Accountable Care Organizations Patients Research Articles

Disparities in Rates of Surgical Intervention Among Racial and Ethnic Minorities in Medicare Accountable Care Organizations.

To assess the effect of Accountable Care Organizations (ACOs) on the use of surgical services among racial and ethnic minorities. Health reform efforts were expected to reduce healthcare disparities. The impact of ACOs on existing disparities in access to surgical care remains unknown. We used national Medicare data (2009-2014) to compare rates of surgery among white, African American, Hispanic, and Asian Medicare beneficiaries for coronary artery bypass grafting, colectomy, total hip arthroplasty, hip fracture repair, and lumbar spine surgery. We performed a pre-post difference in differences analysis between African American, Hispanic, and Asian patients receiving surgical care in ACO and non-ACO organizations before and after the implementation of ACOs. The time period 2009 to 2011 was considered the pre-ACO period, and 2012 to 2014 the post-ACO period. Rates of surgical intervention in the ACO cohort were significantly lower (P < 0.001) as compared to non-ACOs for whites, African Americans, Hispanics, and Asians in both the pre- and post-ACO periods. There was no significant difference in the adjusted change in the rate of surgical interventions among minority patients as compared to whites in ACOs and non-ACOs between 2009 to 2011 and 2012 to 2014. The odds of receiving surgical intervention were lowest for minority patients in ACOs during the post-ACO period (P < 0.001). We found persistent differences in the use of surgery among racial and ethnic minorities between the time periods 2009 to 2011 and 2012 to 2014. These disparities were not impacted by the formation of ACOs. Programs that specifically incentivize ACOs to improve surgical access for minorities may be necessary.

Evaluation of the Skilled Nursing Facility (SNF) Transitional Care Management Program (TCMP) Using Decision Support on Post-Acute Discharge SNF Length of Stay and Subsequent Hospital Readmissions

Accounting for both significant total medical expense and variation, managing Skilled Nursing Facility (SNF) post-acute care (PAC) utilization has become a major focus area for accountable care organizations (ACOs). In 2017 our healthcare system implemented the SNF TCMP across 5 hospitals for our Medicare ACO population beginning with Hospital D as a pilot in 2015. Our SNF TCMP includes 2 major elements: 1) use of dedicated care managers who oversee the care of our medicare ACO patients requiring PAC SNF level of care through that patient’s entire PAC SNF episode guided by 2) use of the LiveSafe tool, a proprietary SNF PAC level-of care, decision-support tool to which we purchased access from naviHealth. This study’s aim was to evaluate independently the effectiveness of our SNF TCMP on PAC disposition outcomes including SNF length of stay (LOS) and 30-day readmission rate for our ACO patients discharged from our 5 hospitals.

Medicare Accountable Care Organizations and Use of Potentially Low-Value Procedures.

To evaluate the effect of Accountable Care Organizations (ACOs) on the use of vertebroplasty and arthroscopic partial meniscectomy, 2 procedures for which randomized controlled trials suggest similar outcomes to sham surgery and therefore may provide low value. Medicare Shared Savings Program ACOs aim to improve quality and decrease health care spending. Reducing the use of potentially low-value procedures can accomplish both of these goals. We performed a retrospective cohort study of patients who underwent potentially low-value orthopedic procedures (vertebroplasty and partial meniscectomy) and a control (hip fracture) from 2010 to 2015 using a 20% sample of national Medicare claims. We performed an interrupted time-series analysis using linear spline models to evaluate the count of each procedure per 1000 patients, stratified by ACO participation. We identified 76 256 patients who underwent arthroscopic partial meniscectomy, 44 539 patients who underwent vertebroplasty, and 50 760 patients who underwent hip fracture admission. Arthroscopic partial meniscectomy rates decreased, vertebroplasty rates remained stable, and hip fracture rates increased for both groups during the study period, with similar trends among ACO and non-ACO patients. After January 1, 2013, ACO and non-ACO populations had similar trends for vertebroplasty (ACO incidence rate ratio [IRR] = 1.15 [1.08-1.23] vs non-ACO IRR = 1.11 [1.05-1.16]), meniscectomy (ACO IRR = 1.06 [1.01-1.12] vs non-ACO IRR = 1.03 [0.99-1.07]), and hip fracture (ACO IRR = 1.08 [1.01-1.14] vs non-ACO IRR = 1.08 [1.03-1.13]). ACOs were not associated with a reduction in the frequency of vertebroplasty and arthroscopic partial meniscectomy.

