Development and evaluation of physician-precepted advanced pharmacy practice experiences (APPEs) within an accountable care organization (ACO).

BACKGROUND AND PURPOSE: The American Council of Pharmaceutical Education (ACPE) standards emphasize that pharmacy graduates should be "practice- and team-ready," and the American Society for Health-System Pharmacists (ASHP) Task Force on accountable care organizations (ACOs) states that curricula at pharmacy schools should be evaluated and reworked to prepare students to practice effectively as members of the health care team within ACOs. The objective of this study was to describe the development of an ACO-based advanced pharmacy practice experience (APPE) rotation block, clinical activities and interventions completed by students during the experience, and perceptions of students, patients, and physician preceptors regarding the experience. EDUCATIONAL ACTIVITY AND SETTING: The rotation block was within outpatient ACO offices and consisted of a four-week rotation with one pharmacy faculty, immediately followed by a four-week elective experience in a different office with a physician serving as primary preceptor. FINDINGS: Eight students completed the rotation block between August 2017 and April 2018. Students documented a total of 1299 clinical activities and 65 interventions. Medication reconciliation and recommendations to initiate a medication were the most commonly completed activities and interventions documented. The experience was positively perceived among surveyed students, patients, and physician preceptors. SUMMARY: The rotation block was successfully implemented with a positive response from students, patients, and physician preceptors. As a result, the program has expanded in accordance with ACPE Standards to create "practice- and team-readiness" among graduates and expose students to interdisciplinary care within ACOs and other settings.

Recommended Cancer Screening in Accountable Care Organizations: Trends in Colonoscopy and Mammography in the Medicare Shared Savings Program.

PURPOSE: Accountable care organizations (ACOs) are a delivery and payment model designed to encourage integrated, high-value care. We designed a study to test the association between ACOs and two recommended cancer screening tests, colonoscopy for colorectal cancer and mammography for breast cancer. METHODS: Using the random 20% sample of Medicare claims, beneficiaries were attributed to ACO or non-ACO cohorts on the basis of providers' enrollment in the Medicare Shared Savings Program. An inverse probability of treatment weighting was used to balance patient characteristics between ACO and non-ACO cohorts. A propensity score-weighted, difference-in-differences analysis was then performed using the same provider groups in 2010-pre-ACO-as a baseline. A secondary analysis for older-nonrecommended-age ranges was performed. RESULTS: Prevalence of colonoscopy in recommended age ranges in ACOs from 2010 to 2014 increased from 15.3% (95% CI, 14.9% to 15.6%) to 17.9% (95% CI, 17.3% to 18.5%). This differed significantly from the change in non-ACOs (difference in differences, 1.2%; P < .001). Among women in ACOs, mammography prevalence rose from 53.7% (95% CI, 53.0% to 54.4%) to 54.9% (95% CI, 54.2% to 55.7%). In contrast to colonoscopy, the difference in mammography prevalence was not significantly different in ACO versus non-ACOs (difference in differences, 0.49%; P < .13). A similar pattern was also observed in older-nonrecommended-age ranges with significant difference in differences (ACO v non-ACO) in colonoscopy, but not mammography. CONCLUSION: The impact of ACOs on cancer screening varies between screening tests. Our results are consistent with a greater effect of ACOs on high-cost, high-complexity screening services, which may be more sensitive to integrated care delivery models.

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 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 postoperative 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 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. 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 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.

Admission diagnoses among patients with heart failure: Variation by ACO performance on a measure of risk-standardized acute admission rates.

BACKGROUND: A key quality metric for Accountable Care Organizations (ACOs) is the rate of hospitalization among patients with heart failure (HF). Among this patient population, non-HF-related hospitalizations account for a substantial proportion of admissions. Understanding the types of admissions and the distribution of admission types across ACOs of varying performance may provide important insights for lowering admission rates. METHODS: We examined admission diagnoses among 220 Medicare Shared Savings Program ACOs in 2013. ACOs were stratified into quartiles by their performance on a measure of unplanned risk-standardized acute admission rates (RSAARs) among patients with HF. Using a previously validated algorithm, we categorized admissions by principal discharge diagnosis into: HF, cardiovascular/non-HF, and noncardiovascular. We compared the mean admission rates by admission type as well as the proportion of admission types across RSAAR quartiles (Q1-Q4). RESULTS: Among 220 ACOs caring for 227,356 patients with HF, the median (IQR) RSAARs per 100 person-years ranged from 64.5 (61.7-67.7) in Q1 (best performers) to 94.0 (90.1-99.9) in Q4 (worst performers). The mean admission rates by admission types for ACOs in Q1 compared with Q4 were as follows: HF admissions: 9.8 (2.2) vs 14.6 (2.8) per 100 person years (P < .0001); cardiovascular/non-HF admissions: 11.1 (1.6) vs 15.9 (2.6) per 100 person-years (P < .0001); and noncardiovascular admissions: 42.7 (5.4) vs 69.6 (11.3) per 100 person-years (P < .0001). The proportion of admission due to HF, cardiovascular/non-HF, and noncardiovascular conditions was 15.4%, 17.5%, and 67.1% in Q1 compared with 14.6%, 15.9%, and 69.4% in Q4 (P < .007). CONCLUSIONS: Although ACOs with the best performance on a measure of all-cause admission rates among people with HF tended to have fewer admissions for HF, cardiovascular/non-HF, and noncardiovascular conditions compared with ACOs with the worst performance (highest admission rates), the largest difference in admission rates were for noncardiovascular admission types. Across all ACOs, two-thirds of admissions of patients with HF were for noncardiovascular causes. These findings suggest that comprehensive approaches are needed to reduce the diverse admission types for which HF patients are at risk.

