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1.
JAMA Health Forum ; 5(3): e240126, 2024 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-38488778

RESUMO

Importance: The Medicare Shared Savings Program (MSSP) includes more than 400 accountable care organizations (ACOs) and is among the largest and longest running value-based payment efforts in the US. However, given recent program reforms and other changes in the health care system, the experiences and perspectives of ACO leaders remain incompletely characterized. Objective: To understand the priorities, strategies, and challenges of ACO leaders in MSSP. Design, Setting, and Participants: In this qualitative study, interviews were conducted with leaders of 49 ACOs of differing sizes, leadership structures, and geographies from MSSP between September 29 and December 29, 2022. Participants were asked about their clinical and care management efforts; how they engaged frontline clinicians; the process by which they distributed shared savings and added or removed practices; and other factors that they believed influenced their success or failure in the program. Main Outcomes and Measures: Leader perspectives on major themes related to ACO initiatives, performance improvement, and the recruitment, engagement, and retention of clinicians. Results: Of the 49 ACOs interviewed, 34 were hospital-associated ACOs (69%), 35 were medium or large (>10 000 attributed beneficiaries) (71%), and 17 were rural (35%). The ACOs had a mean (SD) tenure of 8.1 (2.1) years in MSSP. Five major themes emerged: (1) ACO leaders reported a focus on annual wellness visits, coding practices, and care transitions; (2) leaders used both relationship-based and metrics-based strategies to promote clinician engagement; (3) ACOs generally distributed half or more of shared savings to participating practices; (4) ACO recruitment and retention efforts were increasingly influenced by market competition; and (5) some hospital-associated ACOs faced misaligned incentives. Conclusions and Relevance: In this study, the ACO leaders reported varied approaches to promoting clinician alignment with ACO goals, an emphasis on increasing annual wellness visits, and new pressures related to growth of other care models. Policymakers hoping to modify or expand the program may wish to incorporate these perspectives into future reforms.


Assuntos
Organizações de Assistência Responsáveis , Idoso , Humanos , Estados Unidos , Medicare , Hospitais , Pesquisa Qualitativa , Renda
2.
Inquiry ; 61: 469580241240177, 2024.
Artigo em Inglês | MEDLINE | ID: mdl-38515280

RESUMO

The Quality Payment Program (QPP) is a Medicare value-based payment program with 2 tracks: -Advanced Alternative Payment Models (A-APMs), including two-sided risk Accountable Care Organizations (ACOs), and Merit-based Incentive Payment System (MIPS). In 2020, A-APM eligible ACO clinicians received an additional 5% positive, and MIPS clinicians received up to 5% negative or 2% positive performance-based adjustments to their Medicare Part B medical services payments. It is unclear whether the different payment adjustments have differential impacts on total medical services payments for ACO and MIPS participants. We compare Medicare Part B medical services payments received by primary care clinicians participating in ACO and MIPS programs using Medicare Provider Utilization and Payment Public Use Files from 2014 to 2018 using difference-in-differences regressions. We have 254 395 observations from 50 879 unique clinicians (ACO = 37.86%; MIPS = 62.14%). Regression results suggest that ACO clinicians have significantly higher Medicare Part B medical services payments ($1003.88; 95% CI: [579.08, 1428.69]) when compared to MIPS clinicians. Our findings suggest that ACO clinicians had a greater increase in medical services payments when compared to MIPS clinicians following QPP participation. Increased payments for Medicare Part B medical services among ACO clinicians may be driven partly by higher payment adjustment rates for ACO clinicians for Part B medical services. However, increased Part B medical services payments could also reflect clinicians switching to increased outpatient services to prevent potentially costly inpatient services. Policymakers should examine both aspects when evaluating QPP effectiveness.