Medicare Spending after 3 Years of the Medicare Shared Savings Program

BackgroundHealth care providers who participate as an accountable care organization (ACO) in the voluntary Medicare Shared Savings Program (MSSP) have incentives to lower spending for Medicare patients while achieving high performance on a set of quality measures. Little is known about the extent to which early savings achieved by ACOs in the program have grown and been replicated by ACOs that entered the program in later years. ACOs that are physician groups have stronger incentives to lower spending than hospital-integrated ACOs.MethodsUsing fee-for-service Medicare claims from 2009 through 2015, we performed difference-in-differences analyses to compare changes in Medicare spending for patients in ACOs before and after entry into the MSSP with concurrent changes in spending for local patients served by providers not participating in the MSSP (control group). We estimated differential changes (i.e., the between-group difference in the change from the pre-entry period) separately for hospital-integrated ACOs and physician-group ACOs that entered the MSSP in 2012, 2013, or 2014.ResultsMSSP participation was associated with differential spending reductions in physician-group ACOs. These reductions grew with longer participation in the program and were significantly greater than the reductions in hospital-integrated ACOs. By 2015, the mean differential change in per-patient Medicare spending was −$474 (−4.9% of the pre-entry mean, P<0.001) for physician-group ACOs that entered in 2012, −$342 (−3.5% of the pre-entry mean, P<0.001) for those that entered in 2013, and −$156 (−1.6% of the pre-entry mean, P=0.009) for those that entered in 2014. The corresponding differential changes for hospital-integrated ACOs were −$169 (P=0.005), −$18 (P=0.78), and $88 (P=0.14), which were significantly lower than for physician-group ACOs (P<0.001). Spending reductions in physician-group ACOs constituted a net savings to Medicare of $256.4 million in 2015, whereas spending reductions in hospital-integrated ACOs were offset by bonus payments.ConclusionsAfter 3 years of the MSSP, participation in shared-savings contracts by physician groups was associated with savings for Medicare that grew over the study period, whereas hospital-integrated ACOs did not produce savings (on average) during the same period. (Funded by the National Institute on Aging.)

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.

Alterations in 90-day morbidity, mortality, and readmission rates following spine surgery in Medicare Accountable Care Organizations (2009–2014)

BACKGROUND CONTEXTThe impact of Accountable Care Organizations (ACOs) on healthcare quality and outcomes, including morbidity, mortality, and readmissions, has not been substantially investigated, especially following spine surgery. PURPOSETo evaluate the impact of ACO formation on postoperative outcomes in the 90-day period following spine surgery. STUDY DESIGNRetrospective review of national Medicare claims data (2009–2014). PATIENT SAMPLEPatients who underwent one of four lumbar spine surgical procedures in an ACO or non-ACO. OUTCOME MEASURESThe development of in-hospital mortality, complications or hospital readmission within 90 days of the surgical procedure. METHODSThe primary outcome measures included postsurgical complications and readmissions at 90 days following surgery. In-hospital mortality and 30-day outcomes were considered secondarily. The primary predictor variable consisted of ACO enrollment designation. Multivariable logistic regression analysis was utilized to adjust for confounders and determine the independent effect of ACO enrollment on postsurgical outcomes. The multivariable model included a propensity score adjustment that accounted for factors associated with the preferential enrollment of patients in ACOs, namely, sociodemographic characteristics, medical co-morbidities, hospital teaching status, bed size, and location. RESULTSIn all, there were 344,813 patients identified for inclusion in this analysis with 97% (n = 332,890) treated in non-ACOs and 3% (n = 11,923) in an ACO. Although modest changes were apparent across both ACOs and non-ACOs over the time-period studied, improvements were slightly more dramatic in non-ACOs leading to statistically significant differences in both 90-day complications and readmissions. Specifically, in the period 2012–2014, ACOs demonstrated an 18% increase in the odds of 90-day complications and a 14% elevation in the odds of 90-day readmissions when compared to non-ACOs. There was no difference in hospital mortality between ACOs and non-ACOs. CONCLUSIONSOur study of Medicare data from 2009 to 2014 failed to demonstrate superior reductions in postoperative morbidity, mortality, and readmissions for beneficiaries treated in ACOs as compared to non-ACOs. These results indicate that meaningful changes in postoperative outcomes should not be anticipated based on organizational participation in ACOs at present.

