Medicaid Accountable Care Organizations Research Articles

Randomized controlled trial of centralized vaccine reminder/recall to improve adult vaccination rates in an accountable care organization setting.

Our objectives were to assess 1) effectiveness of using Colorado's Immunization Information System (CIIS) to send out vaccine reminder/recalls (R/Rs) centrally vs. usual care for adult vaccine delivery within an accountable care organization (ACO) and 2) practice staff's perception of centralized R/R. From 9/2016 to 4/2017, we conducted a randomized controlled trial among adults enrolled in a Medicaid ACO at six healthcare entities. Adults were divided into two strata: 15,153 age 19–64 and 616 age 65+. Adults age 19–64 who needed influenza and/or Tdap vaccine, and adults age 65+ who needed influenza, and/or Tdap, and/or a pneumococcal vaccine were randomized to receive up to 3 R/Rs by autodialed telephone and mail or usual care. Documentation of receipt of any needed vaccines in CIIS within six months was the primary outcome. We assessed intervention effectiveness using mixed effect logistic regression. Thirteen semi-structured exit interviews were conducted with staff from each healthcare entity. The intervention was not associated with the primary outcome for the age 19–64 population [OR 1.06 (95% CI 0.98–1.15)] or age 65+ population [(OR 0.96 (0.69–1.32)]. Practice staff perceived the intervention to be beneficial and not burdensome. Perceived barriers included lack of availability of appointments and adults receiving only influenza vaccine when other vaccines were needed. In conclusion, centralized R/R was not effective at improving adult vaccination rates in a Medicaid ACO. Future studies should consider better harmonizing vaccine centralized R/Rs with vaccine delivery efforts within the practice setting.Clinical Trials Registration Number: NCT02133391.

Colorectal cancer screening in newly insured Medicaid members: a review of concurrent federal and state policies

BackgroundColorectal cancer (CRC) screening is underutilized by Medicaid enrollees and the uninsured. Multiple national and state policies were enacted from 2010 to 2014 to increase access to Medicaid and to promote CRC screening among Medicaid enrollees. We aimed to determine the impact of these policies on screening initiation among newly enrolled Oregon Medicaid beneficiaries age-eligible for CRC screening.MethodsWe identified national and state policies affecting Medicaid coverage and preventive services in Oregon during 2010–2014. We used Oregon Medicaid claims data from 2010 to 2015 to conduct a cohort analysis of enrollees who turned 50 and became age-eligible for CRC screening (a prevention milestone, and an age at which guideline-concordant screening can be assessed within a single year) during each year from 2010 to 2014. We calculated risk ratios to assess whether first year of Medicaid enrollment and/or year turned 50 was associated with CRC screening initiation.ResultsWe identified 14,576 Oregon Medicaid enrollees who turned 50 during 2010–2014; 2429 (17%) completed CRC screening within 12 months after turning 50. Individuals newly enrolled in Medicaid in 2013 or 2014 were 1.58 and 1.31 times more likely, respectively, to initiate CRC screening than those enrolled by 2010. A primary care visit in the calendar year, having one or more chronic conditions, and being Hispanic was also associated with CRC screening initiation.DiscussionThe increased uptake of CRC screening in 2013 and 2014 is associated with the timing of policies such as Medicaid expansion, enhanced federal matching for preventive services offered to Medicaid enrollees without cost sharing, and formation of Medicaid accountable care organizations, which included CRC screening as an incentivized quality metric.

Medicaid Accountable Care Organizations in Four States: Implementation and Early Impacts.