Assuntos
Organizações de Assistência Responsáveis , Medicare Part B , Idoso , Humanos , Estados Unidos , Motivação , Assistência Ambulatorial
3.
Popul Health Manag ; 27(1): 8-12, 2024 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-38324751

RESUMO

The journey to value relies heavily on a strong foundation in population health and on supporting systems of care. However, as the Centers for Medicare & Medicaid Services and commercial insurers rethink reimbursements to achieve cost savings, both patients and payments to health care organizations are at risk. The case for value-based care is ever stronger yet health systems will have to mature their culture, population health infrastructure, technologies and analytics capabilities, and leadership and management systems. In this article, the authors describe the functional organizational structure of the clinical transformation team responsible for population health in the University Hospitals Accountable Care Organizations (ACO). Based on their experiences building and evolving population health for the University Hospitals ACO, the authors layout the 3 pillars supporting their structure, including operations, clinical design, and data and analytics, and key areas of focus for each pillar.


Assuntos
Organizações de Assistência Responsáveis , Saúde da População , Idoso , Estados Unidos , Humanos , Medicare
4.
Popul Health Manag ; 27(1): 49-54, 2024 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-38324750

RESUMO

Value-based care arrangements have been the cornerstone of accountable care for decades. Risk arrangements with government and commercial insurance plans are ubiquitous, with most contracts focusing on upside risk only, meaning payers reward providers for good performance without punishing them for poor performance on quality and cost. However, payers are increasingly moving into downside risk arrangements, bringing to mind global capitation in the 1990s wherein several health systems failed. In this article, the authors focus on their framework for succeeding in value-based arrangements at University Hospitals Accountable Care Organization, including essential structural elements that provider organizations need to successfully assume downside risk in value-based arrangements. These elements include quality performance and reporting, risk adjustment, utilization management, care management and clinical services, network integrity, technology, and contracting and financial reconciliation. Each of these elements has an important place in the strategic roadmap to value, even if downside risk is not taken. This roadmap was developed through an applied approach and intends to fill the gap in published practical models of how provider organizations can maneuver value-based arrangements.


Assuntos
Organizações de Assistência Responsáveis , Estados Unidos , Hospitais Universitários , Risco Ajustado
5.
BMC Health Serv Res ; 24(1): 69, 2024 Jan 13.
Artigo em Inglês | MEDLINE | ID: mdl-38218820

RESUMO

BACKGROUND: Post-hospitalization remote patient monitoring (RPM) has potential to improve health outcomes for high-risk patients with chronic medical conditions. The purpose of this study is to determine the extent to which RPM for patients with congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD) is associated with reductions in post-hospitalization mortality, hospital readmission, and ED visits within an Accountable Care Organization (ACO). METHODS: Nonrandomized prospective study of patients in an ACO offered enrollment in RPM upon hospital discharge between February 2021 and December 2021. RPM comprised of vital sign monitoring equipment (blood pressure monitor, scale, pulse oximeter), tablet device with symptom tracking software and educational material, and nurse-provided oversight and triage. Expected enrollment was for at least 30-days of monitoring, and outcomes were followed for 6 months following enrollment. The co-primary outcomes were (a) the composite of death, hospital admission, or emergency care visit within 180 days of eligibility, and (b) time to occurrence of this composite. Secondary outcomes were each component individually, the composite of death or hospital admission, and outpatient office visits. Adjusted analyses involved doubly robust estimation to address confounding by indication. RESULTS: Of 361 patients offered remote monitoring (251 with CHF and 110 with COPD), 140 elected to enroll (106 with CHF and 34 with COPD). The median duration of RPM-enrollment was 54 days (IQR 34-85). Neither the 6-month frequency of the co-primary composite outcome (59% vs 66%, FDR p-value = 0.47) nor the time to this composite (median 29 vs 38 days, FDR p-value = 0.60) differed between the groups, but 6-month mortality was lower in the RPM group (6.4% vs 17%, FDR p-value = 0.02). After adjustment for confounders, RPM enrollment was associated with nonsignificantly decreased odds for the composite outcome (adjusted OR [aOR] 0.68, 99% CI 0.25-1.34, FDR p-value 0.30) and lower 6-month mortality (aOR 0.41, 99% CI 0.00-0.86, FDR p-value 0.20). CONCLUSIONS: RPM enrollment may be associated with improved health outcomes, including 6-month mortality, for selected patient populations.


