Success Of Accountable Care Organizations Research Articles

The Relationship Between Governing Board Composition and Medicare Shared Savings Program Accountable Care Organizations Outcomes: an Observational Study.

Early studies of Medicare Shared Savings Program (MSSP) accountable care organizations (ACOs) suggested that physician leadership was an important driver of ACO success, but it is unknown whether the demographic and professional composition of current MSSP ACO governing boards is associated with ACOs' publicly reported outcomes. To investigate whether governing boards with higher physician participation and greater female involvement have better outcomes. Cross-sectional observational study. All 2017 MSSP ACOs identified by the Center for Medicare and Medicaid Services ACO Public Use Files (PUF). We collected governing board composition from ACO websites in 2019. Outcome metrics included risk-standardized readmission and unplanned admissions rates. We used descriptive statistics and linear regression models to examine the association between board composition and outcomes. Of the 339 ACOs that still existed in 2019 and had available data, 77% had physician-majority boards and 11.5% had no women on their boards. Eighty-nine percent reported a Medicare beneficiary on their board, of which about one-third had a woman representative. The average number of members on MSSP ACO boards was 12, with a mean of 67% physicians and 24% women. Board composition varied minimally by ACO characteristics, such as geographic region, number of beneficiaries, or type of participants. Higher levels of physician participation in ACO governing boards were associated with lower all-cause unplanned admission rates for patients with heart failure (p = - 0.26, p < 0.001) and for patients with multiple chronic conditions (p = - 0.28, p = 0.001). The number of women on the board was not associated with any outcome differences. MSSP ACO governing boards were predominately male and physician-led. Physician involvement may be important for achieving quality goals, while lack of female involvement showcases an opportunity to diversify boards.

Are ACOs Ready to be Accountable for Medication Use?

BACKGROUND: Accountable care organizations (ACOs) have the potential to lower costs and improve quality through incentives and coordinated care. However, the design brings with it many new challenges. One such challenge is the optimal use of pharmaceuticals. Most ACOs have not yet focused on this integral facet of care, even though medications are a critical component to achieving the lower costs and improved quality that are anticipated with this new model. OBJECTIVE: To evaluate whether ACOs are prepared to maximize the value of medications for achieving quality benchmarks and cost offsets. METHODS: During the fall of 2012, an electronic readiness self-assessment was developed using a portion of the questions and question methodology from the National Survey of Accountable Care Organizations, along with original questions developed by the authors. The assessment was tested and subsequently revised based on feedback from pilot testing with 5 ACO representatives. The revised assessment was distributed via e-mail to a convenience sample (n=175) of ACO members of the American Medical Group Association, Brookings-Dartmouth ACO Learning Network, and Premier Healthcare Alliance. RESULTS: The self-assessment was completed by 46 ACO representatives (26% response rate). ACOs reported high readiness to manage medications in a few areas, such as transmitting prescriptions electronically (70%), being able to integrate medical and pharmacy data into a single database (54%), and having a formulary in place that encourages generic use when appropriate (50%). However, many areas have substantial room for improvement with few ACOs reporting high readiness. Some notable areas include being able to quantify the cost offsets and hence demonstrate the value of appropriate medication use (7%), notifying a physician when a prescription has been filled (9%), having protocols in place to avoid medication duplication and polypharmacy (17%), and having quality metrics in place for a broad diversity of conditions (22%). CONCLUSIONS: Developing the capabilities to support, monitor, and ensure appropriate medication use will be critical to achieve optimal patient outcomes and ACO success. The ACOs surveyed have embarked upon an important journey towards this goal, but critical gaps remain before they can become fully accountable. While many of these organizations have begun adopting health information technologies that allow them to maximize the value of medications for achieving quality outcomes and cost offsets, a significant lag was identified in their inability to use these technologies to their full capacities. In order to provide further guidance, the authors have begun documenting case studies for public release that would provide ACOs with examples of how certain medication issues have been addressed by ACOs or relevant organizations. The authors hope that these case studies will help ACOs optimize the value of pharmaceuticals and achieve the "triple aim" of improving care, health, and cost. DISCLOSURES: There was no outside funding for this study, and the authors report no conflicts of interest related to the article. Concept and design were primarily from Dubois and Kotzbauer, with help from Feldman, Penso, and Westrich. Data collection was done by Feldman, Penso, Pope, and Westrich, and all authors participated in data interpretation. The manuscript was written primarily by Westrich, with help from all other authors, and revision was done primarily by Lustig and Westrich, with help from all other authors.

