quarter of membership. Both turnover and leakage hamper the ability of ACOs to manage spending. Modifications that address potentially intrinsic vs avoidable sources of population turnover and increase patient incentives for care within vs outside of ACOs could help address medical spending growth within commercial ACO programs.

Impact of a selective narrow network with comprehensive patient navigation on access, utilization, expenditures, and enrollee experiences.

To examine the effect of enrollee switching from a broad-network accountable care organization (ACO) health maintenance organization (HMO) to a "high performance" ACO-HMO with a selective narrow network and comprehensive patient navigation system on access, utilization, expenditures, and enrollee experiences. Secondary administrative data were obtained for 2016-2020, and primary interview and survey data in 2021. Fixed-effects instrumental variable analyses of administrative data and regression analyses of survey data. Outcomes included access, utilization, expenditures, and enrollee experience. Background information was gathered via interviews. We obtained medical expenditure/enrollment and access data on continuously enrolled members in a broad-network ACO-HMO (n=24,555), a subset of those who switched to a high-performance ACO-HMO in 2018 (n=7664); interviews of organizational leaders (n=13); and an enrollee survey (n=512). Health care effectiveness data and information Set (HEDIS) access measures were not different across plans. However, annual utilization dropped by 15.5 percentage points (95% CI: 18.1, 12.9) more in the high-performance ACO-HMO, with relative annual expenditures declining by $1251 (95% CI: $1461, $1042) per person per year. High-performance ACO-HMO enrollees were 10.1 percentage points (95% CI 0.001, 0.201) more likely to access primary care usually or always as soon as needed and 11.2 percentage points (95% CI 0.007, 0.217) more likely to access specialty care usually or always as soon as needed. Plan satisfaction was 7.1 percentage points (95% CI: -0.001, 0.138) higher in the high-performance ACO-HMO. Interviewees noted the comprehensive patient navigation system was designed to ensure patients remained in the narrow network to receive care. ACO and HMO contracts with selective narrow networks supported by comprehensive patient navigation can reduce expenditures and improve specialty access and patient satisfaction compared to broad-network plans that lack these features. Payers should consider implementing narrow networks with comprehensive support systems.

Coding-Driven Changes In Measured Risk In Accountable Care Organizations.

Claims data, which form the foundation of risk adjustment in payment for health care services, may reflect efforts to capture more-or more severe-clinical conditions rather than true changes in health status. This can distort payments. We quantify this in the context of Medicare's accountable care organization (ACO) program by comparing risk scores derived from two different measurement approaches. One approach uses diagnoses coded on claims based on Centers for Medicare and Medicaid Services Hierarchical Condition Categories (HCC), and the other uses self-reported, survey-based health data from the Consumer Assessment of Healthcare Providers and Systems (CAHPS). During 2013-16 HCC-based risk scores grew faster than CAHPS-based risk scores (2.1percent versus 0.3percent annually), and the gap in HCC- and CAHPS-based risk score growth varied widely across ACOs. The average gap in risk score growth appears to be the result primarily of HCC coding practices rather than poor performance of the CAHPS model, suggesting that coding practices (not necessarily driven by ACO contracts) may account for most of the observed risk score growth for ACO beneficiaries.

Savings or Selection? Initial Spending Reductions in the Medicare Shared Savings Program and Considerations for Reform.

The Medicare Shared Savings Program (MSSP) establishes incentives for participating accountable care organizations (ACOs) to lower spending for their attributed fee-for-service Medicare patients. Turnover in ACO physicians and patient panels has raised concerns that ACOs may be earning shared-savings bonuses by selecting lower-risk patients or providers with lower-risk panels. We conducted three sets of analyses of Medicare claims data. First, we estimated overall MSSP savings through 2015 using a difference-in-differences approach and methods that eliminated selection bias from ACO program exit or changes in the practices or physicians included in ACO contracts. We then checked for residual risk selection at the patient level. Second, we reestimated savings with methods that address undetected risk selection but could introduce bias from other sources. These included patient fixed effects, baseline or prospective assignment, and area-level MSSP exposure to hold patient populations constant. Third, we tested for changes in provider composition or provider billing that may have contributed to bonuses, even if they were eliminated as sources of bias in the evaluation analyses. MSSP participation was associated with modest and increasing annual gross savings in the 2012-2013 entry cohorts of ACOs that reached $139 to $302 per patient by 2015. Savings in the 2014 entry cohort were small and not statistically significant. Robustness checks revealed no evidence of residual risk selection. Alternative methods to address risk selection produced results that were substantively consistent with our primary analysis but varied somewhat and were more sensitive to adjustment for patient characteristics, suggesting the introduction of bias from within-patient changes in time-varying characteristics. We found no evidence of ACO manipulation of provider composition or billing to inflate savings. Finally, larger savings for physician group ACOs were robust to consideration of differential changes in organizational structure among non-ACO providers (eg, from consolidation). Participation in the original MSSP program was associated with modest savings and not with favorable risk selection. These findings suggest an opportunity to build on early progress. Understanding the effect of new opportunities and incentives for risk selection in the revamped MSSP will be important for guiding future program reforms.