Thursday, September 27, 2018 1:05 PM–2:05 PM The Spine Journal Outstanding Paper Awards

BACKGROUND CONTEXT The impact of Accountable Care Organizations (ACOs) on healthcare quality and outcomes, including morbidity, mortality and readmissions, has not been substantially investigated, especially following spine surgery. PURPOSE To evaluate the impact of ACO formation on post-operative outcomes in the 90-day period following spine surgery. STUDY DESIGN Retrospective review of national Medicare claims data (2009-2014). PATIENT SAMPLE Patients who underwent one of four lumbar spine surgical procedures in an ACO or non-ACO. OUTCOME MEASURES The development of in-hospital mortality, complications or hospital readmission within 90-days of the surgical procedure. METHODS The primary outcome measures included post-surgical complications and readmissions at 90-days following surgery. In-hospital mortality and 30- day outcomes considered secondarily. The primary predictor variable consisted of ACO enrollment designation. Multivariable logistic regression analysis was utilized to adjust for confounders and determine the independent effect of ACO-enrollment on post-surgical outcomes. The multivariable model included a propensity score adjustment that accounted for factors associated with the preferential enrollment of patients in ACOs; namely socio-demographic characteristics, medical co-morbidities, hospital teaching status, bed size and location. RESULTS In all, there were 344,813 patients identified for inclusion in this analysis with 97% (n=332,890) treated in non-ACOs and 3% (n=11,923) in an ACO. Although modest changes were apparent across both ACOs and non-ACOs over the time-period studied, improvements were slightly more dramatic in non-ACOs leading to statistically significant differences in both 90-day complications and readmissions. Specifically, in the period 2012-2014, ACOs demonstrated an 18% increase in the odds of 90-day complications and a 14% elevation in the odds of 90-day readmissions when compared to non- ACOs. There was no difference in hospital mortality between ACOs and non-ACOs. CONCLUSIONS Our study of Medicare data from 2009-2014 failed to demonstrate superior reductions in postoperative morbidity, mortality and readmissions for beneficiaries treated in ACOs as compared to non-ACOs. These results indicate that meaningful changes in post-operative outcomes should not be anticipated based on organizational participation in ACOs at present. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Wednesday, September 26, 2018 7:35 AM–9:00 AM ePosters: P68. Alterations in 90-day morbidity, mortality and readmission rates following spine surgery in Medicare accountable care organizations (2009–2014)