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.

Regional cost and experience, not size or hospital inclusion, helps predict ACO success.

The Medicare Shared Savings Program (MSSP) continues to expand and now includes 434 accountable care organizations (ACOs) serving more than 7 million beneficiaries. During 2014, 86 of these ACOs earned over $300 million in shared savings payments by promoting higher-quality patient care at a lower cost.Whether organizational characteristics, regional cost of care, or experience in the MSSP are associated with the ability to achieve shared savings remains uncertain.Using financial results from 2013 and 2014, we examined all 339 MSSP ACOs with a 2012, 2013, or 2014 start-date. We used a cross-sectional analysis to examine all ACOs and used a multivariate logistic model to predict probability of achieving shared savings.Experience, as measured by years in the MSSP program, was associated with success and the ability to earn shared savings varied regionally. This variation was strongly associated with differences in regional Medicare fee-for-service per capita costs: ACOs in high cost regions were more likely to earn savings. In the multivariate model, the number of ACO beneficiaries, inclusion of a hospital or involvement of an academic medical center, was not associated with likelihood of earning shared savings, after accounting for regional baseline cost variation.These results suggest ACOs are learning and improving from their experience. Additionally, the results highlight regional differences in ACO success and the strong association with variation in regional per capita costs, which can inform CMS policy to help promote ACO success nationwide.

The Healthy Lifestyle Team is Central to the Success of Accountable Care Organizations

M r Smith is a 45-year-old man at substantial risk for cardiovascular disease (CVD) because of the following laboratory findings: body mass index (BMI; calculated as the weight in kilograms divided by the height in meters squared), 29.5; resting blood pressure (BP), 130/85 mmHg; low-density lipoprotein cholesterol (LDL-C), 130 mg/dL (to convert to mmol/L, multiply by 0.0259); highdensity lipoprotein cholesterol (HDL-C), 38 mg/dL (to convert to mmol/L, multiply by 0.0259); triglycerides, 180 mg/dL (to convert to mmol/L, multiply by 0.0113); fasting blood glucose, 110 mg/dL (to convert to mmol/L, multiply by 0.0555); hemoglobin A1c, 6.4% (to convert to a proportion of total hemoglobin, multiply by 0.01); sedentary lifestyle; and poor dietary habits. However, Mr Smith has never smoked, and his family history does not indicate a genetic predisposition for hypertension, dyslipidemia, or CVD. Mr Smith is going to his primary care physician for a health assessment; he completes forms pertaining to general health information and insurance coverage and is brought to an examination room by a nurse, who measures his heart rate and BP. To this point, everything described is consistent with how health care in this setting has been conducted for decades. However, in the not too distant future, the following will take place next. The nurse then asks him to complete physical activity (PA)/ exercise training (ET) and dietary questionnaires, explaining that this is part of his vital signs assessment. The physician enters the room, exchanges some introductory dialogue, listens to heart sounds, and asks some standard questions pertaining to symptoms of CVD, of which there were none. The physician reviews Mr Smith’s questionnaire responses: (1) low daily PA (approximately 3000 steps per day), (2) not participating in regular ET, (3) high total fat intake (approximately 40%), and (4) high sodium intake (approximately 3000 mg/d). The conversation then quickly centers on PA, ET, and diet. Mr Smith shares more information regarding his predominantly sedentary lifestyle; the physician is acutely aware that this pattern is a significant health concern. He then provides more detail regarding his dietary habits, which the physician also recognizes to be rather poor and disconcerting. After Mr Smith answers all questions pertaining to these core lifestyle habits, the physician is ready to provide a diagnosis and care plan: “Mr Smith, you have poor lifestyle habits, which, if not treated immediately, will likely lead to the development of one or more noncommunicable diseases (NCDs).” The physician then explains to the patient that BP, cholesterol, and blood glucose medications may be unnecessary. To treat the patient’s condition, the healthy lifestyle team will prescribe the following medical interventions: (1) strategies to increase daily PA, (2) a regular ET program, (3) guidance on a healthy diet, and (4) behavioral strategies to optimize healthy lifestyle success. This programwill be individually tailored, and the patient will need to be an active participant in developing this plan. Mr Smith is then scheduled for appointments with 3 other members of the healthy lifestyle team, in this case an exercise physiologist, dietician, and behavioral counselor. Mr Smith has his appointments with the exercise physiologist, dietician, and behavioral counselor within the next week, all on the same day. The exercise physiologist performs an exercise test to assess aerobic capacity, which was 20% below the predicted norm. The exercise physiologist discusses the test results followed by a conversation regarding ways to increase daily PA and how to initiate an ET program with an ultimate goal of 150 minutes or more of moderate-intensity exercise per week. Mr Smith has a smartphone, and the exercise physiologist instructs him on how to use an application that allows for tracking of daily PA and the ET program. The dietician then meets with Mr Smith in the healthy lifestyle counseling From the Department of Physical Therapy and Integrative Physiology Laboratory, College of Applied Science, University of Illinois, Chicago (R.A.); and Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, LA (C.J.L.).