As state Medicaid programs consider alternative payment models (APMs), many are choosing accountable care organizations (ACOs) as a way to improve health outcomes, coordinate care, and reduce expenditures. Four states (Maine, Massachusetts, Minnesota, and Vermont) leveraged State Innovation Model awards to create or expand Medicaid ACOs. We used a mixed-methods design to assess achievements and challenges with ACO implementation and the impact of Medicaid ACOs on health care utilization, quality, and expenditures in three states. We integrated findings from key informant interviews, focus groups, document review, and difference-in-difference analyses using data from Medicaid claims and an all-payer claims database. States built their Medicaid ACOs on existing health care reforms and infrastructure. Facilitators of implementation included allowing flexibility in design and implementation, targeting technical assistance, and making clinical, cost, and use data readily available to providers. Barriers included provider concerns about their ability to influence patient behavior, sustainability of provider practice transformation efforts when shared savings are reinvested into the health system and not shared with participating clinicians, and limited integration between health care and social service providers. Medicaid ACOs were associated with some improvements in use, quality, and expenditures, including statistically significant reductions in emergency department visits. Only Vermont's ACO demonstrated slower growth in total Medicaid expenditures. Four states demonstrated that adoption of ACOs for Medicaid beneficiaries was both possible and, for three states, associated with some improvements in care. States revised these models over time to address stakeholder concerns, increase provider participation, and enable some providers to accept financial risk for Medicaid patients. Lessons learned from these early efforts can inform the design and implementation of APMs in other Medicaid programs.

Behavioral Health Integration With Primary Care: Implementation Experience and Impacts From the State Innovation Model Round 1 States.

Increasing numbers of states are looking for ways to address behavioral health (BH) conditions among their residents. The first round of the State Innovation Models (SIM) Initiative provided financial and technical support to six states since 2013 to test the ability of state governments to lead health care system transformation. All six SIM states invested in integration of BH and primary care services. This study summarizes states' progress, challenges, and lessons learned on BH integration. Additionally, the study reports impacts on expenditure, utilization, and quality-of-care outcomes for persons with BH conditions across four SIM states. We use a mixed-methods design, drawing on focus groups and key informant interviews to reach conclusions on implementation and quantitative analysis using Medicaid claims data to assess impact. For three Medicaid accountable care organization (ACO) models funded under SIM, we used a difference-in-differences regression model to compare outcomes for model participants with BH conditions and an in-state comparison group before-and-after model implementation. For the behavioral health home (BHH) model in Maine, we used a pre-post design to assess how outcomes for model participants changed over time. Informal relationship building, tailored technical assistance, and the promotion of data sharing were key factors in making progress. After three years of implementation, the growth in total expenditures was less than the comparison group by $128 (-$253, -$3; p < 0.10) and $62 (-$87, -$36; p < 0.001) per beneficiary per month for beneficiaries with BH conditions attributed to an ACO in Minnesota and Vermont, respectively. Likewise, there were reductions in emergency department use for ACO participants in all three states after two to four years of implementation. However, there was no improvement in BH-related quality metrics for ACO beneficiaries in all three states. Although participants in the BHH model had increased expenditures after two years of implementation, use of primary care and specialty care services increased by 3% and 8%, respectively, and antidepressant medication adherence also improved. The SIM Round 1 states made considerable progress in integrating BH and primary care services, and there were promising findings for all models. Taken together, there is some evidence that Medicaid payment models can improve patterns of care for beneficiaries with BH conditions.

Addressing Social Determinants of Health: Challenges and Opportunities in a Value-Based Model.

* Abbreviations: ACO — : accountable care organization CMS — : Center for Medicare and Medicaid Services SDoH — : social determinants of health Two forces are reverberating within the US health care system. The first is the medical system’s recognition that addressing a patient’s social circumstances is necessary to promote health and prevent disease. Pediatrics has long espoused the strong influence of family and social conditions on children’s wellbeing. The second force is movement away from fee-for-service reimbursement to a value-based model in which payment is based on quality measures and health outcomes. This value-based system, which was first tested in private insurers and Medicare, has now been extended into Medicaid, which is the largest insurer of US children. By 2020, accountable care organizations (ACOs) will cover 100 million Americans.1 These forces’ convergence is influencing Medicaid-related health policies. Medicaid managed-care-organization programs in 30 states are encouraging screening for social needs and providing referrals for social services. Some statewide Medicaid ACO programs require social determinants of health (SDoH) interventions (eg, housing programs) and include health-related social-need screening as a quality measure.2 The Center for Medicare and Medicaid Services (CMS) also recently announced the Integrated Care for Kids Model, a child-centered service delivery and state payment model that is aimed at reducing expenditures and improving quality of care for children through the prevention, early identification, and treatment of behavioral and physical health needs. The opportunity to engage the health care system with nonmedical sectors (eg, human services, … Address correspondence to Arvin Garg, MD, MPH, Division of General Pediatrics, Department of Pediatrics, School of Medicine, Boston University, Boston Medical Center, 88 E. Newton St, Vose Hall, Third Floor, Boston, MA 02118. E-mail: arvin.garg{at}bmc.org

Does a transition to accountable care in Medicaid shift the modality of colorectal cancer testing?