BACKGROUND CONTEXT The impact of accountable care organizations (ACOs) on health care quality and outcomes, including morbidity, mortality and readmissions, has not been substantially investigated, especially following spine surgery. PURPOSE To evaluate the impact of ACO formation on postoperative outcomes in the 90-day period following spine surgery STUDY DESIGN/SETTING Retrospective review of a 100% sample of Medicare claims (2009–2014). PATIENT SAMPLE Patients who underwent one of four lumbar spine surgical procedures in an ACO or nonACO. OUTCOME MEASURES The development of in-hospital mortality, complications or hospital readmission within 90-days of the surgical procedure. METHODS The primary outcome measures included post-surgical complications and readmissions at 90-days following surgery. In-hospital mortality and 30-day outcomes considered secondarily. The primary predictor variable consisted of ACO enrollment designation. Multivariable logistic regression analysis was utilized to adjust for confounders and determine the independent effect of ACO-enrollment on postsurgical outcomes. The multivariable model included a propensity score adjustment that accounted for factors associated with the preferential enrollment of patients in ACOs; namely socio-demographic characteristics, medical co-morbidities, hospital teaching status, bed size and location. RESULTS In all, there were 344,813 patients identified for inclusion in this analysis with 97% (n=332,890) treated in nonACOs and 3% (n=11,923) in an ACO. Although modest changes were apparent across both ACOs and nonACOs over the time-period studied, improvements were slightly more dramatic in nonACOs leading to statistically significant differences in both 90-day complications and readmissions. Specifically, in the period 2012-2014, ACOs demonstrated an 18% increase in the likelihood of 90-day complications and a 14% elevation in the likelihood of 90-day readmissions when compared to nonACOs. There was no difference in hospital mortality between ACOs and nonACOs. CONCLUSIONS Our study of Medicare data from 2009 to 2014 failed to demonstrate superior reductions in postoperative morbidity, mortality and readmissions for beneficiaries treated in ACOs as compared to nonACOs. These results indicate that meaningful changes in postoperative outcomes should not be anticipated based on organizational participation in ACOs at present.

Medicare ACO Program Savings Not Tied To Preventable Hospitalizations Or Concentrated Among High-Risk Patients.

It has been widely assumed that better management and coordination of care for chronic conditions and high-risk patients would be the leading mechanisms for achieving savings in accountable care organizations (ACOs), specifically by reducing acute care needs through enhanced outpatient and preventive care. We examined the extent to which changes in spending and hospitalizations for ACO patients in the Medicare Shared Savings Program (MSSP) have been consistent with this expectation. By 2014, participation in the MSSP was associated with significant reductions in total Medicare fee-for-service spending for ACO patients but with proportionately smaller reductions in hospitalizations and some increases in hospitalizations for ambulatory care-sensitive conditions. In addition, spending reductions were not clearly concentrated among high-risk patients: Reductions for those patients accounted for only 38percent of the total reduction among ACOs entering the MSSP in 2012, and reductions among 2013 MSSP entrants were almost entirely concentrated among lower-risk patients. These findings suggest that, on average, care coordination and management efforts focused on ambulatory care-sensitive conditions and high-risk patients have not been the major drivers of early savings in the MSSP.

A model to determine payments associated with radiology procedures

ObjectiveAcross the United States, there is a growing number of patients in Accountable Care Organizations and under risk contracts with commercial insurance. This is due to proliferation of new value-based payment models and care delivery reform efforts. In this context, the business model of radiology within a hospital or health system context is shifting from a primary profit-center to a cost-center with a goal of cost savings. Radiology departments need to increasingly understand how the transactional nature of the business relates to financial rewards. The main challenge with current reporting systems is that the information is presented only at an aggregated level, and often not broken down further, for instance, by type of exam. As such, the primary objective of this research is to provide better visibility into payments associated with individual radiology procedures in order to better calibrate expense/capital structure of the imaging enterprise to the actual revenue or value-add to the organization it belongs to. Materials and methodsWe propose a methodology that can be used to determine technical payments at a procedure level. We use a proportion based model to allocate payments to individual radiology procedures based on total charges (which also includes non-radiology related charges). ResultsUsing a production dataset containing 424,250 radiology exams we calculated the overall average technical charge for Radiology to be $873.08 per procedure and the corresponding average payment to be $326.43 (range: $48.27 for XR and $2750.11 for PET/CT) resulting in an average payment percentage of 37.39% across all exams. DiscussionWe describe how charges associated with a procedure can be used to approximate technical payments at a more granular level with a focus on Radiology. The methodology is generalizable to approximate payment for other services as well. Understanding payments associated with each procedure can be useful during strategic practice planning. ConclusionsCharge-to-total charge ratio can be used to approximate radiology payments at a procedure level.