The Accountable Care Organization for Surgical Care.

Rising health care costs superimposed on uncertainty surrounding the relationship between health care spending and quality have resulted in an urgent need to develop strategies to better align health care payment with value. Such approaches, at least in theory, work to achieve the dual aims of reducing growth in health care spending and improving population health. To date, surgery has not been prioritized in accountable care organizations (ACOs). Nonetheless, it is critically important to begin to consider strategic and impactful mechanisms through which surgery can be seamlessly woven into innovative population health models.

Purchasers to Insurers: Standardize Your ACO Measures.

Building on a similar effort in California, Catalyst for Payment Reform is proposing a standardized set of 50 ACO measures. A timely development. In the first quarter of last year, an estimated 19.1 million lives were covered by 715 commercial ACOs, compared with 17.2 million lives a year earlier.

Care coordination at a pediatric accountable care organization (ACO): A qualitative analysis.

OBJECTIVE: Care coordinators may help manage care for children with chronic illness. Their role in pediatric epilepsy care is understudied. We aimed to qualitatively describe the content of a care coordination intervention for children with epilepsy. METHODS: We conducted nine semi-structured interviews and one focus group with care coordinators at a pediatric accountable care organization (ACO) in Ohio. The care coordinators used a modified version of a published care coordination checklist for children with epilepsy (Patel AD, 2014). We analyzed transcripts using thematic analysis. We focused on (1) the content of the intervention; and (2) perceptions of facilitators and barriers to improve outcomes, with an emphasis on epilepsy specific facilitators and barriers. RESULTS: Care coordinators interacted with children and families in multiple contexts (phone calls, physician visits, home visits), and included relationship building (developing rapport and trust between families and the health system), communication (transmission of information between the child, family, physician, and other care providers), and service (help with housing, transportation, scheduling, liaison with community resources, etc.). Facilitators and barriers of care coordination included factors related to parents, physicians, health system, payers, and community. Epilepsy-specific barriers included stigma (felt & enacted) and the anxiety associated with clinical uncertainty. Epilepsy related facilitators included a seizure action plan, written educational materials, and an epilepsy specific care coordination checklist. CONCLUSION: In addition to facilitators and barriers common to many care coordination programs, pediatric epilepsy care coordinators should be particularly aware of epilepsy stigma and clinical uncertainty. A care coordination checklist and epilepsy focused educational materials written to accommodate people with low health literacy may provide additional benefit. Further research is required to understand the effect of care coordination on costs, use of health services, seizure control, and quality of life for children with epilepsy.

Determinants of success in Shared Savings Programs: An analysis of ACO and market characteristics.

BACKGROUND: Medicare's Accountable Care Organization (ACO) programs introduced shared savings to traditional Medicare, which allow providers who reduce health care costs for their patients to retain a percentage of the savings they generate. OBJECTIVE: To examine ACO and market factors associated with superior financial performance in Medicare ACO programs. METHODS: We obtained financial performance data from the Centers for Medicare and Medicaid Services (CMS); we derived market-level characteristics from Medicare claims; and we collected ACO characteristics from the National Survey of ACOs for 215 ACOs. We examined the association between ACO financial performance and ACO provider composition, leadership structure, beneficiary characteristics, risk bearing experience, quality and process improvement capabilities, physician performance management, market competition, CMS-assigned financial benchmark, and ACO contract start date. We examined two outcomes from Medicare ACOs' first performance year: savings per Medicare beneficiary and earning shared savings payments (a dichotomous variable). RESULTS: When modeling the ACO ability to save and earn shared savings payments, we estimated positive regression coefficients for a greater proportion of primary care providers in the ACO, more practicing physicians on the governing board, physician leadership, active engagement in reducing hospital re-admissions, a greater proportion of disabled Medicare beneficiaries assigned to the ACO, financial incentives offered to physicians, a larger financial benchmark, and greater ACO market penetration. No characteristic of organizational structure was significantly associated with both outcomes of savings per beneficiary and likelihood of achieving shared savings. ACO prior experience with risk-bearing contracts was positively correlated with savings and significantly increased the likelihood of receiving shared savings payments. CONCLUSIONS: In the first year, performance is quite heterogeneous, yet organizational structure does not consistently predict performance. Organizations with large financial benchmarks at baseline have greater opportunities to achieve savings. Findings on prior risk bearing suggest that ACOs learn over time under risk-bearing contracts. IMPLICATIONS: Given the lack of predictive power for organizational characteristics, CMS should continue to encourage diversity in organizational structures for ACO participants, and provide alternative funding and risk bearing mechanisms to continue to allow a diverse group of organizations to participate. LEVEL OF EVIDENCE: III.