Best Practices: Improving Patient Outcomes and Costs in an ACO Through Comprehensive Medication Therapy Management

One of the most important and often overlooked challenges for accountable care organizations (ACOs) is ensuring the optimal use of pharmaceuticals, which can be accomplished by utilizing pharmacists' skillsets and leveraging their full clinical expertise. Developing capabilities that support, monitor, and ensure appropriate medication use, efficacy, and safety is critical to achieving optimal patient outcomes and, ultimately, to an ACO's success. The program described in this article highlights the best practices of Fairview Pharmacy Services' Medication Therapy Management (MTM) program with additional thoughts and considerations on this and similar MTM programs provided by The Working Group on Optimizing Medication Therapy in Value-Based Healthcare. Fairview Pharmacy Services utilizes 23 MTM pharmacists (approximately 18 full-time equivalents) working in 30 locations, who conduct pharmacotherapy workups as part of the MTM services that Fairview provides. Pharmacists focus on patients in a comprehensive manner and assess all of their diseases and medications. Responsibilities include (a) identification of a patient's drug-related needs with a commitment to meet those needs; (b) an assessment and confirmation that all of a patient's drug therapy is appropriately indicated, effective and safe, and that the patient is compliant; (c) achievement of therapy outcomes and ensuring documentation of those outcomes; and (d) collaboration with all members of a patient's care team. Since 1998, pharmacists have cared for more than 20,000 patients and resolved more than 107,000 medication-related problems which, if left unresolved, could have led to hospital readmissions and emergency visits. Since becoming a Pioneer ACO, Fairview pharmacists have focused on the highest-risk members and have seen over 670 ACO patients, resolving over 2,780 medication-related problems. In terms of clinical outcomes, MTM contributed to optimal care in complex patients with diabetes. A review of 2007 data found that the percentage of diabetes patients optimally managed (as measured by a composite of hemoglobin A1c, low-density lipoprotein, blood pressure, aspirin use, and no smoking) was significantly higher for MTM patients (21% vs. 45%, P less than 0.01). The Fairview MTM also showed a 12:1 return on investment (ROI) when comparing the overall health care costs of patients receiving MTM services with patients who did not receive those services. Developing an MTM program to manage and optimize pharmaceuticals will be a cornerstone to managing the health of a population. Important lessons have been learned that may be helpful to other health systems developing MTM programs. In an accountable care environment measuring the return on the investment of all care interventions, including MTM will be essential to maintain the program. The ACO will also have to be able to correctly identify which patients are candidates for MTM services and provide pharmacists with enough autonomy, including scheduling face-to-face interactions with patients and the ability to change prescriptions if necessary, to ensure that timely and effective care is delivered. In order for an ACO to deliver high quality patient-centered medication services, there must be clear lines of communication between providers, pharmacists, and the other care providers within the organization. Finally, a strong and visionary leader is critical to ensuring the success of an MTM program and ultimately the ACO itself. While there is a plethora of literature touting the benefits of either in-person or telephonic-based MTM, there is little research to date that directly compares these 2 MTM delivery types. It is critical for research to address the direct and indirect costs associated with starting and maintaining an MTM program. Information such as technologies required to start a program and length of time until a program breaks even or meets a sufficient ROI can be helpful for health care providers in similar health systems pitching a similar type of program. Finally, there has yet to be significant empirical research into the cost savings of utilizing a pharmacist and MTM services associated with meeting quality and cost benchmarks in an accountable care payment arrangement.