Assuntos
Organizações de Assistência Responsáveis , Insuficiência Cardíaca , Doença Pulmonar Obstrutiva Crônica , Humanos , Estudos Prospectivos , Hospitalização , Doença Pulmonar Obstrutiva Crônica/terapia , Doença Crônica , Insuficiência Cardíaca/terapia
6.
J Healthc Manag ; 69(1): 74-86, 2024.
Artigo em Inglês | MEDLINE | ID: mdl-38175536

RESUMO

GOALS: Of 513 accountable care organizations (ACOs) participating in the Medicare Shared Savings Program (MSSP) in 2020, 67% generated a positive shared savings of approximately $2.3 billion. This research aimed to examine their financial performance trends and drivers over time. METHODS: The unit of analysis was the ACO in each year of the study period from 2016 to 2020. The dependent variable was the ACOs' total shared savings earned annually per beneficiary. The independent variables included ACO age, risk model, clinician staffing type, and provider type (hybrid, hospital-led, or physician-led). Covariates were the average risk score among beneficiaries, payer type, and calendar year. The Centers for Medicare & Medicaid Services (CMS) public use files (PUFs) and a commercial healthcare data aggregator were the data sources. RESULTS: ACOs' earned shared savings grew annually by 35%, while the proportions of ACOs with positive shared savings grew by 21%. For 1-year increase in ACO age, an additional $0.57 of shared savings per beneficiary was observed. ACOs with two-sided risk contracting were associated with an average marginal increase of $109 in shared savings per beneficiary compared to ACOs with one-sided risk contracting. Primary care physicians were associated with the greatest increase in earned shared savings per beneficiary. In contrast, nurse practitioners/physician assistants/clinical nurse specialists were associated with a reduction in earned shared savings. Under a one-sided risk model, hospital-led ACOs were associated with $18 higher average shared savings earning per beneficiary compared to hybrid ACOs, while physician-led ACOs were associated with lower average saved shared earnings per beneficiary at -$2 compared to hybrid ACOs. Provider-type results were not statistically significant at the 5% nominal level. No statistically significant differences were observed between provider types under a two-sided risk model. PRACTICAL APPLICATIONS: For all ACO provider types, building broader primary care provider networks was correlated with positive financial results. Future research should examine whether ACOs are conducting specific preventive screenings for cancer or monitoring conditions such as diabetes, hypertension, heart disease, obesity, mental disorders, and joint disorders. Such studies may answer health policy and strategy questions about the effects of incentives for improved ACO performance in serving a healthier population.


Assuntos
Organizações de Assistência Responsáveis , Estados Unidos , Humanos , Idoso , Medicare , Instalações de Saúde , Política de Saúde , Nível de Saúde
7.
Hemodial Int ; 28(1): 6-16, 2024 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-37936554

RESUMO

Value-based primary care has reduced health care costs, improved the quality of rendered care, and enhanced the patient experience. Value-based care emphasizes prevention, outreach, follow-up, patient engagement, and comprehensive, whole-person health. Primary care Accountable Care Organizations have leveraged technology-enabled workflows, practice transformation, and cutting-edge data and analytics to achieve success. These efforts are increasingly aided by predictive modeling used in the context of patient identification and prioritization algorithms. Value-based kidney care programs can glean salient takeaways from successful value-based primary care methods and models. The kidney care community is experiencing unprecedented transformation as novel payer programs and financial models burgeon. The authors contend these efforts can be accelerated by the adoption of techniques honed in value-based primary care. To optimize value-based kidney care, though, nephrology thought leaders must transcend the archetype of value-based primary care. To do so, the nephrology community must: (1) impel behavioral change among fee-for-service adherents; (2) harness emerging policy, guidelines, and quality measures; (3) adopt innovative tools, technologies, and therapies. In aggregating lessons from value-based primary care-and leveraging novel methodologies and approaches-the kidney care community will be better equipped to achieve the quadruple aim for kidney care.