The Population Health Value Framework: Creating Value by Reducing Costs of Care for Patient Subpopulations With Chronic Conditions.

With the growth in risk-based and accountable care organization contracts, creating value by redesigning care to reduce costs and improve outcomes and the patient experience has become an urgent priority for health care systems. In 2016, UCLA (University of California, Los Angeles) Health implemented a system-wide population health approach to identify patient populations with high expenses and promote proactive, value-based care. The authors created the Patient Health Value framework to guide value creation: (1) identify patient populations with high expenses and reasons for spending, (2) create design teams to understand the patient story, (3) create custom analytics and spending-based risk stratification, and (4) develop care pathways based on spending risk tiers. Primary care patients with three chronic conditions-dementia, chronic kidney disease (CKD), and cancer-were identified as high-cost subpopulations. For each patient subpopulation, a multispecialty, multidisciplinary design team identified reasons for spending and created care pathways to meet patient needs according to spending risk. Larger, lower-risk cohorts received necessary but less intensive interventions, while smaller, higher-risk cohorts received more intensive interventions. Preliminary analyses showed a 1% monthly decrease in inpatient bed day utilization among dementia patients (incident rate ratio [IRR] 0.99, P < .03) and a 2% monthly decrease in hospitalizations (IRR 0.98, P < .001) among CKD patients. Use of the Patient Health Value framework is expanding across other high-cost subpopulations with chronic conditions. UCLA Health is using the framework to organize care across specialties, build capacity, and grow a culture for value.

ACO Contracts With Downside Financial Risk Growing, But Still In The Minority.

Success of the accountable care organization (ACO) model may require stronger financial incentives, such as including downside risk in contracts. Using the National Survey of ACOs, we explored ACO structure and contracts in 2012-18. Though the number of ACO contracts and the proportion of ACOs with multiple contracts have grown, the proportion bearing downside risk has increased only modestly.

Clinical coordination in accountable care organizations: A qualitative study.

Background:Accountable care organizations (ACOs) are becoming a common payment and delivery model. Despite widespread interest, little empirical research has examined what efforts or strategies ACOs are using to change care and reduce costs. Knowledge of ACOs' clinical efforts can provide important context for understanding ACO performance, particularly to distinguish arenas where ACOs have and have not attempted care transformation.Purpose:The aim of the study was to understand ACOs' efforts to change clinical care during the first 18 months of ACO contracts.Methods:We conducted semistructured interviews between July and December 2013. Our sample includes ACOs that began performance contracts in 2012, including Medicare Shared Savings Program and Pioneer participants, stratified across key factors. In total, we conducted interviews with executives from 30 ACOs. Iterative qualitative analysis identified common patterns and themes.Results:ACOs in the first year of performance contracts are commonly focusing on four areas: first, transforming primary care through increased access and team-based care; second, reducing avoidable emergency department use; third, strengthening practice-based care management; and fourth, developing new boundary spanner roles and activities. ACOs were doing little around transforming specialty care, acute and postacute care, or standardizing care across practices during the first 18 months of ACO performance contracts.Practice Implications:Results suggest that cost reductions associated with ACOs in the first years of contracts may be related to primary care. Although in the long term many hope ACOs will achieve coordination across a wide array of care settings and providers, in the short term providers under ACO contracts are focused largely on primary care-related strategies. Our work provides a template of the common areas of clinical activity in the first years of ACO contracts, which may be informative to providers considering becoming an ACO. Further research will be needed to understand how these strategies are associated with performance.