BackgroundHealth care reform is changing preventive services delivery. This study explored trajectories in colorectal cancer (CRC) testing over a 5-year period that included implementation of 16 Medicaid Accountable Care Organizations (ACOs, 2012) and Medicaid expansion (2014) – two provisions of the Affordable Care Act (ACA) - within the state of Oregon, USA.MethodsRetrospective analysis of Oregon’s Medicaid claims for enrollee’s eligible for CRC screening (50–64 years) spanning January 2010 through December 2014. Our analysis was conducted and refined April 2016 through June 2018. The analysis assessed the annual probability of patients receiving CRC testing and the modality used (e.g., colonoscopy, fecal testing) relative to a baseline year (2010). We hypothesized that CRC testing would increase following Medicaid ACO formation – called Coordinated Care Organizations (CCOs).ResultsA total of 132,424 unique Medicaid enrollees (representing 255,192 person-years) met inclusion criteria over the 5-year study. Controlling for demographic and regional factors, the predicted probability of CRC testing was significantly higher in 2014 (+ 1.4 percentage points, p < 0.001) compared to the 2010 baseline but not in 2012 or 2013. Increased fecal testing using Fecal Occult Blood Tests (FOBT) or Fecal Immunochemical Tests (FIT) played a prominent role in 2014. The uptick in statewide fecal testing appears driven primarily by a subset of CCOs.ConclusionsObserved CRC testing did not immediately increase following the transition to CCOs in 2012. However increased testing in 2014, may reflect a delay in implementation of interventions to increase CRC screening and/or a strong desire by newly insured Medicaid CCO members to receive preventive care.

Behavioral Health Integration in a Medicaid Accountable Care Organization: Management Lessons from a Health Center.

Behavioral health integration, including as used in Medicaid Accountable Care Organizations, can improve care and decrease costs. Our model strives to integrate fully its medical, behavioral health, and substance use disorder services into one primary care clinic. Merged management has decreased wait times, improved billing, and enabled several promising innovations.

Lessons from the Camden Coalition of Healthcare Providers' First Medicaid Shared Savings Performance Evaluation.

Accountable Care Organizations (ACOs) aim to reduce health care costs while improving patient outcomes. Camden Coalition of Healthcare Providers' (Camden Coalition) work already aligned with this aim before receiving state approval to operate a certified Medicaid ACO in New Jersey. Upon its formation, the Camden Coalition ACO partnered with UnitedHealthcare and, through state legislation, Rutgers Center for State Health Policy (CSHP) was established as its external evaluator. In evaluating the Camden Coalition ACO, Rutgers CSHP built on the Medicare Shared Savings model, but modified it based on the understanding that the Medicaid population differs from the Medicare population. Annual savings rate (ASR) was used to measure shared savings, and was calculated at the Medicaid product level and aggregated up to reflect a single ASR for the first performance year. The calculated performance yielded a range of shared savings from an ASR of 0.4% to 5.3%, depending on which dollar amount was used to create the outlier ceiling (limit at which a subset of members with expensive utilization patterns are excluded) and how the appropriate statewide trend factor (the expected percentage increase in Medicaid costs across the state) was chosen. In all scenarios, the ASR resulted in less cost savings than predicted. The unfavorable results may be caused by the fact that the evaluation was not calibrated to capture areas where Camden Coalition's ACO was likely to make its impact. Future ACO evaluations should be designed to better correlate with the patient populations and practice areas of the ACO.

Control Versus Administrative Discretion in Negotiating Voluntary P4P Networks: The Case of Medicaid Accountable Care Organizations

Government sponsored pay-for-performance systems (P4P) have emerged in many contexts, including those featuring third-party federalism such as Medicaid. In this vein, voluntary networks called Medicaid accountable care organizations (ACOs) seek to achieve health care savings while boosting the quality of care. Drawing on evidence from four states, this study probes how collaborative governance strategies that downplay formal democratic controls and enhance administrative flexibility shaped the response to two implementation problems. We find that administrative flexibility, combined with signals of support from political principals, helped galvanize ACO formation but undermined efforts to tailor performance metrics to the needs of Medicaid enrollees.