Assuntos
Organizações de Assistência Responsáveis , Insuficiência Renal Crônica , Humanos , Estados Unidos , Diálise Renal , Insuficiência Renal Crônica/terapia , Custos de Cuidados de Saúde , Atenção Primária à Saúde
9.
J Am Board Fam Med ; 36(6): 966-975, 2024 Jan 05.
Artigo em Inglês | MEDLINE | ID: mdl-37907349

RESUMO

BACKGROUND: Advance care planning (ACP), a process of sharing one's values and preferences for future medical treatments, can improve quality of life, reduce loved ones' anxiety, and decrease unwanted medical utilization and costs. Despite benefits to patients and health care systems, ACP uptake often remains low, due partially to lack of knowledge and difficulty initiating discussions. Digital tools may help reduce these barriers to entry. METHODS: We retrospectively examined data from pilot deployment of Koda Health patient-facing ACP among Houston Methodist Coordinated Care patients, for quality improvement (QI) purposes. Patients referred by nurse navigators could access Koda's digital platform, complete ACP, and share the legal documentation generated. Analyzed measures include usage rates and ACP-related decisions within the platform. RESULTS: Of eligible patients (n = 203), 52.7% voluntarily completed their plan. Engagement and completion rates were similar across demographics. Patients indicated majority preference (66.4%) toward spending the last days of life at home. Most patients indicated wanting no life-support intervention if quality of life became unacceptable (51 to 71% across 4 treatments). Life-support decisions were similar between demographic categories, excepting CPR and dialysis, wherein a greater portion of Black patients than White patients preferred at least trial intervention, rather than none. CONCLUSIONS: As an observational QI analysis, limitations include bounded geographical reach and lack of data on ACP impacts to subsequent health care utilization, which future studies will address. Findings suggest that digital health tools like Koda can effectively facilitate equitable ACP access and may help support health systems and providers in offering comprehensive ACP.


Assuntos
Organizações de Assistência Responsáveis , Planejamento Antecipado de Cuidados , Humanos , Estudos Retrospectivos , Qualidade de Vida
10.
Health Serv Res ; 59 Suppl 1: e14257, 2024 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-37963450

RESUMO

OBJECTIVE: The state of Vermont has a statewide waiver from the centers for medicare and medicaid services to allow all-payer Accountable Care Organizations (ACOs). The Vermont all-payer model (VAPM) waiver is layered upon previous reforms establishing regional community health teams (CHTs) and medical homes. The waiver is intended to incentivize healthcare value and quality and create alignment between health system payers, providers, and CHTs. The objective of this study was to examine CHT's trade-offs and preferences for health, equity, and spending and the alignment with VAPM priorities. DATA SOURCES/STUDY SETTING: Data were gathered from a survey and discrete choice experiment among CHT leadership and CHT team members of the 13 CHTs in Vermont. STUDY DESIGN: We used conditional logit models to model the choice as a function of its characteristics (attributes) and mixed logit models to analyze whether preferences for programs varied by persons and roles within CHTs. DATA COLLECTION/EXTRACTION METHODS: There were 60 respondents who completed the survey online with 14 choice tasks, with three program options in each task, for a total sample size of 2520. PRINCIPAL FINDINGS: We found that CHTs prioritized programs in the community health plan and those with quantitative evidence of effectiveness. They were less likely to choose either programs targeting racial and ethnic minorities or programs having a small effect on a large population. Preferences did not vary across individual or community attributes. Program priorities of the VAPM, especially healthcare spending, were not prioritized. CONCLUSIONS: The results suggest that the new VAPM does not automatically create system alignment: CHTs tended to prioritize local needs and voices. The statewide priorities are less important to CHTs, which have excellent internal alignment. This creates potential disconnection between state and community health goals. However, CHTs and the VAPM prioritize similar populations, indicating an opportunity to increase alignment by allowing flexible programs tailored to local needs. CHTs also prioritized programs with a strong evidence base, suggesting another potential avenue to create system alignment.