Spending Among Cancer Patients between ACO and Non-ACO Participants

Of the many initiatives aimed at improving the value of healthcare services in the United States, Accountable Care Organizations (ACOs) in particular are receiving substantial policy attention from both sides of the political aisle. Cancer is a common and costly condition with considerable variation in intensity and quality of care delivered. While early evidence from ACOs shows modest reductions in healthcare costs for Medicare beneficiaries overall, we are unaware of any data looking specifically at the impact of ACOs on spending for patients with cancer. We studied the 2014 claims of a 20% sample of Medicare fee-for-service (FFS) beneficiaries, age 65 and over who were continuously enrolled, and were age 65 or older. We used ACO assignments of patients by CMS to identify those in an ACO vs not in an ACO. We identified patients with breast, central nervous system, gastrointestinal, gynecologic, head and neck, lung, lymphoma and sarcoma malignancies using ICD9 codes. We identified beneficiary age, race, sex, Medicaid eligibility as an indicator of poverty, and chronic conditions as covariates. We calculated mean annual standardized costs overall as well as stratified by the following categories of spending: inpatient, outpatient, physician, Part D, skilled nursing facility, home health, and hospice. Physician spending was further categorized as follows: evaluation and management, procedures, imaging, durable medical equipment and other. Spending was adjusted for patient characteristics and by chronic conditions, using the Chronic Conditions Warehouse. We repeated our analyses stratified by individual tumor types. Our sample consisted of 913,942 beneficiaries with solid tumors, of whom 21% were in an ACO. ACO beneficiaries had modest but significantly higher total annual standardized costs compared to beneficiaries not in an ACO ($22,576 vs. $21, 484; P < 0.001). The ACO group also had higher inpatient, overall physician spending, skilled nursing facility and home health spending but lower hospice spending compared to non-ACO beneficiaries ($543 vs. $783; P < 0.001). There were no differences between the two groups with respect to Part D ($3,498 vs. $3,542; P = 0.097) and outpatient spending ($4,452 vs. $4,399; P = 0.13). When we further stratified physician spending, spending on ACO patients was greater for five out of six categories, with durable medical equipment being the exception. The results were similar when we looked at spending for individual cancers. Standardized total spending among patients with solid cancers treated in an ACO was significantly higher compared to those not in an ACO. This study suggests that ACOs have not yet started targeting cancer care to lower healthcare spending or if they have, they have not yet made much headway. Given that cancer represents a substantially expensive set of conditions, it may be a primary target for future ACO interventions.

Breast Cancer Screening for Patients of Rural Accountable Care Organization Clinics: A Multi-Level Analysis of Barriers and Facilitators.

Not all women 50-74years received biennial mammography and the situation is worse in rural areas. Accountable care organizations (ACO) emphasize coordinated care, use of electronic health system, and preventive quality measures and these practices may improve their patients' breast cancer screening rate. Using medical record data of 8,347 women patients aged 50-74years from eight rural ACO clinics in Nebraska, this study examined patient-, provider-, and county-level barriers and facilitators for breast cancer screening. A generalized estimating equations model was used to account for the correlation among patients from the same provider and county. The multi-level logistic regression results suggest that uninsured non-Hispanic Black patients were less likely to meet the biennial mammography screening guideline. Patients whose preferred language being English, having a preventive visit in the past 12 months, having one or more chronic conditions were more likely to meet the biennial mammography screening guideline. Patients with a primary care provider (PCP) that was male, without a medical doctor degree were less likely to screen biennially. Patients with a PCP that reviewed performance report quarterly, or manually checked patients' mammography screening status during visits were more likely to screen biennially. Interestingly, patients whose PCP reported being reminded by a care coordination team were less likely to screen biennially. Patients living in counties with more PCPs were also more likely to screen biennially. The study findings suggest that efforts targeting individual and practice-level barriers could be most effective in improving mammography screening for these rural ACO patients.