Spending Among Patients With Cancer in the First 2 Years of Accountable Care Organization Participation.

Spending on patients with cancer can be substantial and has continued to increase in recent years. Accountable Care Organizations (ACOs) are arguably the most important national experiment to control health care spending, yet how ACOs are managing patients with cancer diagnoses is largely unknown. We aimed to determine whether practices that became ACOs had changes in overall or cancer-specific spending among patients with cancer. Using 2011 to 2015 national Medicare claims, practices that became part of ACOs were identified and matched to non-ACO practices within the same geographic region. We calculated total and category-specific annual spending per beneficiary as well as spending for and utilization of emergency departments, inpatient admissions, hospice, chemotherapy, and radiation therapy. A difference-in-differences model was used to examine changes in spending and utilization associated with ACO contracts in the Medicare Shared Savings Program for beneficiaries with cancer. We found that the introduction of ACOs had no meaningful impact on overall spending in patients with cancer (-$308 per beneficiary in ACOs v -$319 in non-ACOs; difference, $11; 95% CI, -$275 to $297; P = .94). We found no changes in total spending in patients within any of the 11 different cancer types examined. Finally, changes in spending and utilization did not meaningfully differ between ACO and non-ACO patients within various categories, including cancer-specific categories. Compared with patients with cancer treated at non-ACO practices, being a patient with a cancer diagnosis in a Medicare ACO is not associated with significantly reduced spending or heath care utilization. The introduction of ACOs does not seem to have had any meaningful effect on spending or utilization for patients with a cancer diagnosis.

Do Changes in Post-acute Care Use at Hospitals Participating in an Accountable Care Organization Spillover to All Medicare Beneficiaries?

While early evidence suggests that Medicare accountable care organizations (ACOs) may reduce post-acute care (PAC) utilization for attributed beneficiaries, whether these effects spill over to all beneficiaries admitted to hospitals participating in ACOs stray is unknown. The objective of this study was to evaluate whether changes in PAC use and Medicare spending spill over to all beneficiaries admitted to hospitals participating in the Medicare Shared Savings Program (MSSP). Observational study using a difference-in-differences design comparing changes in PAC utilization and spending among beneficiaries admitted to ACO-participating hospitals before and after the start of the ACO contracts, compared to those admitted to non-ACO hospitals. A total of 233 hospitals participate in MSSP ACOs and 3103 non-ACO hospitals. A national sample of 11,683,573 Medicare beneficiaries experiencing 26,503,086 hospital admissions from 2010 to 2013. Admission to a hospital participating in an MSSP ACO. The probability of discharge and Medicare payments to inpatient rehabilitation facilities (IRF), skilled nursing facilities (SNF), and home health agencies (HHA). For beneficiaries admitted to hospitals that joined an ACO, the likelihood of being discharged to PAC did not change after the hospital joined the ACO compared with non-ACO hospitals over the same period (differential change in probability of discharge to any PAC was 0.000 (P = 0.89), SNF was 0.000 (P = 0.73), IRF was 0.000 (P = 0.96), and HHA was 0.001 (P = 0.57)). Payments reduced significantly for PAC overall (- $130.41, P = 0.03), but not for any individual PAC type alone. These results were consistent in samples that were conditional on discharge to any PAC, across conditions with high PAC use nationally, and among ACO-participating hospitals that also had a PAC participant. Hospital participation in an ACO did not result in spillovers in PAC utilization or payments to all beneficiaries, even when considering high PAC-use conditions and ACO hospitals that also have an ACO-participating PAC.

The Hidden Roles That Management Partners Play In Accountable Care Organizations.

Accountable care organizations (ACOs) are often discussed and promoted as driven by physicians, hospitals, and other health care providers. However, because of the flexible nature of ACO contracts, management organizations may also become partners in ACOs. We used data from 2013-15 on 276 ACOs from the National Survey of Accountable Care Organizations to understand the prevalence of nonprovider management partners' involvement in ACOs, the services these partners provide, and the structure of ACOs that have such partners. We found that 37percent of ACOs reported having a management partner, and two-thirds of these ACOs reported that the partner shared in the financial risks or rewards. Among ACOs with partners, 94percent had data services provided by the partner, 87percent received administrative services, 68percent received educational services, and 66percent received care coordination services. Half received all four of these services from their partner. ACOs with partners were more heavily primary care than other ACOs. ACOs with and without partners had similar performance on costs and quality in Medicare ACO programs. Our findings suggest that management partners play a central role in many ACOs, perhaps supplying smaller and physician-run ACOs with services or expertise perceived as necessary for ACO success.