Changes in Quality of Life Among Enrollees in Hennepin Health: A Medicaid Expansion ACO.

Despite limited program evaluations of Medicaid accountable care organizations (ACOs), no studies have examined if cost-saving goals negatively affect quality of life and health care experiences of low-income enrollees. The Hennepin Health ACO uses an integrated care model to address the physical, behavioral, and social needs of Medicaid expansion enrollees. As part of a larger evaluation, we conducted semistructured interviews with 35 primary care using Hennepin Health members enrolled for 2 or more years. Using fuzzy set qualitative comparative analysis, we assessed enrollee complexity and use of the care model and improvements in quality of life. We found improved quality of life was consistently associated with strong bonds to primary care, consistent mental health care, and support from extended care team members. Comprehensive, integrated care models within ACOs may improve quality of life for low-income Medicaid enrollees through coordinated primary and mental health care.

Benefits of Medical Home Care Reaching Beyond Chronically Ill Teens: Exploring Parent Health-Related Quality of Life

BackgroundCaring for teens with special health care needs places physical and mental health burdens on parents, which can be exacerbated by the stresses of transitions to independence. Medical homes can improve teen transitions to greater self-management and reduce health care–related time and financial burdens for families. We examined the association between parent-reported teen medical home status and caregiver health-related quality of life (HRQOL). MethodsThe study sample included parents or caregivers of teens with special health care needs aged 15 to 18 recruited from a pediatric Medicaid accountable care organization who participated in a survey (response rate, 40.5%). The primary outcome was parent HRQOL scores (0–100 points) measured using the Pediatric Quality of Life Inventory Family Impact Module. Medical home status was based on parent report of teen's health care meeting medical home criteria. Linear regression models were used to estimate HRQOL scores, adjusted for demographic characteristics, health literacy, and teen functional limitation. ResultsAmong 488 parents, 27% reported their teen received care consistent with a medical home. Adjusted parent HRQOL scores were significantly higher among those whose teens had a medical home (74.40; 95% confidence interval, 71.31–77.48), relative to those whose teens did not (65.78; 95% confidence interval, 63.92–67.65). Medical home subscale analyses showed HRQOL scores had significant positive associations with family-centered care and coordinated care, but not other subscales. ConclusionsTeen medical home status was positively associated with caregiver HRQOL, suggesting that the medical home may benefit overall caregiver well-being. In particular, receiving care that was family centered and coordinated appeared to be the most beneficial.

Minnesota Integrated Health Partnership Demonstration: Implementation of a Medicaid ACO Model.

In recent years, accountable care organizations (ACOs) have become more prevalent in the United States. This study describes the origins, implementation, and early results of Minnesota's Medicaid ACO payment model, the Integrated Health Partnership (IHP) demonstration project. We describe the structure of the program and present preliminary evaluation results to document the state's important work and to provide lessons for other states interested in implementing Medicaid ACOs. The IHP program has expanded in size over time, the state has reported significant savings, and evidence exists of capacity building among participating providers. We identify factors that may have contributed to the program's early success, but more work is needed to investigate the specific drivers of quality improvement and savings within Minnesota's ACO program and to compare the design and effects of the IHP with other Medicaid and Medicare ACO programs. We conclude with comments about the future of the state's Medicaid ACO program and situate Minnesota's findings within the context of the broader ACO movement.

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.

Planning and Designing the Improving Addiction Care Team (IMPACT) for Hospitalized Adults with Substance Use Disorder.