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.

Systems Opportunities to Reduce ED Crowding From Nonemergency Referrals.

Emergency department (ED) crowding threatens patient safety and is associated with increased mortality. This study explored the role of nonurgent referrals to the ED in crowding and collaborated on a large quality initiative with the study institution's accountable care organization (ACO) to provide timely alternatives to such referrals. Fifty-two percent of nonemergent ED patients report contacting a medical provider prior to coming to the ED, with 70% of those providers directing the patient to go to the ED. Fifty-nine percent of patients indicated that they would have accepted a clinic appointment in lieu of going to the ED. The authors collaborated on a multidisciplinary ED alternatives quality improvement effort with leadership to address these nonemergent referrals. ED visits per 1000 ACO patients declined significantly following survey results and ACO implementation of increased alternative ambulatory resources.

Thirty-day and 90-day hospital readmission after outpatient upper extremity hemodialysis access creation

ObjectivePatients with end-stage renal disease have multiple comorbidities and are at increased risk for postoperative complications and resource utilization. Our goal was to determine the rate and causes of 30-day and 90-day hospital readmissions after the creation of outpatient hemodialysis access. MethodsWe retrospectively reviewed all outpatient upper extremity hemodialysis access creations performed at our medical center from 2008 to 2015. Readmission was defined as any inpatient status admission ≤30 and 90 days. Reasons for such admissions were analyzed, and multivariate analyses assessed risk factors. ResultsWe identified 537 patients (60% male). Average age was 59 years. Access type included radiocephalic (4.5%), brachiocephalic (50.7%), brachiobasilic (22.5%), and prosthetic (20%) arteriovenous fistulas. The 90-day mortality rate was 0.7%. Postoperative hospital readmission rates were 25.5% at 30 days and 47.7% at 90 days. Reasons for admission were access related in 10.9% and dialysis catheter related in 6.9%. Other reasons for admission included shortness of breath/volume overload (15.8%), gastrointestinal (11.9%), cardiac/chest pain (10.9%), unrelated infectious causes (11.9%), failure to thrive (5%), altered mental status (4%), electrolyte abnormalities (3%), and musculoskeletal (2.5%). Preoperative predictors of all cause 30-day readmission included dementia (odds ratio [OR], 5.76; 95% confidence interval [CI], 1.34-24.8; P = .018), hypertension (OR, 3.92; 95% CI, 1.07-14.4; P = .039), chronic obstructive pulmonary disease (OR, 2.19; 95% CI, 1.01-4.76; P = .046), and current smoking (OR, 2.14; 95% CI, 1.32-3.47; P = .002). Predictors of all cause 90-day readmission were hepatic insufficiency (OR, 6.08; 95% CI, 1.2-30.8; P = .029), hypertension (OR, 3.43; 95% CI, 1.36-8.65; P = .009), black race (OR, 2.47; 95% CI, 1.48-4.14; P = .001), Hispanic ethnicity (OR, 2.04; 95% CI, 1.01-4.11; P = .046), and obesity (OR, 1.5; 95% CI, 1.02-2.19; P = .039). Predictors of 90-day access-related readmission included chronic obstructive pulmonary disease (OR, 5.27; 95% CI, 1.38-20.0; P = .015), previous stroke (OR, 3.76; 95% CI, 1.5-9.4; P = .005), being on dialysis at time of the operation (OR, 2.8; 95% CI, 1.17-6.84; P = .022), and prosthetic graft placement (OR, 2.86; 95% CI, 1.07-7.6; P = .036). An additional 9.7% had at least one emergency department presentation ≤90 days but were not admitted. ConclusionsPatients undergoing placement of hemodialysis access are at high risk for readmission mostly from causes unrelated to their operation. This has an effect for global care for these patients as well as care of these patients in accountable care organizations.