Quality of Care Improves for Patients with Diabetes in Medicare Shared Savings Accountable Care Organizations: Organizational Characteristics Associated with Performance.

Accountable care organizations (ACOs), a primary care-centric delivery and payment model, aim to promote integrated population health, which may improve care for those with chronic conditions such as diabetes. Research has shown that, overall, the ACO model is effective at reducing costs, but there is substantial variation in how effective different types of ACOs are at impacting costs and improving care delivery. This study examines how ACO organizational characteristics - such as composition, staffing, care management, and experiences with health reform - were associated with quality of care delivered to patients with diabetes. Secondary data were analyzed retrospectively to examine Medicare Shared Savings Program (MSSP) ACOs' performance on diabetes metrics in the first 2 years of ACO contracts. Ordinary least squares was used to analyze 162 MSSP ACOs with publicly available performance data and the National Survey of ACOs. ACOs improved performance significantly for patients with diabetes between contract years 1 and 2. In year 1, also having a private payer contract and an increased number of services within the ACO were positively associated with performance, while having a community health center or a hospital were negatively associated with performance. Better performance in year 1 was negatively associated with improved performance in year 2. This study found that ACOs substantively improved diabetes management within initial contract years. ACOs may need different types of support throughout their contracts to ensure continued improvements in performance.

Medicare Accountable Care Organizations and Antidepressant Use by Patients With Depression.

This study examined whether Medicare accountable care organization (ACO) programs were associated with early changes in antidepressant use or adherence among beneficiaries with depression. A difference-in-difference design was used to compare claims from Medicare fee-for-service beneficiaries (2009-2013) and ACO patients with those from local control groups. Outcome measures were total antidepressant days supplied, filling one or more antidepressant prescriptions, and proportion of days covered (PDC) by supply among antidepressant users (adherence). Among antidepressant users, ACO contracts were associated with slight differential increases in PDC (.4-.8 percentage point, p≤.03), depending on ACO program and entry year. The proportion of patients with one or more prescriptions was unchanged or decreased slightly for ACO patients with depression, such that total supply did not consistently increase. Medicare ACO programs were associated with early modest increases in antidepressant adherence but not with increases in the proportion of patients with depression who received antidepressants.

End-of-Life Care Planning in Accountable Care Organizations: Associations with Organizational Characteristics and Capabilities.

To measure the extent to which accountable care organizations (ACOs) have adopted end-of-life (EOL) care planning processes and characterize those ACOs that have established processes related to EOL. This study uses data from three waves (2012-2015) of the National Survey of ACOs. Respondents were 397 ACOs participating in Medicare, Medicaid, and commercial ACO contracts. This is a cross-sectional survey study using multivariate ordered logit regression models. We measured the extent to which the ACO had adopted EOL care planning processes as well as organizational characteristics, including care management, utilization management, health informatics, and shared decision-making capabilities, palliative care, and patient-centered medical home experience. Twenty-one percent of ACOs had few or no EOL care planning processes, 60 percent had some processes, and 19.6 percent had advanced processes. ACOs with a hospital in their system (OR: 3.07; p=.01), and ACOs with advanced care management (OR: 1.43; p=.02), utilization management (OR: 1.58, p=.00), and shared decision-making capabilities (OR: 16.3, p=.000) were more likely to have EOL care planning processes than those with no hospital or few to no capabilities. There remains considerable room for today's ACOs to increase uptake of EOL care planning, possibly by leveraging existing care management, utilization management, and shared decision-making processes.

