Shared Savings Program Accountable Care Research Articles

Consumer Assessment of Healthcare Providers and Systems Among Racial and Ethnic Minority Patients With Alzheimer Disease and Related Dementias

Consumer Assessment of Healthcare Providers and Systems (CAHPS) measures have been used widely to measure patient-centered care. Evidence is needed to understand CAHPS measures among racial and ethnic minority patients with Alzheimer disease and related dementias (ADRD). To examine racial and ethnic disparities in CAHPS among patients with ADRD and to examine the association between social determinants of health and CAHPS disparities. This study focused on patients with ADRD who were enrolled in Medicare Shared Savings Program Accountable Care Organizations (ACOs). The primary data sets were the 2017 Medicare Beneficiary Summary File and the beneficiary-level ACO data. The study population was limited to community-based beneficiaries who had a diagnosis of ADRD and were aged 65 years and older. Cross-sectional analyses and the decomposition approach were implemented. Data were analyzed from November 2021 to July 2022. Enrollment in a Medicare Shared Savings Program ACO. Six ACO CAHPS measures were included: getting timely care, appointments, and information; how well providers communicate; patients' rating of provider; access to specialists; health promotion and education; and shared decision-making. ACO CAHPS were continuous measures with possible ranges from 0 to 100. The summation of these 6 measures as an overall index was also created. In CAHPS measures, the term provider can include hospitals, home health care agencies, and doctors, among others. The final sample included 568 368 beneficiaries (347 783 female patients [61.2%]; 38 030 African American patients [6.69%], 6258 Asian patients [1.10%], 18 231 Hispanic patients [3.21%], and 505 849 White patients [89.0%]; mean [SD] age, 82.17 [7.95] years). Significant racial and ethnic disparities in CAHPS scores were observed. After controlling for beneficiary, hospital, and area characteristics, compared with their White counterparts, African American or Black (coefficient = -1.05; 95% CI, -1.15 to -0.95; P < .001), Asian (coefficient = -0.414; 95% CI, -0.623 to -0.205; P < .001), and Hispanic (coefficient = -0.099; 95% CI, -0.229 to 0.032; P = .14) patients with ADRD reported lower total CAHPS scores. Disparities were also observed among individual ACO CAHPS. Decomposition results showed that a proxy for social determinants of health explained 10% to 13% of disparities of ACO CAHPS between African American or Black vs White and Hispanic vs White patients with ADRD. Most of the racial and ethnic disparities, especially those between White and Asian individuals, could not be explained by the models used to analyze data. These results demonstrated significant variations in CAHPS by race and ethnicity among patients with ADRD enrolled in ACOs. Social determinants of health are critical in explaining racial and ethnic disparities. More research is needed to explain disparities in CAHPS.

An analysis of Medicare accountable care organization expense reports.

To understand the investments that Medicare Shared Savings Program accountable care organizations (ACOs) in the ACO Investment Model (AIM) made to participate in the program and the costs that they incurred as a result of their efforts to lower spending and improve quality. We conducted a systematic review and categorization of all available and approved quarterly expenses reported by AIM ACOs. We reviewed final approved quarterly expense reports submitted by ACOs detailing how they spent funds in the quarter. All distinct line-item descriptions were classified into a more informative and consistent set of categories. We then applied higher conceptual dimensions (type of care input and type of ACO strategy) to these newly categorized expenses to facilitate additional analysis of spending patterns. AIM ACOs reported expenses of $264.8 million over the 3 performance years (2016-2018). The majority of the $264.8 million in expenditures was incurred for personnel (55.5%), followed by infrastructure (22.3%), management firm expenses (15.3%), and internal programs and systems (6.9%). The dominant identifiable ACO strategy was care coordination and management, accounting for 52.9% of related ACO expenses. AIM ACOs invested most heavily in personnel, information technology, and care management, with less than half of the investments explicitly tied to a strategy for improving quality or reducing spending. Efforts to change clinician practice patterns, alter the way patients access the health care system, and institute other practice redesigns were not primary targets for investment.

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.

Evolving Radiologist Participation in Medicare Shared Savings Program Accountable Care Organizations.