Changes in Postacute Care in the Medicare Shared Savings Program

ImportancePostacute care is thought to be a major source of wasteful spending. The extent to which accountable care organizations (ACOs) can limit postacute care spending has implications for the importance and design of other payment models that include postacute care.ObjectiveTo assess changes in postacute care spending and use of postacute care associated with provider participation as ACOs in the Medicare Shared Savings Program (MSSP) and the pathways by which they occurred.Design, Setting, and ParticipantsWith the use of fee-for-service Medicare claims from a random 20% sample of beneficiaries with 25 544 650 patient-years, 8 395 426 hospital admissions, and 1 595 352 stays in skilled nursing facilities (SNFs) from January 1, 2009, to December 31, 2014, difference-in-difference comparisons of beneficiaries served by ACOs with beneficiaries served by local non-ACO health care professionals (control group) were performed before vs after entry into the MSSP. Differential changes were estimated separately for cohorts of ACOs entering the MSSP in 2012, 2013, and 2014.ExposuresPatient attribution to an ACO in the MSSP.Main Outcomes and MeasuresPostacute spending, discharge to a facility, length of SNF stays, readmissions, use of highly rated SNFs, and mortality, adjusted for patient characteristics.ResultsFor the 2012 cohort of 114 ACOs, participation in the MSSP was associated with an overall reduction in postacute spending (differential change in 2014 for ACOs vs control group, −$106 per beneficiary [95% CI, –$176 to –$35], or −9.0% of the precontract unadjusted mean of $1172; P = .003) that was driven by differential reductions in acute inpatient care, discharges to facilities rather than home (−0.6 percentage points [95% CI, –1.1 to 0.0], or −2.7% of the unadjusted precontract mean of 22.6%; P = .03), and length of SNF stays (−0.60 days per stay [95% CI, –0.99 to –0.22], or −2.2% of the precontract unadjusted mean of 27.07 days; P = .002). Reductions in use of SNFs and length of stay were largely due to within-hospital or within-SNF changes in care specifically for ACO patients. Participation in the MSSP was associated with smaller significant reductions in SNF spending in 2014 for the 2013 ACO cohort (–$27 per beneficiary [95% CI, –$49 to –$6], or –3.3% of the precontract unadjusted mean of $813; P = .01) but not in the 2013 or 2014 cohort’s first year of participation (–$13 per beneficiary [95% CI, –$33 to $6]; P = .19; and $4 per beneficiary [95% CI, –$15 to $24]; P = .66). Estimates were similar for ACOs with and without financial ties to hospitals. Participation in the MSSP was not associated with significant changes in 30-day readmissions, use of highly rated SNFs, or mortality.Conclusions and RelevanceParticipation in the MSSP has been associated with significant reductions in postacute spending without ostensible deterioration in quality of care. Spending reductions were more consistent with clinicians working within hospitals and SNFs to influence care for ACO patients than with hospital-wide initiatives by ACOs or use of preferred SNFs.