Assuntos
Organizações de Assistência Responsáveis , Medicare , Idoso , Estados Unidos , Humanos , Saúde Pública , Inquéritos e Questionários
11.
Psychiatr Serv ; 75(2): 182-185, 2024 Feb 01.
Artigo em Inglês | MEDLINE | ID: mdl-37614155

RESUMO

OBJECTIVE: This report aimed to assess how accountable care organizations (ACOs) addressed ongoing opioid use disorder treatment needs over time. METHODS: Responses from the 2018 (N=308 organizations) and 2022 (N=276) National Survey of Accountable Care Organizations (response rate=55% in both years) were used to examine changes in availability of medication for opioid use disorder (MOUD) among ACOs with Medicare and Medicaid contracts. RESULTS: The percentage of respondents offering at least one MOUD grew from 39% in 2018 to 52% in 2022 (p<0.01). MOUDs were more likely to be available in 2022 among ACOs with (vs. without) in-network substance use treatment facilities (80% vs. 33%, p<0.001). The percentage of 2022 respondents who reported offering MOUD was similar in states with high versus low opioid overdose mortality rates. CONCLUSIONS: Despite growing availability of MOUD among ACOs, nearly half reported not offering any MOUD in 2022, and the availability of MOUD did not increase with treatment need.


Assuntos
Organizações de Assistência Responsáveis , Buprenorfina , Transtornos Relacionados ao Uso de Opioides , Idoso , Humanos , Estados Unidos , Medicare , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Medicaid , Buprenorfina/uso terapêutico
12.
J Am Med Dir Assoc ; 25(1): 53-57.e2, 2024 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-38081322

RESUMO

OBJECTIVES: Under the Accountable Care Organization (ACO) model, reductions in healthcare spending have been achieved by targeting post-acute care, particularly in skilled nursing facilities (SNFs). People with Alzheimer disease and related dementias (ADRD) are frequently discharged to SNF for post-acute care and may be at particular risk for unintended consequences of SNF cost reduction efforts. We examined SNF length of stay (LOS) and outcomes among ACO-attributed and non-ACO-attributed ADRD patients. DESIGN: Observational serial cross-sectional study. SETTING AND PARTICIPANTS: Twenty percent national random sample of fee-for-service Medicare beneficiaries (2013-2017) to identify beneficiaries with a diagnosis of ADRD and with a hospitalization followed by SNF admission (n = 263,676). METHODS: Our primary covariate of interest was ACO (n = 66,842) and non-ACO (n = 196,834) attribution. Hospital readmission and death were measured for 3 time periods (<30, 31-90, and 91-180 days) following hospital discharge. We used 2-stage least squares regression to predict LOS as a function of ACO attribution, and patient and facility characteristics. RESULTS: ACO-attributed ADRD patients have shorter SNF LOS than their non-ACO counterparts (31.7 vs 32.8 days; P < .001). Hospital readmission rates for ACO vs non-ACO differed at ≤30 days (13.9% vs 14.6%; P < .001) but were similar at 31-90 days and 91-180 days. No significant difference was observed in mortality post-hospital discharge for ACO vs non-ACO at ≤30 days; however, slightly higher mortality was observed at 31-90 days (8.4% vs 8.8%; P = .002) and 91-180 days (7.6% vs 7.9%; P = .011). No significant association was found between LOS and readmission, with small effects on mortality favoring ACOs in fully adjusted models. CONCLUSIONS AND IMPLICATIONS: Being an ACO-attributed patient is associated with shorter SNF LOS but is not associated with changes in readmission or mortality after controlling for other factors. Policies that shorten LOS may not have adverse effects on outcomes for people living with dementia.


Assuntos
Organizações de Assistência Responsáveis , Demência , Humanos , Idoso , Estados Unidos , Instituições de Cuidados Especializados de Enfermagem , Medicare , Estudos Transversais , Readmissão do Paciente , Alta do Paciente
13.
Popul Health Manag ; 27(1): 55-59, 2024 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-38011716

RESUMO

Accountable care organizations (ACOs) are often tasked with helping providers to deliver care efficiently and with higher quality outcomes. For an ACO to succeed in delivering efficient care, it is important to direct resources toward patients who exhibit the greatest levels of opportunity while focusing attention toward mitigating their needs. Home-based palliative care (HBPC) services are known to address patient needs for those with serious illness while decreasing the total cost of care (TCC). In this retrospective review, ACO researchers reviewed cost, quality, and utilization patterns for 3418 beneficiaries within a Medicare Shared Saving Program approaching the end of life comparing decedents who received HBPC versus those who did not receive the service. Those individuals who received HBPC services were significantly less likely to be hospitalized (51% reduction in the HBPC group), more likely to use hospice (70% vs. 43%; P = 0.001), and their TCC was less than that of those who did not receive the service ($27,203 vs. $36,089: P = 0.0163). Although more research needs to be done to understand the specific components of care delivery that are helpful in decreasing unnecessary utilization, in this retrospective review in an accountable care population, HBPC is associated with a significant decrease in cost and utilization in a population approaching end of life.