People with substance use disorders (SUD) have high rates of hospitalization and readmission, long lengths of stay, and skyrocketing healthcare costs. Yet, models for improving care are extremely limited. We performed a needs assessment and then convened academic and community partners, including a hospital, community SUD organizations, and Medicaid accountable care organizations, to design a care model for medically complex hospitalized patients with SUD. Needs assessment showed that 58% to 67% of participants who reported active substance use said they were interested in cutting back or quitting. Many reported interest in medication for addiction treatment (MAT). Participants had high rates of costly readmissions and longer than expected length of stay. Community stakeholders identified long wait times and lack of resources for medically complex patients as key barriers. We developed the Improving Addiction Care Team (IMPACT), which includes an inpatient addiction medicine consultation service, rapid-access pathways to posthospital SUD treatment, and a medically enhanced residential care model that integrates antibiotic infusion and residential addiction care. We developed a business case and secured funding from Medicaid and hospital payers. IMPACT provides one pathway for hospitals, payers, and communities to collaboratively address the SUD epidemic. Journal of Hospital Medicine 2017;12:339-342.

For Super-Utilizers, Integrated Care Offers A New Path.

Many health systems continue to experiment with the best way to care for those patients who end up in the hospital most frequently.

Oregon's Medicaid Reform And Transition To Global Budgets Were Associated With Reductions In Expenditures.

In 2012 Oregon initiated an ambitious delivery system reform, moving the majority of its Medicaid enrollees into sixteen coordinated care organizations, a type of Medicaid accountable care organization. Using claims data, we assessed measures of access, appropriateness of care, utilization, and expenditures for five service areas (evaluation and management, imaging, procedures, tests, and inpatient facility care), comparing Oregon to the neighboring state of Washington. Overall, the transformation into coordinated care organizations was associated with a 7percent relative reduction in expenditures across the sum of these services, attributable primarily to reductions in inpatient utilization. The change to coordinated care organizations also demonstrated reductions in avoidable emergency department visits and improvements in some measures of appropriateness of care, but also exhibited reductions in primary care visits, a potential area of concern. Oregon's coordinated care organizations could provide lessons for controlling health care spending for other state Medicaid programs.

Early Performance in Medicaid Accountable Care Organizations

Several state Medicaid reforms are under way, but the relative performance of different approaches is unclear. To compare the performance of Oregon's and Colorado's Medicaid Accountable Care Organization (ACO) models. Oregon initiated its Medicaid transformation in 2012, supported by a $1.9 billion investment from the federal government, moving most Medicaid enrollees into 16 Coordinated Care Organizations, which managed care within a global budget. Colorado initiated its Medicaid Accountable Care Collaborative in 2011, creating 7 Regional Care Collaborative Organizations that received funding to coordinate care with providers and connect Medicaid enrollees with community services. Data spanning July 1, 2010, through December 31, 2014 (18 months before intervention and 24 months after intervention, treating 2012 as a transition year) were analyzed for 452 371 Oregon and 330 511 Colorado Medicaid enrollees, assessing changes in outcomes using difference-in-differences analyses of regional focus, primary care homes, and care coordination. Oregon's Coordinated Care Organization model was more comprehensive in its reform goals and in the imposition of downside financial risk. Regional focus, primary care homes, and care coordination in Medicaid ACOs. Performance on claims-based measures of standardized expenditures and utilization for selected services, access, preventable hospitalizations, and appropriateness of care. In a total of 782 882 Medicaid enrollees, 45.0% were male, with mean (SD) age 16.74 (14.41) years. Standardized expenditures for selected services declined in both states during the 2010-2014 period, but these decreases were not significantly different between the 2 states. Oregon's model was associated with reductions in emergency department visits (-6.28 per 1000 beneficiary-months; 95% CI, -10.51 to -2.05) and primary care visits (-15.09 visits per 1000 beneficiary-months; 95% CI, -26.57 to -3.61), improvements in acute preventable hospital admissions (-1.01 admissions per 1000 beneficiary-months; 95% CI, -1.61 to -0.42), 3 of 4 measures of access (well-child visits, ages 3-6 years, 2.69%; 95% CI, 1.20% to 4.19%; adolescent well-care visits, 6.77%; 95% CI, 5.22% to 8.32%; and adult access to preventive ambulatory care, 1.26%; 95% CI, 0.28% to 2.25%), and 1 of 4 measures of appropriateness of care (avoidance of head imaging for uncomplicated headache, 2.59%; 95% CI, 1.35% to 3.83%). Two years into implementation, Oregon's and Colorado's Medicaid ACO models exhibited similar performance on standardized expenditures for selected services. Oregon's model, marked by a large federal investment and movement to global budgets, was associated with improvements in some measures of utilization, access, and quality, but Colorado's model paralleled Oregon's on several other metrics.