The aim of this study was to temporally characterize radiologist participation in Medicare Shared Savings Program (MSSP) accountable care organizations (ACOs). Using CMS Physician and Other Supplier Public Use Files, ACO provider-level Research Identifiable Files, and Shared Savings Program ACO Public-Use Files for 2013 through 2018, characteristics of radiologist ACO participation were assessed over time. Between 2013 and 2018, the percentage of Medicare-participating radiologists affiliated with MSSP ACOs increased from 10.4% to 34.9%. During that time, the share of large ACOs (>20,000 beneficiaries) with participating radiologists averaged 87.0%, and the shares of medium ACOs (10,000-20,000) and small ACOs (<10,000) with participating radiologists rose from 62.5% to 66.0% and from 26.3% to 51.6%, respectively. The number of physicians in MSSP ACOs with radiologists was substantially larger than those without radiologists (mean range across years, 573-945 versus 107-179). Primary care physicians constituted a larger percentage of the physician population for ACOs without radiologists (average across years, 66.3% versus 38.5%), and ACOs with radiologists had a higher rate of specialist representation (56.0% versus 33.7%). Beneficiary age, race, and sex demographics were similar among radiologist-participating versus nonparticipating ACOs. In recent years, radiologist participation in MSSP ACOs has increased substantially. ACOs with radiologist participation are large and more diverse in their physician specialty composition. Nonparticipating radiologists should prepare accordingly.

Transitional care management visits to improve coordination of care.

This report aimed to determine whether transitional care management (TCM) services, provided by Inspira Care Connect, LLC (ICC), a Track 1 Medicare Shared Savings Program accountable care organization, were effective in reducing 30-day readmission rates, observation stay days, and emergency department visits, along with mortality rates, total costs, and frequency of primary care physician (PCP) visits among Medicare beneficiaries served by ICC. In accordance with TCM programming, ICC contacted the majority of patients telephonically within 48business hours after discharge from an inpatient setting and scheduled a face-to-face visit with the patient's PCP within 1 to 14 days after discharge from an inpatient setting. The patients were provided with non-face-to-face services as needed throughout the 30-day period. The effectiveness of the TCM model was measured using a retrospective propensity score matching design, which allowed for an accurate comparison between those who received TCM and similar ICC Medicare beneficiaries who did not. The analysis utilized Medicare parts A and B claims from January 1, 2016, to December 31,2017. Patients who received TCM had lower 30-day readmission rates than those who did not (P < .05). The services provided to ICC Medicare patients through the TCM model may have enhanced the ability to identify problems at an earlier stage, resulting in the prevention of complications and unnecessary utilization of costly health care services.

Longitudinal participation in delivery and payment reform programs among US Primary Care Organizations.

To assess longitudinal primary care organization participation patterns in large-scale reform programs and identify organizational characteristics associated with multiprogram participation. Secondary data analysis of national program participation data over an eight-year period (2009-2016). We conducted a retrospective, observational study by creating a unique set of data linkages (including Medicare and Medicaid Meaningful Use and Medicare Shared Savings Program Accountable Care Organization (MSSP ACO) participation from CMS, Patient-Centered Medical Home (PCMH) participation from the National Committee for Quality Assurance, and organizational characteristics) to measure longitudinal participation and identify what types of organizations participate in one or more of these reform programs. We used multivariate models to identify organizational characteristics that differentiate those that participate in none, one, or two-to-three programs. We used Medicare claims to identify organizations that delivered primary care services (n=56,287) and then linked organizations to program participation data and characteristics. No program achieved more than 50% participation across the 56,287 organizations in a given year, and participation levels flattened or decreased in later years. 36% of organizations did not participate in any program over the eight-year study period; 50% participated in one; 13% in two; and 1% in all three. 14.31% of organizations participated in five or more years of Meaningful Use while 3.84% of organizations participated in five years of the MSSP ACO Program and 0.64% participated in at least five years of PCMH. Larger organizations, those with younger providers, those with more primary care providers, and those with larger Medicare patient panels were more likely to participate in more programs. Primary care transformation via use of voluntary programs, each with their own participation requirements and approach to incentives, has failed to broadly engage primary care organizations. Those that have chosen to participate in multiple programs are likely those already providing high-quality care.