Capsule commentary on Lewis et al., Innovation in the safety net: integrating community health centers through accountable care.

Lewis et al.1 explore to what extent community health centers (CHCs) are being incorporated into accountable care organizations (ACOs). CHCs play a large role in caring for underserved communities and vulnerable populations, yet they are often segmented from other health care providers. The authors suggest ACOs could provide a mechanism through which CHCs integrate with other providers. This work is notable simply for that fact that it is actual data provided by real ACOs. Since passage of the Affordable Care Act, thought pieces have extolled the virtues of ACOs for their potential to reorganize payment and care delivery to achieve the triple aim of better care and better health at a lower cost.2 Publications have examined market features associated with ACO formation3 and care in ACO-like healthcare systems,4 but there have been few analyses published using either data provided by an ACO or about actual ACO patient populations. Therefore, the work of Lewis et al. is a rare example of information collected from actual ACOs. They start with the National Survey of ACOs, which includes all ACOs in the United States as of August 2012, including both federal and commercial payers. Of 292 potentially eligible organizations, 173 (70 %) provided information about organizational characteristics; 18 participated in semi-structured telephone interviews. The authors find that 28 % of ACOs include a CHC and are largely similar to non-CHC ACOs in terms of organization, size, and capabilities. In addition, ACO+CHCs had more experience with patient-centered medical homes, public reporting and risk bearing. Ultimately, the qualitative interviews suggest that CHCs were seen as helping their respective ACOs through their expertise in primary care transformation and caring for high-need patients, both areas likely critical for ACO success. The authors note that it is not possible to determine causality and know whether these relationships would have developed outside of ACO-specific initiatives. Regardless, the ACO experiment is an important one occurring in health policy right now. Understanding baseline characteristics is an important first step, but ongoing analyses that can help both define and then understand success and failure will be critical.

Attention To Surgeons And Surgical Care Is Largely Missing From Early Medicare Accountable Care Organizations

The Affordable Care Act supports the growth of accountable care organizations (ACOs) as a potentially powerful model for health care delivery and payment. The model focuses on primary care. However, surgeons and other specialists have a large role to play in caring for ACOs' patients. No studies have yet investigated the role of surgical care in the ACO model. Using case studies and a survey, we examined the early experience of fifty-nine Medicare-approved ACOs in providing surgical care. We found that ACOs have so far devoted little attention to surgical care. Instead, they have emphasized coordinating care for patients with chronic conditions and reducing unnecessary hospital readmissions and ED visits. In the years to come, ACOs will likely focus more on surgical care. Some ACOs have the ability to affect surgical practice patterns through referral pressures, but local market conditions may limit ACOs' abilities to alter surgeons' behavior. Policy makers, ACO administrators, and surgeons need to be aware of these trends because they have the potential to affect the surgical care provided to ACO patients as well as the success of ACOs themselves.

The PGP Demonstrations: Were They Sufficient to Justify Accountable Care Organizations?

The Physician Group Practice (PGP) Demonstr-ation Project was designed to try to establish whether high-quality healthcare can be delivered to Medicare patients, while simultaneously lowering overall Medicare costs. In this project, participating healthcare organizations were provided a portion of any savings achieved, provided that certain quality goals were also achieved. The results of this project were used to provide evidence as to the feasibility of Accountable Care Organizations (ACOs), a healthcare delivery approach, which is rapidly becoming more prevalent. While the quality measures achieved by the vast majority of participants in the PGP Demonstration Project were widespread, the financial performance of these organizations was quite mixed. Many participating organizations received no shared savings whatsoever, while one received more “shared savings” payment that the others combined. Problems with the evidence supporting PGPs’ cost savings are discussed, and, based on these concerns, the future success of ACOs is questioned.