Assuntos
Organizações de Assistência Responsáveis , Cuidados Paliativos , Idoso , Humanos , Estados Unidos , Medicare , Estudos Retrospectivos , Morte
14.
JAMA Health Forum ; 4(12): e234449, 2023 Dec 01.
Artigo em Inglês | MEDLINE | ID: mdl-38100095

RESUMO

Importance: The Medicare Shared Savings Program (MSSP) is the largest and most important alternative payment model that has been implemented by the Centers for Medicare & Medicaid Services (CMS). Its budgetary impact to CMS is not well understood. Objective: To evaluate the association between the MSSP and net savings to CMS for performance years 2013 to 2021. Design, Setting, and Participants: The economic evaluation used publicly reported data on the MSSP from April 1, 2012, to December 31, 2021, and estimates extracted from 2 prior studies. Main Outcomes and Measures: Net savings to CMS, calculated as the difference between incentive payments to MSSP accountable care organizations and gross spending reductions. Incentive payments were calculated using the publicly reported data. The association of the MSSP with gross medical spending in traditional Medicare was extracted from 2 prior studies. Spillovers of the MSSP to Medicare Advantage (MA) were estimated by evaluating how gross spending reductions from the MSSP impacted benchmark payments to MA plans. Savings from traditional Medicare and MA were then combined. Results: The MSSP was associated with net losses to traditional Medicare of between $584 million and $1.423 billion over the study period. Savings from MSSP-related reductions to MA benchmarks totaled between $4.480 billion and $4.923 billion. Across traditional Medicare and MA, the MSSP was associated with savings of between $3.057 billion and $4.339 billion. This represents approximately 0.075% of combined spending for traditional Medicare and MA over the study period. Conclusions and Relevance: This economic evaluation found that the MSSP was associated with net losses to traditional Medicare, net savings to MA, and overall net savings to CMS. The total budget impact of the MSSP to CMS was small and continues to be uncertain due to challenges in estimating the effects of the MSSP on gross spending, particularly in recent years.


Assuntos
Organizações de Assistência Responsáveis , Medicare Part C , Idoso , Estados Unidos , Humanos , Benchmarking , Orçamentos , Análise Custo-Benefício
15.
Am J Manag Care ; 29(11): 601-604, 2023 11.
Artigo em Inglês | MEDLINE | ID: mdl-37948647

RESUMO

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


Assuntos
Organizações de Assistência Responsáveis , Medicare , Idoso , Humanos , Estados Unidos , Estudos Transversais , Medicaid , Contratos , Redução de Custos
16.
PLoS One ; 18(11): e0295024, 2023.
Artigo em Inglês | MEDLINE | ID: mdl-38033169

RESUMO

The objective of this study was to determine the prevalence and predictors of testing for sexually transmitted infections (STIs) under an accountable care model of health care delivery. Data sources were claims and encounter records from the Massachusetts Medicaid and Children's Health Insurance Program (MassHealth) for enrollees aged 13 to 64 years in 2019. This cross-sectional study examines the one-year prevalence of STI testing and evaluates social determinants of health and other patient characteristics as predictors of such testing in both primary care and other settings. We identified visits with STI testing using procedure codes and primary care settings from provider code types. Among 740,417 members, 55% were female, 11% were homeless or unstably housed, and 15% had some level of disability. While the prevalence of testing in any setting was 20% (N = 151,428), only 57,215 members had testing performed in a primary care setting, resulting in an 8% prevalence of testing by primary care clinicians (PCCs). Members enrolled in a managed care organization (MCO) were significantly less likely to be tested by a primary care provider than those enrolled in accountable care organization (ACO) plans that have specific incentives for primary care practices to coordinate care. Enrollees in a Primary Care ACO had the highest rates of STI testing, both overall and by primary care providers. Massachusetts' ACO delivery systems may be able to help practices increase STI screening with explicit incentives for STI testing in primary care settings.