Pediatric Accountable Care Organizations: Insight From Early Adopters.

Partly in response to incentives in the Affordable Care Act, there has been major growth in accountable care organizations (ACO) in both the private and public sectors. For several reasons, growth of ACOs in pediatric care has been more modest than for older populations. The American Academy of Pediatrics collaborated with Leavitt Partners, LLC, to carry out a study of pediatric ACOs, including a series of 5 case studies of diverse pediatric models, a scan of Medicaid ACOs, and a summit of leaders in pediatric ACO development. These collaborative activities identified several issues in ACO formation and sustainability in pediatric settings and outlined a number of opportunities for the pediatric community in areas of organization, model change, and market dynamics; payment, financing, and contracting; quality and value; and use of new technologies. These insights can guide future work in pediatric ACO development.

Acute care revisits after adenotonsillectomy in a pediatric Medicaid population in Ohio

IntroductionGuidelines for inpatient admission after pediatric tonsillectomy have been proposed to improve the safety of this procedure. This study examined the association between performing adenotonsillectomy in an inpatient setting and acute care revisits within 30 days among children enrolled in a Medicaid Accountable Care Organization in Ohio. MethodsThe Accountable Care Organization's claims database was queried for adenotonsillectomies performed in children ages 0–18 years in 2008–2014. Procedures associated with an inpatient facility stay were classified as inpatient adenotonsillectomies. The primary outcome was emergency department visit or inpatient re-admission within 30 days. Secondary outcomes were revisits within 7 days and >7 days post-discharge. Logistic regression was used to test for association between inpatient procedure and need for revisits. ResultsAdenotonsillectomies in 8835 girls and 7773 boys (age 6.8 ± 3.8 years) were analyzed, of which 842 (5%) were inpatient procedures. Revisits were required in 2511 (15%) cases and were primarily visits to the emergency department. In multivariable analysis, inpatient and outpatient procedures had comparable need for 30-day revisits (OR = 0.85; 95% CI: 0.69, 1.05; p = 0.124). In sub-analyses, inpatient adenotonsillectomy was associated with lower odds of early (≤7 days post-discharge; OR = 0.76; 95% CI: 0.58, 0.99; p = 0.045) but not later (≥8 days) revisits. ConclusionsIn a pediatric Medicaid population, inpatient adenotonsillectomy was not associated with greater odds of acute care revisits, compared to outpatient procedures. Appropriate risk stratification of children undergoing adenotonsillectomy can reduce the need for early acute care revisits by scheduling high-risk patients for prolonged observation.

Spending Carveouts Substantially Improve the Accuracy of Performance Measurement in Shared Savings Arrangements: Findings From Simulation Analysis of Medicaid ACOs.

Accuracy of spending-based provider performance metrics is limited by random variation and components of spending that are uncontrollable by providers. Such components vary according to the care management focus and operational maturity of each provider group. This study uses data from New Jersey Medicaid accountable care organizations (ACOs) to examine how carving out uncontrollable components of spending affects the accuracy of performance measures in shared savings arrangements. Spending on injury care, custodial care in facilities (CCF), and amounts above $100 000 per patient are used as examples of potentially uncontrollable spending. Data from 7 applicant Medicaid ACOs are used to conduct Monte Carlo simulations examining the effects of carving out each type of uncontrollable spending under the assumption that controllable spending is reduced by 5%. The simulations show that failure to carve out uncontrollable injury care spending adds −3 to +1 percentage points of bias to the measurement of the true average savings rate (ASR) of 5% and can increase mean squared error (MSE) by a factor of up to 3. Failure to carve out uncontrollable CCF spending generates bias ranging from −4 to +9 percentage points and increases MSE by factors of 8 or more. Failure to carve out uncontrollable spending above $100 000 per person generates bias ranging from −5 to +5 percentage points and increases MSE by factors of 13 or more. Compared with the main modeling reported above, sensitivity analyses find even greater distortions in measured performance when uncontrollable spending is not carved out of the ASR calculation.