Association between specialist compensation and Accountable Care Organization performance.

To determine if Medicare Shared Savings Program Accountable Care Organizations (ACOs) using cost reduction measures in specialist compensation demonstrated better performance. National, cross-sectional survey data on ACOs (2013-2015) linked to public-use data on ACO performance (2014-2016). We compared characteristics of ACOs that did and did not report use of cost reduction measures in specialist compensation and determined the association between using this approach and ACO savings, outpatient spending, and specialist visit rates. Of 160 ACOs surveyed, 26 percent reported using cost reduction measures to help determine specialist compensation. ACOs using cost reduction in specialist compensation were more often physician-led (68.3 vs 49.6 percent) and served higher-risk patients (mean Hierarchical Condition Category score 1.09 vs 1.05). These ACOs had similar savings per beneficiary year (adjusted difference $82.6 [95% CI -77.9, 243.1]), outpatient spending per beneficiary year (-24.0 [95% CI -248.9, 200.8]), and specialist visits per 1000 beneficiary years (369.7 [95% CI -9.3, 748.7]). Incentivizing specialists on cost reduction was not associated with ACO savings in the short term. Further work is needed to determine the most effective approach to engage specialists in ACO efforts.

Review of “Association Between Hospital Participation in Medicare Shared Savings Program Accountable Care Organizations and Readmission Following Major Surgery” by Borza T et al in Ann Surg 269:873–878, 2019

Review of “Association Between Hospital Participation in Medicare Shared Savings Program Accountable Care Organizations and Readmission Following Major Surgery” by Borza T et al in Ann Surg 269:873–878, 2019

Association Between Specialist Office Visits and Health Expenditures in Accountable Care Organizations

Accountable care organizations (ACOs) aim to control health expenditures while improving quality of care. Primary care has been emphasized as a means to reduce spending, but little is known about the implications of using specialists for achieving this ACO objective. To examine the association between ACO-beneficiary office visits conducted by specialists and the cost and utilization outcomes of those visits. This cross-sectional study obtained data on 620 distinct ACOs from the Centers for Medicare & Medicaid Services Shared Savings Program Accountable Care Organizations Public-Use Files from April 1, 2012, to September 30, 2017. Generalized estimating equation models were used for analysis of ACOs, adjusting for ACO-beneficiary health status, Medicare enrollment groups, ACO size, and proportion of participating specialists. Specialist encounter proportion, the percentage of office visits provided by a specialist, was categorized into 7 discrete groups: less than 35%, 35% to less than 40%, 40% to less than 45% (reference group), 45% to less than 50%, 50% to less than 55%, 55% to less than 60%, and 60% or greater. The primary outcome was total expenditures (given in US dollars) per assigned beneficiary person-year. The secondary outcomes were total numbers of emergency department visits, hospital discharges, skilled nursing facility discharges, and magnetic resonance imaging orders. In total, the data set included 1836 ACO-year (number of participation years per ACO) observations for 620 distinct ACOs. Those ACOs with a specialist encounter proportion of 40% to less than 45% had $1129 (95% CI, $445-$1814) lower per-beneficiary person-year spending than did ACOs in the lowest specialist encounter proportion group and had $752 (95% CI, $115-$1389) lower per-beneficiary person-year spending compared with ACOs in the highest specialist encounter proportion group. Monotonic decreases in emergency department visits, hospital discharges, and skilled nursing facility discharges were observed with increasing specialist encounter proportion. Conversely, monotonic increases in magnetic resonance imaging volume discharges were observed with increasing specialist encounter proportion. These findings suggest that an ACO's ability to reduce spending may require sufficient involvement in care processes from specialists, who seem to complement the intrinsic primary care approach in ACOs.

Association Between Hospital Participation in Medicare Shared Savings Program Accountable Care Organizations and Readmission Following Major Surgery.