Breast Imaging: A Paradigm for Accountable Care Organizations.

OBJECTIVE: Accountable care organizations (ACOs) are being promoted by the Centers of Medicare Services as alternative payment models for radiology reimbursement. Because of its clinical orientation, focus on prevention, standardized reporting, quality orientation through mandatory accreditation, and value demonstration through established outcome metrics, breast imaging offers a unique paradigm for the ACO model in radiology. CONCLUSION: In radiology, breast imaging represents the paradigm for ACOs.

Accountable Care Organizations: what they mean for the country and for neurointerventionalists.

The Affordable Care Act is celebrating its fifth anniversary and remains one of the most significant attempts to reform healthcare in US history. Prior to the federal legislation, Accountable Care Organizations had largely been part of an academic discussion about how to control rising healthcare costs, but have since become a fixture in our national healthcare landscape. A fundamental shift is underway in the relationship between healthcare delivery and payment models. Some elements of Accountable Care Organizations may remain unfamiliar to most healthcare providers, including neurointerventional specialists. In this paper we review the fundamental concepts behind and the current forms of Accountable Care Organizations, and discuss the challenges and opportunities they present for neurointerventionalists.

A Few Thoughts about ACO Antitrust Issues from a Local Enforcement Perspective.

Accountable care organizations (ACOs), joint ventures of commercial insurers and various groups of medical providers such as physicians, specialists, and hospitals whose development in California has been quickened by the Affordable Care Act, carry with them both promise and pitfalls. On the positive side of the ledger, ACOs may improve the quality of medical care even as they lower the costs of that care. On the negative side of the ledger, ACOs may lead to a gain in market power for their participations, allowing those participants to increase the prices they charge to commercial insurers. It is thus a key question for antitrust enforcers to figure out how to separate the sheep from the goats. This article, representing our personal views as state antitrust enforcers in the California attorney general's office, offers our reflection on a number of ACO articles and studies in this special issue through the prism of this key question and sets out a number of additional issues that we believe warrant study in conjunction with ACOs.

The effect of accountable care organizations on oncology practice.

Cancer care accounts for a significant portion of the rise in health care costs, and therefore, as national efforts escalate to control cost, cancer care will be a focus of concern. Cost increases in cancer care are related to many factors, including increasing cancer incidence in an aging population, the introduction of new high-cost therapeutics, and the high cost of end-of-life care. Accountable care organizations (ACOs) have been one of the major efforts directed at controlling health care costs. How cancer care will fit into the rubric of ACOs is not entirely clear but will certainly evolve over the coming years. The oncology profession has the opportunity to play a role in this evolution or could leave the evolution to others driving the process, such as the Centers for Medicare and Medicaid Services (CMS), private payers, and ACOs. Ideally all parties will work together to provide a construct for high-value, high-quality care for patients with cancer while contributing to cost control in overall health care.

[Analysis of qualifications of medical and health institutions and certified doctors for providing occupational disease diagnosis in China].

OBJECTIVE: To investigate the qualifications and current situations of the medical and health institutions and certified doctors for providing occupational disease diagnosis in China and to provide a reference for developing relevant policies. METHODS: Work reports and questionnaires survey were used to investigate the qualifications of all medical and health institutions and certified doctors for providing occupational disease diagnosis in China and their acceptance and diagnosis of occupational disease cases from 2006 to 2010. The rate for the work reports was 100%, and the response rate for the questionnaires was 71.0%. RESULTS: By the end of 2010, in the 31 provincial-level regions (excluding Hong Kong, Macao, and Taiwan) in China, there had been 503 medical and health institutions which were qualified for providing occupational disease diagnosis, including 207 centers for disease control and prevention, accounting for 41.2%, 145 general hospitals, accounting for 28.8%, 69 enterprise-owned hospitals, accounting for 13.7%, and 64 institutes or centers for occupational disease prevention and control, accounting for 12.7%; 4986 certified doctors got the qualification for providing occupational disease diagnosis, with 9.4 certified doctors on average in each institution, and there was 0.65 certified doctor per 100 000 employees. In addition, 16.5% of the institutions got all the qualifications for diagnosing 9 occupational diseases, and 17.1% of the institutions got the qualification for diagnosing one occupational disease. Each certified doctor accepted diagnosis of 16.8 cases of occupational diseases on average every year. CONCLUSION: A national occupational disease diagnosis network has been established in China, but the imbalance in regional distribution and specialty programs still exists among the qualified medical and health institutions and certified doctors. It is essential to further strengthen the development of regional qualified medical and health institutions and training of qualified doctors.