Accountable Care Organizations and Prostate Cancer Care

IntroductionAccountable care organizations have the potential to increase the value of health care by improving population health and enhancing financial stewardship. How practice context modifies effects on a specialty focused disease, such as prostate cancer care, has implications for their success. MethodsWe performed a retrospective cohort study of newly diagnosed men with prostate cancer between 2012 and 2013 using national Medicare data. Practice affiliation (small single specialty, large single specialty, multispecialty groups) and accountable care organization alignment were measured at the patient level. Generalized linear multivariable models were fitted to derive adjusted rates of treatment and spending for the 12-month period after diagnosis according to accountable care organization alignment and practice affiliation. ResultsOf 15,640 patients with newly diagnosed prostate cancer 1,100 (7.0%) were aligned with accountable care organizations. Patients in these organizations had use of curative treatment similar to that of those not in accountable care organizations (71.4% vs 70.0%, respectively, p=0.33), which did not vary with practice affiliation (p=0.39). Adjusted spending was higher among patients in accountable care organizations ($20,916 vs $19,773, p=0.03). However, this relationship was independent of practice affiliation (p=0.90). Higher accountable care organization penetration within a practice was associated with increased spending (p <0.05) but not with treatment (p=0.87). ConclusionsPatients with prostate cancer aligned with accountable care organizations had similar rates of treatment but increased spending in the year after diagnosis. These findings were similar across practice affiliations. Better specialist engagement by accountable care organizations may be necessary for them to alter practice patterns for specialty care.

Era of a Single Population-Based Payment to a Cancer Center: Delivering the Value of Interventional Oncology in Accountable Care Organizations.

To curtail increasing health care costs, the government has ushered in the era of the Accountable care organization (ACO). The purposes of this review are to evaluate the effects the ACO will have on the practice of interventional oncology and its role in cancer care and to explore methods to assimilate. Proposed action points include integration into the modern-day cancer center, adoption of an outpatient clinic, mandatory performance measures, and workflow and cost analysis. If adaptations are made, interventional oncology can continue its role in cancer treatment, will provide more effective care, and reach more patients in the new ACO.

Improving performance of an accountable care organization on a quality measure assessing β-blocker use in systolic heart failure.

The implementation and outcomes are described for a clinical pharmacist-generated initiative to improve the performance of a Medicare Pioneer accountable care organization (ACO) quality measure evaluating the percentage of patients at least 18 years of age with heart failure and a left ventricular ejection fraction (LVEF) of less than 40% who are prescribed with an evidence-based β-blocker (carvedilol, metoprolol succinate, or bisoprolol). Atrius Health clinical pharmacists developed several educational documents to facilitate appropriate prescribing of evidence-based therapies in patients with heart failure. After educating clinicians, clinical pharmacists reviewed patient charts to determine eligibility for initiating or switching to evidence-based β-blocker therapy. Medicare Pioneer ACO patients 18-85 years of age with heart failure and a current or prior LVEF of less than 40% were reviewed. Patients had a current prescription for metoprolol tartrate, atenolol, or no β-blocker. Patients were considered ineligible if they had a documented contraindication or intolerance to β-blocker therapy or were clinically unstable. Recommendations to initiate or switch to an appropriate β-blocker were sent electronically by a clinical pharmacist to an eligible patient's treating physician before a scheduled office visit. In approximately three months, 48 patients underwent chart review by a clinical pharmacist. Performance improved by 8% after the implementation, with 82% of eligible patients achieving the quality measure in 2014-an increase from 74% in 2013. The performance on a Medicare Pioneer ACO quality measure evaluating β-blocker use in systolic heart failure improved in a one-year period after a clinical pharmacist-generated initiative was implemented at Atrius Health practice sites.

The volunteer's dilemma and alternate solutions for ensuring responsibility within accountable care organizations

ABSTRACTThe emphasis on accountable care organizations (ACOs) in recent health care reform increases the potential for social dilemmas such as the volunteer's dilemma within networks of providers who collectively share responsibility for a patient population. Providers in an ACO often receive financial incentives based on how well the group performs in defined quality measures. Care interventions may be indicated for certain patients, such as postdischarge follow-up to prevent readmission. However, the providers conducting the interventions may be unreliable if they vary in their belief in the intervention's effectiveness. We characterize such potential for care coordination failures as instability of an asymmetric equilibrium, illustrated by an example in which ACO patients would benefit from interventions to prevent readmission but individual providers or care teams do not perceive sufficient value in conducting the intervention. We then propose three economic mechanisms that can help ensure that patients receive indicated interventions, illustrate the impact of each with an example, and explore conditions that lead to significant improvements in overall utility.