To evaluate the effect of Medicare Shared Savings Program accountable care organizations (ACOs) on hospital readmission after common surgical procedures. Hospital readmissions following surgery lead to worse patient outcomes and wasteful spending. ACOs, and their associated hospitals, have strong incentives to reduce readmissions from 2 distinct Centers for Medicare and Medicaid Services policies. We performed a retrospective cohort study using a 20% national Medicare sample to identify beneficiaries undergoing 1 of 7 common surgical procedures-abdominal aortic aneurysm repair, colectomy, cystectomy, prostatectomy, lung resection, total knee arthroplasty, and total hip arthroplasty-between 2010 and 2014. The primary outcome was 30-day risk-adjusted readmission rate. We performed difference-in-differences analyses using multilevel logistic regression models to quantify the effect of hospital ACO affiliation on readmissions following these procedures. Patients underwent a procedure at one of 2974 hospitals, of which 389 were ACO affiliated. The 30-day risk-adjusted readmission rate decreased from 8.4% (95% CI, 8.1-8.7%) to 7.0% (95% CI, 6.7-7.3%) for ACO affiliated hospitals (P < 0.001) and from 7.9% (95% CI, 7.8-8.0%) to 7.1% (95% CI, 6.9-7.2%) for non-ACO hospitals (P < 0.001). The difference-in-differences of the 2 trends demonstrated an additional 0.52% (95% CI, 0.97-0.078%) absolute reduction in readmissions at ACO hospitals (P = 0.021), which would translate to 4410 hospitalizations avoided. Readmissions following common procedures decreased significantly from 2010 to 2014. Hospital affiliation with Shared Savings ACOs was associated with significant additional reductions in readmissions. This emphasis on readmission reduction is 1 mechanism through which ACOs improve value in a surgical population.

ACOs' Impact on Hospitalization Rates of Rural Older Adults With Diabetes: Early Indications.

The purpose of this study was to examine the impact of Medicare Shared Savings Program Accountable Care Organizations (SSP ACOs), along with other factors, on diabetes-related hospitalization rates for rural older adults. Using an early year of the SSP ACO program, we conducted multiple linear regressions to examine the effect of ACO participation on African American and white older adults. In neither model was ACO affiliation found to have a statistically significant impact on diabetes-related hospitalization rates. This study provides baseline measures for patient outcomes during the initial years of ACO formation.

Variation in prostate cancer treatment and spending among Medicare shared savings program accountable care organizations.

Accountable care organizations (ACOs) have been shown to reduce prostate cancer treatment among men unlikely to benefit because of competing risks (ie, potential overtreatment). This study assessed whether the level of engagement in ACOs by urologists affected rates of treatment, overtreatment, and spending. A 20% sample of national Medicare data was used to identify men diagnosed with prostate cancer between 2012 and 2014. The extent of urologist engagement in an ACO, as measured by the proportion of patients in an ACO managed by an ACO-participating urologist, served as the exposure. The use of treatment, potential overtreatment (ie, treatment in men with a ≥75% risk of 10-year noncancer mortality), and average payments in the year after diagnosis for each ACO were modeled. Among 2822 men with newly diagnosed prostate cancer, the median rates of treatment and potential overtreatment by an ACO were 71.3% (range, 23.6%-79.5%) and 53.6% (range, 12.4%-76.9%), respectively. Average Medicare payments among ACOs in the year after diagnosis ranged from $16,523.52 to $34,766.33. Stronger urologist-ACO engagement was not associated with treatment (odds ratio, 0.87; 95% confidence interval, 0.6-1.2; P = .4) or spending (9.7% decrease in spending; P = .08). However, urologist engagement was associated with a lower likelihood of potential overtreatment (odds ratio, 0.29; 95% confidence interval, 0.1-0.86; P = .03). ACOs vary widely in treatment, potential overtreatment, and spending for prostate cancer. ACOs with stronger urologist engagement are less likely to treat men with a high risk of noncancer mortality, and this suggests that organizations that better engage specialists may be able to improve the value of specialty care. Cancer 2018. © 2018 American Cancer Society.

Distribution of Visits for Chronic Conditions Between Primary Care and Specialist Providers in Medicare Shared Savings Accountable Care Organizations.