Assuntos
Organizações de Assistência Responsáveis , Infecções Sexualmente Transmissíveis , Estados Unidos/epidemiologia , Criança , Humanos , Feminino , Masculino , Medicaid , Estudos Transversais , Infecções Sexualmente Transmissíveis/diagnóstico , Infecções Sexualmente Transmissíveis/epidemiologia , Infecções Sexualmente Transmissíveis/prevenção & controle , Atenção Primária à Saúde
17.
Pediatrics ; 152(6)2023 Dec 01.
Artigo em Inglês | MEDLINE | ID: mdl-38013488

RESUMO

BACKGROUND AND OBJECTIVES: Children and Youth with Special Health Care Needs have high healthcare utilization, fragmented care, and unmet health needs. Accountable Care Organizations (ACOs) increasingly use pediatric care management to improve quality and reduce unnecessary utilization. We evaluated effects of pediatric care management on total medical expense (TME) and utilization; perceived quality of care coordination, unmet needs, and patient and family experience; and differential impact by payor, risk score, care manager discipline, and behavioral health diagnosis. METHODS: Mixed-methods analysis including claims using quasi-stepped-wedge design pre and postenrollment to estimate difference-in-differences, participant survey, and semistructured interviews. Participants included 1321 patients with medical, behavioral, or social needs, high utilization, in Medicaid or commercial ACOs, and enrolled in multidisciplinary, primary care-embedded care management. RESULTS: TME significantly declined 1 to 6 months postenrollment and continued through 19 to 24 months (-$645.48 per member per month, P < .001). Emergency department and inpatient utilization significantly decreased 7 to 12 months post-enrollment and persisted through 19 to 24 months (-29% emergency department, P = .012; -82% inpatient, P < .001). Of respondents, 87.2% of survey respondents were somewhat or very satisfied with care coordination, 56.1% received education coordination when needed, and 81.5% had no unmet health needs. Emergency department or inpatient utilization decreases were consistent across payors and care manager disciplines, occurred sooner with behavioral health diagnoses, and were significant among children with above-median risk scores. Satisfaction and experience were equivalent across groups, with more unmet needs and frustration with above-median risk scores. CONCLUSIONS: Pediatric care management in multipayor ACOs may effectively reduce TME and utilization and clinically provide high-quality care coordination, including education and family stress, with high participant satisfaction.


Assuntos
Organizações de Assistência Responsáveis , Medicaid , Adolescente , Estados Unidos , Humanos , Criança , Qualidade da Assistência à Saúde , Aceitação pelo Paciente de Cuidados de Saúde
18.
Health Aff (Millwood) ; 42(11): 1478-1487, 2023 11.
Artigo em Inglês | MEDLINE | ID: mdl-37931192

RESUMO

Accountable care organizations (ACOs) have become Medicare's dominant care model because policy makers believe that ACOs will improve the quality and efficiency of care for chronic conditions. Depression and anxiety disorders are the most prevalent and undertreated chronic mental health conditions in Medicare. Yet it is unknown whether ACOs influence treatment and outcomes for these conditions. To explore these questions, this longitudinal study used data from the 2016-19 Medicare Current Beneficiary Survey, linked to validated depression and anxiety symptom instruments, among diagnosed and undiagnosed fee-for-service Medicare patients with these conditions. Among patients not enrolled in ACOs at baseline, those who newly enrolled in ACOs in the following year were 24 percent less likely to have their depression or anxiety treated during the year than patients who remained unenrolled in ACOs, and they saw no relative improvements at twelve months in their depression and anxiety symptoms. Better-designed incentives are needed to motivate Medicare ACOs to improve mental health treatment.