PD32-04 SURGEON ENGAGEMENT IN EARLY ACCOUNTABLE CARE ORGANIZATIONS

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Value of Care: Cost and Outcomes Measures III1 Apr 2017PD32-04 SURGEON ENGAGEMENT IN EARLY ACCOUNTABLE CARE ORGANIZATIONS Matthew Resnick, Amy Graves, Melinda Buntin, Michael Richards, and David Penson Matthew ResnickMatthew Resnick More articles by this author , Amy GravesAmy Graves More articles by this author , Melinda BuntinMelinda Buntin More articles by this author , Michael RichardsMichael Richards More articles by this author , and David PensonDavid Penson More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1395AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Despite marked growth in Accountable Care Organizations (ACOs), little is known about either the magnitude of surgeon engagement or key drivers of surgeon engagement in early ACO programs. We aimed to characterize the landscape of surgeon engagement in early ACOs and identify specialty-, organization-, and market-factors associated with early ACO participation. METHODS Using data from SK&A, a commercial research firm, we evaluated independent, group, and integrated U.S. surgical practices, performing a cross-sectional analysis of 2015 ACO enrollment among 125,425 U.S. surgeons. We fit a multivariable logistic regression model to evaluate associations between ACO affiliation, surgical specialty, and organizational structure while adjusting for surgeon characteristics. RESULTS Of 125,425 U.S. surgeons, 27,956 (22.3%) reported enrollment in at least 1 ACO program in 2015. We identified significant heterogeneity in the proportion of ACO-enrolled surgeons by surgical specialty, with trauma and transplant reporting the highest magnitude of ACO enrollment, (36% for both) and plastic surgeons reported the lowest magnitude of ACO enrollment (12.9%) followed by ophthalmology (16.0%) and hand (18.6%). 22.8% of urologists reported at least 1 ACO contract. Practice organization was strongly associated with ACO enrollment, with surgeons in group practices and integrated health systems had higher odds of ACO affiliation relative to those practicing independently (aOR 1.57, 95% CI 1.50, 1.64; aOR 4.87, 95% CI 4.68, 5.07, respectively). We observed a statistically significant interaction (p<0.001) between surgical specialty and practice organization. Model-derived predicted probabilities revealed that, within each specialty, surgeons in an integrated health system had the highest predicted probabilities of ACO affiliation while those practicing in groups had smaller predicted probabilities and those practicing independently generally had the lowest. This pattern was largely consistent across surgical specialties. CONCLUSIONS We observed considerable variation in ACO enrollment among U.S. surgeons. Observed variation appears to be largely mediated by differences in practice organization, with surgeons practicing in integrated health systems more likely to engage in ACO contracts than those in independent practice. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e589-e590 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Matthew Resnick More articles by this author Amy Graves More articles by this author Melinda Buntin More articles by this author Michael Richards More articles by this author David Penson More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

ACOs Serving High Proportions Of Racial And Ethnic Minorities Lag In Quality Performance.

Accountable care organizations (ACOs) are intended, in part, to improve health care quality. However, little is known about how ACOs may affect disparities or how providers serving disadvantaged patients perform under Medicare ACO contracts. We analyzed racial and ethnic disparities in health care outcomes among ACOs to investigate the association between the share of an ACO's patients who are members of racial or ethnic minority groups and the ACO's performance on quality measures. Using data from Medicare and a national survey of ACOs, we found that having a higher proportion of minority patients was associated with worse scores on twenty-five of thirty-three Medicare quality performance measures, two disease composite measures, and an overall quality composite measure. However, ACOs serving a high share of minority patients were similar to other ACOs in most observable characteristics and capabilities, including provider composition, services, and clinical capabilities. Our findings suggest that ACOs with a high share of minority patients may struggle with quality performance under ACO contracts, especially during their early years of participation-maintaining or potentially exacerbating current inequities. Policy makers must consider how to refine ACO programs to encourage the participation of providers that serve minority patients and to reward performance appropriately.

Early Efforts By Medicare Accountable Care Organizations Have Limited Effect On Mental Illness Care And Management

People with mental illness use more health care and have worse outcomes than those without such illnesses. In response to incentives to reduce spending, accountable care organizations (ACOs) may therefore attempt to improve their management of mental illness. We examined changes in mental health spending, utilization, and quality measures associated with ACO contracts in the Medicare Shared Savings Program and Pioneer model for beneficiaries with mental illness, using Medicare claims for the period 2008-13 and difference-in-differences comparisons with local non-ACO providers. Pioneer contracts were associated with lower spending on mental health admissions in the first year of the contract, an effect that was attenuated in the second year. Otherwise, ACO contracts were associated with no changes in mental health spending or readmissions, outpatient follow-up after mental health admissions, rates of depression diagnosis, or mental health status. These results suggest that ACOs have not yet focused on mental illness or have been largely unsuccessful in early efforts to improve their management of it.