Medicare Shared Savings Program Accountable Care Organizations (ACOs) may focus more on primary care given ACO financial incentives. We examine variation in primary care treatment of 8 prevalent chronic conditions across ACOs and the factors affecting the variation, and compare the role of primary care in ACOs and non-ACOs. We conduct regression models at the ACO-level to identify factors predicting higher proportions of chronic condition visits delivered by primary care providers (PCPs) using 2013 Medicare claims and enrollment data. We compare the distribution of visits to PCPs, specialists and advanced practice providers between ACO-attributed and non-ACO-attributed beneficiaries. At the ACO-level, the proportion of patients who are white and of the local population who are college educated, the complexity of the patient population, and the supply of specialists were negatively associated with the proportion of chronic condition visits delivered by PCPs, whereas the percentage of contracted physicians within the ACO who were PCPs was positively associated. These results varied when subanalyses were conducted for each specific chronic condition. ACO care for chronic conditions was managed similar to that of care for non-ACO Medicare beneficiaries in 2013, but that some ACOs utilize PCPs to manage chronic conditions more than others. Many ACOs may underutilize PCPs, and thus could actively shift care to less expensive primary care for potential savings to payers. Barriers to that shift could include low numbers of PCPs contracted in the ACO, and existing referral patterns and patient relationships with specialists.

Advanced Imaging Utilization and Cost Savings Among Medicare Shared Savings Program Accountable Care Organizations: An Initial Exploratory Analysis

IntroductionThe purpose of this study was to explore associations between CT and MRI utilization and cost savings achieved by Medicare Shared Savings Program (MSSP)-participating accountable care organizations (ACOs). MethodsSummary data were obtained for all MSSP-participating ACOs (n = 214 in 2013; n = 333 in 2014). Multivariable regressions were performed to assess associations of CT and MRI utilization with ACOs’ total savings and reaching minimum savings rates to share in Medicare savings. ResultsIn 2014, 54.4% of ACOs achieved savings, meeting minimum rates to share in savings in 27.6%. Independent positive predictors of total savings included beneficiary risk scores (β = +20,265,720, P = .003) and MRI events (β = +19,964, P = .018) but not CT events (β = +2,084, P = .635). Independent positive predictors of meeting minimum savings rates included beneficiary risk scores (odds ratio = 2108, P = .001) and MRI events (odds ratio = 1.008, P = .002), but not CT events (odds ratio = 1.002, P = .289). Measures not independently associated with savings were total beneficiaries; beneficiaries’ gender, age, race or ethnicity; and Medicare enrollment type (P > .05). For ACOs with 2013 and 2014 data, neither increases nor decreases in CT and MRI events between years were associated with 2014 total savings or meeting savings thresholds (P ≥ .466). ConclusionHigher MRI utilization rates were independently associated with small but significant MSSP ACO savings. The value of MRI might relate to the favorable impact of appropriate advanced imaging utilization on downstream outcomes and other resource utilization. Because MSSP ACOs represent a highly select group of sophisticated organizations subject to rigorous quality and care coordination standards, further research will be necessary to determine if these associations are generalizable to other health care settings.

Recent Evidence on the Inclusion of Hospice and Palliative Care Physicians in Medicare Shared Savings Program Accountable Care Organization Networks

To document the presence of hospice and palliative physicians in Medicare Shared Savings Program (MSSP) ACOs. End-of-life care exhibits extreme variation in quality, cost, and patient experience. This baseline creates opportunities for improvements that would be financially rewarded in the new value-based reimbursement environment, such as the accountable care organization (ACO) model. Little is known about how ACOs have responded to this opportunity by including hospice and palliative providers in their formal provider networks. This is a cross-sectional analysis of 2014 MSSP ACO provider networks assessing inclusion of a hospice or palliative physician. This study included MSSP ACO provider networks. Approximately three-quarters of MSSP ACOs did not formally contract with a hospice or palliative care physician in 2014. Inclusion of a hospice or palliative physician was associated with other specialists that commonly refer to hospice and palliative care, such as oncologists. By rewarding innovation that lowers expenditures, the ACO model encourages attention to care that exhibits high variation and expense. Both hospice and palliative care have been shown to reduce costs and improve the patient experience, making them potentially powerful tools in an ACO's arsenal. However, the MSSP ACO model has not emphasized care of seriously and terminally ill individuals, and thus it is not surprising that there has been consistently low inclusion of hospice and palliative care physicians in MSSP provider networks.