Assuntos
Organizações de Assistência Responsáveis , Medicare , Humanos , Idoso , Estados Unidos , Estudos Longitudinais , Depressão , Saúde Mental , Medidas de Resultados Relatados pelo Paciente , Transtornos de Ansiedade
19.
JAMA Health Forum ; 4(9): e233124, 2023 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-37713209

RESUMO

Importance: As the US accelerates adoption of alternative payment through global payment models such as Accountable Care Organizations (ACOs) or Medicare Advantage (MA), high spending for cancer care is a potential target for savings. Objective: To quantify the extent to which ACOs and other risk-bearing organizations operating in a specific geographic area (hospital referral region [HRR]) could achieve savings by steering patients to efficient medical oncology practices. Design, Setting, and Participants: This observational study included serial cross-sections of Medicare beneficiaries with cancer from 2010 to 2018. Data were analyzed from August 2021 to March 2023. Main Outcomes and Measures: Total spending and spending by category in the 1-year period following an index visit for a patient with newly diagnosed (incident) or poor-prognosis cancer. Results: The incident cohort included 1 309 825 patients with a mean age of 74.0 years; the most common cancer types were breast (21.4%), lung (16.7%), and colorectal cancer (10.0%). The poor prognosis cohort included 1 429 973 (mean age, 72.7 years); the most common cancer types were lung (26.6%), lymphoma (11.7%), and leukemia (7.3%). Options for steering varied across markets; the top quartile market had 10 or more oncology practices, but the bottom quartile had 3 or fewer oncology practices. Total spending (including Medicare Part D) in the incident cohort increased from a mean of $57 314 in 2009 to 2010 to $66 028 in 2016 to 2017. Within markets, total spending for practices in the highest spending quartile was 19% higher than in the lowest quartile. Hospital spending was the single largest component of spending in both time periods ($20 390 and $19 718, respectively) followed by Part B (infused) chemotherapy ($8022 and $11 699). Correlations in practice-level spending between the first-year (2009) and second-year (2010) spending were high (>0.90 in all categories with most >0.98), but these attenuated over time. Conclusions and Relevance: These results suggest there may be opportunities for ACOs and other risk-bearing organizations to select or drive referrals to lower-spending oncology practices in many local markets.


Assuntos
Organizações de Assistência Responsáveis , Leucemia , Medicare Part D , Estados Unidos , Humanos , Idoso , Oncologia , Mama
20.
Health Care Manage Rev ; 48(4): 301-310, 2023.
Artigo em Inglês | MEDLINE | ID: mdl-37615940

RESUMO

BACKGROUND: Care coordination is central to accountable care organizations (ACOs), especially in Medicaid where many patients have complex medical and social needs. Little is known about how to best organize care coordination resources in this context, particularly whether to centralize them. We examined how care coordinators' location, management, and colocation of both (within ACO headquarters, practice sites, or other organizations) relate to care quality and coordination. METHODS: We conducted a cross-sectional analysis of surveys administered to a sample of practice sites covering all 17 Medicaid ACOs in Massachusetts ( n = 225, response rate = 64%). We applied controlled, cluster-robust regressions, adjusting the significance threshold for the number of ACO clusters, to assess how clinical information sharing across settings, care quality improvement, knowledge of social service referral, and cross-resource coordination (i.e., the ability of multiple resources to work well together) relate to where care coordinators were physically located and/or managed. RESULTS: Centralizing care coordinators at ACO headquarters was associated with greater information sharing. Embedding care coordinators in practices was associated with greater care quality improvement. Embedding coordinators at other organizations was associated with less information sharing and care quality improvement. Managing coordinators at practice sites and other organizations were associated with better care quality improvement and cross-resource coordination, respectively. Colocating the two functions showed no significant differences. PRACTICE IMPLICATIONS: Choosing care coordinators' locations may present trade-offs. ACOs may strategically choose embedding care coordinators at practice sites for enhanced care quality versus centralizing them at the ACO to facilitate information sharing.


Assuntos
Organizações de Assistência Responsáveis , Estados Unidos , Humanos , Estudos Transversais , Medicaid , Melhoria de Qualidade , Qualidade da Assistência à Saúde
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