Changes in Low-Value Services in Year 1 of the Medicare Pioneer Accountable Care Organization Program.

Wasteful practices are widespread in the US health care system. It is unclear if payment models intended to improve health care efficiency, such as the Medicare accountable care organization (ACO) programs, discourage the provision of low-value services. To assess whether the first year of the Medicare Pioneer ACO program was associated with a reduction in use of low-value services. In a difference-in-differences analysis, we compared use of low-value services between Medicare fee-for-service beneficiaries attributed to health care provider groups that entered the Pioneer program (ACO group) and beneficiaries attributed to other health care providers (control group) before (2009-2011) vs after (2012) Pioneer ACO contracts began. Data analysis was conducted from December 1, 2014, to June 27, 2015. Comparisons were adjusted for beneficiaries' sociodemographic and clinical characteristics as well as for geography. We decomposed estimates according to service characteristics (clinical category, price, and sensitivity to patient preferences) and compared estimates between subgroups of ACOs with higher vs lower baseline use of low-value services. Use of, and spending on, 31 services in instances that provide minimal clinical benefit, measured as annual service counts per 100 beneficiaries and price-standardized annual service spending per 100 beneficiaries. During the precontract period, trends in the use of low-value services were similar for the ACO and control groups. The first year of ACO contracts was associated with a differential reduction (95% CI) of 0.8 low-value services per 100 beneficiaries for the ACO group (-1.2 to -0.4; P < .001), corresponding to a 1.9% differential reduction in service quantity (-2.9% to -0.9%) and a 4.5% differential reduction in spending on low-value services (-7.5% to -1.4%; P = .004). Differential reductions were similar for services less sensitive vs more sensitive to patient preferences and for higher- vs lower-priced services. The ACOs with higher than their markets' mean baseline levels of low-value service use experienced greater service reductions (-1.2 services per 100 beneficiaries; -1.7 to -0.7; P < .001) than did ACOs with use below the mean (-0.2 services per 100 beneficiaries, -0.6 to -0.2; P = .41; P = .003 for test of difference between subgroups). During its first year, the Pioneer ACO program was associated with modest reductions in low-value services, with greater reductions for organizations providing more low-value care. Accountable care organization-like risk contracts may be able to discourage use of low-value services even without specifying services to target.

Performance Differences in Year 1 of Pioneer Accountable Care Organizations

BackgroundIn 2012, a total of 32 organizations entered the Pioneer accountable care organization (ACO) program, in which providers can share savings with Medicare if spending falls below a financial benchmark. Performance differences associated with characteristics of Pioneer ACOs have not been well described.MethodsIn a difference-in-differences analysis of Medicare fee-for-service claims, we compared Medicare spending for beneficiaries attributed to Pioneer ACOs (ACO group) with other beneficiaries (control group) before (2009 through 2011) and after (2012) the start of Pioneer ACO contracts, with adjustment for geographic area and beneficiaries' sociodemographic and clinical characteristics. We estimated differential changes in spending for several subgroups of ACOs: those with and those without clear financial integration between hospitals and physician groups, those with higher and those with lower baseline spending, and the 13 ACOs that withdrew from the Pioneer program after 2012 and the 19 that did not.ResultsAdjusted Medicare spending and spending trends were similar in the ACO group and the control group during the precontract period. In 2012, the total adjusted per-beneficiary spending differentially changed in the ACO group as compared with the control group (−$29.2 per quarter, P=0.007), consistent with a 1.2% savings. Savings were significantly greater for ACOs with baseline spending above the local average, as compared with those with baseline spending below the local average (P=0.05 for interaction), and for those serving high-spending areas, as compared with those serving low-spending areas (P=0.04). Savings were similar in ACOs with financial integration between hospitals and physician groups and those without, as well as in ACOs that withdrew from the program and those that did not.ConclusionsYear 1 of the Pioneer ACO program was associated with modest reductions in Medicare spending. Savings were greater for ACOs with higher baseline spending than for those with lower baseline spending and were unrelated to withdrawal from the program. (Funded by the National Institute on Aging and others.)