Early effect of Medicare Shared Savings Program accountable care organization participation on prostate cancer care.

Accountable care organizations (ACOs) can improve prostate cancer care by decreasing treatment variations (ie, avoidance of treatment in low-value settings). Herein, the authors performed a study to understand the effect of Medicare Shared Savings Program ACOs on prostate cancer care. Using a 20% Medicare sample, the authors identified men with newly diagnosed prostate cancer from 2010 through 2013. Rates of treatment, potential overtreatment (ie, treatment in men with a ≥75% chance of 10-year mortality from competing risks), and Medicare payments were measured using regression models. The impact of ACO participation was assessed using difference-in-differences analyses. Before implementation of ACOs, the treatment rate was 71.8% (95% confidence interval [95% CI], 70.2%-73.3%) for ACO-aligned beneficiaries and 72.3% (95% CI, 71.7%-73.0% [P = .51]) for non-ACO-aligned beneficiaries. After implementation, this rate declined to 68.4% (95% CI, 66.1%-70.7% [P = .017]) for ACO-aligned beneficiaries and 69.3% (95% CI, 68.5%-70.1% [P<.001]) for non-ACO-aligned beneficiaries. There was no differential effect noted for ACO participation. The rate of potential overtreatment decreased from 48.2% (95% CI, 43.1%-53.3%) to 40.2% (95% CI, 32.4%-48.0% [P = .087]) for ACO-aligned beneficiaries and increased from 44.3% (95% CI, 42.1%-46.5%) to 47.0% (95% CI, 44.5%-49.5% [P = .11]) for non-ACO-aligned beneficiaries. These changes resulted in a significant relative decrease in overtreatment of 17% for ACO-aligned beneficiaries (difference-in-differences, 10.8%; P = .031). Payments were not found to be differentially affected by ACO alignment. The treatment of prostate cancer and annual payments decreased significantly between 2010 and 2013, but ACO participation did not appear to impact these trends. Among men least likely to benefit, Medicare Shared Savings Program ACO alignment was associated with a significant decline in prostate cancer treatment. Cancer 2018;124:563-70. © 2017 American Cancer Society.

Does Patient-Centered Medical Home Recognition Relate to Accountable Care Organization Participation?

As of April 2015, less than 10% of Medicare Shared Savings Program Accountable Care Organizations (MSSP ACOs) included Rural Health Clinics (RHCs). In order to understand why RHCs are not participating in this ACO model in greater numbers, this study examined the influence of several factors on ACO participation. Data for this study were collected via a survey distributed during the summers of 2012, 2013, and 2014 to all RHCs in 9 states. This study had a cross-sectional design using survey research. The unit of analysis was the RHC; the total sample size was 178. This study found that those respondents who reported knowing very little about ACOs had the lowest "willingness to join an ACO" score and that the passage of time increased RHC willingness to join an ACO. Also, patient-centered medical home (PCMH) recognition was the most influential factor related to an RHC's adopting the ACO model. If ACO model adoption is to increase in rural areas, this study suggests that strategies would need to include methods for (1) targeting RHCs that have PCMH recognition; (2) increasing PCMH recognition in rural areas; and (3) increasing RHC knowledge about what an ACO is, how the model works, and why this model may benefit RHCs and other rural primary care providers.

Primary care focus and utilization in the Medicare shared savings program accountable care organizations