Are ACOs ready to be accountable for medication use?

Accountable care organizations (ACOs) have the potential to lower costs and improve quality through incentives and coordinated care. However, the design brings with it many new challenges. One such challenge is the optimal use of pharmaceuticals. Most ACOs have not yet focused on this integral facet of care, even though medications are a critical component to achieving the lower costs and improved quality that are anticipated with this new model. To evaluate whether ACOs are prepared to maximize the value of medications for achieving quality benchmarks and cost offsets. During the fall of 2012, an electronic readiness self-assessment was developed using a portion of the questions and question methodology from the National Survey of Accountable Care Organizations, along with original questions developed by the authors. The assessment was tested and subsequently revised based on feedback from pilot testing with 5 ACO representatives. The revised assessment was distributed via e-mail to a convenience sample (n=175) of ACO members of the American Medical Group Association, Brookings-Dartmouth ACO Learning Network, and Premier Healthcare Alliance. The self-assessment was completed by 46 ACO representatives (26% response rate). ACOs reported high readiness to manage medications in a few areas, such as transmitting prescriptions electronically (70%), being able to integrate medical and pharmacy data into a single database (54%), and having a formulary in place that encourages generic use when appropriate (50%). However, many areas have substantial room for improvement with few ACOs reporting high readiness. Some notable areas include being able to quantify the cost offsets and hence demonstrate the value of appropriate medication use (7%), notifying a physician when a prescription has been filled (9%), having protocols in place to avoid medication duplication and polypharmacy (17%), and having quality metrics in place for a broad diversity of conditions (22%). Developing the capabilities to support, monitor, and ensure appropriate medication use will be critical to achieve optimal patient outcomes and ACO success. The ACOs surveyed have embarked upon an important journey towards this goal, but critical gaps remain before they can become fully accountable. While many of these organizations have begun adopting health information technologies that allow them to maximize the value of medications for achieving quality outcomes and cost offsets, a significant lag was identified in their inability to use these technologies to their full capacities. In order to provide further guidance, the authors have begun documenting case studies for public release that would provide ACOs with examples of how certain medication issues have been addressed by ACOs or relevant organizations. The authors hope that these case studies will help ACOs optimize the value of pharmaceuticals and achieve the "triple aim" of improving care, health, and cost.

Accountable Care Organizations: A Challenging Opportunity for Primary Care to Demonstrate its Value

Accountable Care Organizations: A Challenging Opportunity for Primary Care to Demonstrate its Value

In‐Center Nocturnal Hemodialysis Performed Thrice‐Weekly—A Provider’s Perspective

Favorable clinical outcomes related to morbidity, mortality, patient well-being, laboratory biomarkers, and medication use have been reported with in-center nocturnal hemodialysis (INHD); nevertheless, it is not entirely clear how much patient selection or physiologic mechanisms related to better fluid management and phosphorus (and calcium) metabolism may explain these outcomes. There are indications that INHD may be a preferred treatment option in specific cases, such as in patients with high interdialytic weight gain, poor tolerance to high ultrafiltration rate, hyperphosphatemia, or for those patients who work or go to school during the day. In the era of the new prospective payment system where quality standards become intertwined with reimbursement, an INHD program may be a useful method to help attain quality goals in facilities that have patients with unfavorable case-mix. The experience of the past decade has shown INHD to be safe and well tolerated by patients. The growth of INHD therapy is a testament to sustainability and feasibility of this treatment option. Prospective clinical trials are needed in this area. If the promise of INHD is fulfilled, it may also prove to be a valuable option for potential success of Accountable Care Organizations where providers need to assume responsibility for more patient-centered care and improvement in clinical outcomes. In summary, based on the current experience, INHD is a viable and valuable option as an additional, alternative hemodialysis (HD) regimen to conventional HD.

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

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