BackgroundAlthough Accountable Care Organizations (ACOs) are defined by the provision of primary care services, the relationship between the intensity of primary care and population-level utilization and costs of health care services has not been examined during early implementation of Medicare Shared Savings Program (MSSP) ACOs. Our objective was to evaluate the association between primary care focus and healthcare utilization and spending in the first performance period of the Medicare Shared Savings Program (MSSP) Accountable Care Organizations (ACOs).MethodsIn this retrospective cohort study, we divided the 220 MSSP ACOs into quartiles of primary care focus based on the percentage of all ambulatory evaluation and management services delivered by a PCP (internist, family physician, or geriatrician).Using multivariable regression, we evaluated rates of utilization and spending during the initial performance period, adjusting for the percentage of non-white patients, region, number of months enrolled in the MSSP, number of beneficiary person years, percentage of dual eligible beneficiaries and percentage of beneficiaries over the age of 74.ResultsThe proportion of ambulatory evaluation and management services delivered by a PCP ranged from <38% (lowest quartile, ACOs with least PCP focus) to >46% (highest quartile, ACOs with greatest PCP focus). ACOs in the highest quartile of PCP focus had higher adjusted rates of utilization of acute care hospital admissions (328 per 1000 person years vs 292 per 1000 person years, p = 0.01) and emergency department visits (756 vs 680 per 1000 person years, p = 0.02) compared with ACOs in the lowest quartile of PCP focus. ACOs in the highest quartile of PCP focus achieved no greater savings per beneficiary relative to their spending benchmarks ($142 above benchmark vs $87 below benchmark, p = 0.13).ConclusionsPrimary care focus was not associated with increased savings or lower utilization of healthcare during the initial implementation of MSSP ACOs.

Impact of Medicare Shared Savings Program Accountable Care Organizations at Screening Mammography: A Retrospective Cohort Study.

Materials and Methods Institutional review board approval was waived, as the study used publicly available unidentifiable data. Medicare data were retrospectively obtained for participating ACOs from 2012 to 2014. Baseline information and the ACO-20 measure (percentage of women aged 40-69 years who underwent screening mammography within 24 months) were obtained. Negative binomial regression models were used to evaluate baseline and longitudinal mammography use, with stratified analyses performed for year of entry into the ACO, number of beneficiaries, and geographic region. Results A total of 333 ACOs with 5 329 831 Medicare beneficiaries (mean size, 16 006 beneficiaries) participated in the MSSP. Screening use varied across ACOs (median, 63.0%; range, 8.8%-90.3%), with differences found across regions (use was highest in the Midwest [66.6%] and lowest in the South [58.2%], P = .038). A total of 208 ACOs reported longitudinal outcomes, with mean change in screening mammography use of +2.6% (range, -33.2% to +42.2%), with 128 (61.6%) ACOs reporting improvements (incidence rate ratio, 1.04; 95% confidence interval: 1.02, 1.07) (P = .002). No longitudinal differences in use were seen across regions (P = .078), year of entry (P = .902), number of beneficiaries (P = .814), or total composite quality score (P = .324), nor was there a difference between ACOs that saved money and those that did not (P = .391). Conclusion ACOs in the MSSP have produced small significant improvements in screening mammography use. © RSNA, 2016.

Urologist Participation in Medicare Shared Savings Program Accountable Care Organizations (ACOs)

To understand the current role of urologists in Medicare Shared Savings Program (MSSP) Accountable Care Organizations (ACOs) and the organizational characteristics of ACOs with participating urologists. Using 2012-2013 Medicare data and the National Provider Identifier Database, we classified each urologist in the U.S. and Puerto Rico as either an MSSP ACO participant or nonparticipating provider. We then examined the distribution of ACO-participating urologists across the U.S. and among the first 220 MSSP ACOs. We also compared the characteristics of ACOs with and without participating urologists. Among 11,084 identified urologists, 1118 (10%) were MSSP ACO participants. ACO-participating urologists practiced more frequently in the Northeast and Midwest (P < .001), and were more commonly female (10% vs 8%, P = .003). At an organizational level, only 110 (50%) of the initial MSSP ACOs included at least one urologist; among this group, the number of participating urologists ranged from 1 to 55. ACOs with one or more participating urologist were larger organizations, with respect to both the number of assigned beneficiaries and the number of providers per 1000 beneficiaries (P < .001 for each comparison). The patient populations served by ACOs with and without urologists were similar (P > .05 for each comparison). A modest percentage of urologists participate in MSSP ACOs, although many of these organizations still lack any formal involvement by urological surgeons. Without such participation, improving the coordination, quality, and cost of urologic care for Medicare beneficiaries may be more challenging.