Provider Care Team Segregation and Operative Mortality Following Coronary Artery Bypass Grafting.

BACKGROUND: Studies have shown that Black patients die more frequently following coronary artery bypass grafting than their White counterparts for reasons not fully explained by disease severity or comorbidity. To examine whether provider care team segregation within hospitals contributes to this inequity, we analyzed national Medicare data. METHODS: Using national Medicare data, we identified beneficiaries who underwent coronary artery bypass grafting at hospitals where this procedure was performed on at least 10 Black and 10 White patients between 2008 and 2014 (n=12 646). After determining the providers who participated in their perioperative care, we examined the extent to which Black and White patients were cared for by unique networks of provider care teams within the same hospital. We then evaluated whether a lack of overlap in composition of the provider care teams treating Black versus White patients (ie, high segregation) was associated with higher 90-day operative mortality among Black patients. RESULTS: The median level of provider care team segregation was high (0.89) but varied across hospitals (interquartile range, 0.85-0.90). On multivariable analysis, after controlling for patient-, hospital-, and community-level differences, mortality rates for White patients were comparable at hospitals with high and low levels of provider care segregation (5.4% [95% CI, 4.7%-6.1%] versus 5.8% [95% CI, 4.7%-7.0%], respectively; P=0.601), while Black patients treated at high-segregation hospitals had significantly higher mortality than those treated at low-segregation hospitals (8.3% [95% CI, 5.4%-12.4%] versus 3.3% [95% CI, 2.0%-5.4%], respectively; P=0.017). The difference in mortality rates for Black and White patients treated at low-segregation hospitals was nonsignificant (-2.5%; P=0.098). CONCLUSIONS: Black patients who undergo coronary artery bypass grafting at a hospital with a higher level of provider care team segregation die more frequently after surgery than Black patients treated at a hospital with a lower level.

Accountable Care Organizations and Spending for Patients Undergoing Long-Term Dialysis.

BACKGROUND AND OBJECTIVES: Despite representing 1% of the population, beneficiaries on long-term dialysis account for over 7% of Medicare's fee-for-service spending. Because of their focus on care coordination, Accountable Care Organizations may be an effective model to reduce spending inefficiencies for this population. We analyzed Medicare data to examine time trends in long-term dialysis beneficiary alignment to Accountable Care Organizations and differences in spending for those who were Accountable Care Organization aligned versus nonaligned. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: In this retrospective cohort study, beneficiaries on long-term dialysis between 2009 and 2016 were identified using a 20% random sample of Medicare beneficiaries. Trends in alignment to an Accountable Care Organization were compared with alignment of the general Medicare population from 2012 to 2016. Using an interrupted time series approach, we examined the association between Accountable Care Organization alignment and the primary outcome of total spending for long-term dialysis beneficiaries from prior to Accountable Care Organization implementation (2009-2011) through implementation of the Comprehensive ESRD Care model in October 2015. We fit linear regression models with generalized estimating equations to adjust for patient characteristics. RESULTS: During the study period, 135,152 beneficiaries on long-term dialysis were identified. The percentage of long-term dialysis beneficiaries aligned to an Accountable Care Organization increased from 6% to 23% from 2012 to 2016. In the time series analysis, spending on Accountable Care Organization-aligned beneficiaries was $143 (95% confidence interval, $5 to $282) less per beneficiary-quarter than spending for nonaligned beneficiaries. In analyses stratified by whether beneficiaries received care from a primary care physician, savings by Accountable Care Organization-aligned beneficiaries were limited to those with care by a primary care physician ($235; 95% confidence interval, $73 to $397). CONCLUSIONS: There was a substantial increase in the percentage of long-term dialysis beneficiaries aligned to an Accountable Care Organization from 2012 to 2016. Moreover, in adjusted models, Accountable Care Organization alignment was associated with modest cost savings among long-term dialysis beneficiaries with care by a primary care physician.

Out-Of-Network Primary Care Is Associated With Higher Per Beneficiary Spending In Medicare ACOs.

Despite expectations that Medicare accountable care organizations (ACOs) would curb health care spending, their effect has been modest. One possible explanation is that ACOs' inability to prohibit out-of-network care limits their control over spending. To examine this possibility, we examined the association between out-of-network care and per beneficiary spending using national Medicare data for 2012-15. While there was no association between out-of-network specialty care and ACO spending, each percentage-point increase in receipt of out-of-network primary care was associated with an increase of $10.79 in quarterly total ACO spending per beneficiary. When we broke down total spending by place of service, we found that out-of-network primary care was associated with higher spending in outpatient, skilled nursing facility, and emergency department settings, but not inpatient settings. Our findings suggest an opportunity for the Medicare program to realize substantial savings, if policy makers developed explicit incentives for beneficiaries to seek more of their primary care within network.

New Persistent Opioid Use After Outpatient Ureteroscopy for Upper Tract Stone Treatment.

OBJECTIVE: To measure the incidence of persistent opioid use following ureteroscopy (URS). Over 100 Americans die every day from opioid overdose. Recent studies suggest that many opioid addictions surface after surgery. METHODS: Using claims data, we identified adults who underwent outpatient URS for treatment of upper tract stones between January 2008 and December 2016 and filled an opioid prescription attributable to URS. We then measured the rate of new persistent opioid use-defined as continued use of opioids 91-180 days after URS among those who were previously opioid-naive. Finally, we fit multivariable models to assess whether new persistent opioid use was associated with the amount of opioid prescribed at the time of URS. RESULTS: In total, 27,740 patients underwent outpatient URS, 51.2% of whom were opioid-naïve. Nearly 1 in 16 (6.2%) opioid-naïve patients developed new persistent opioid use after URS. Six months following surgery, beneficiaries with new persistent opioid use continued to fill prescriptions with daily doses of 4.2 oral morphine equivalents. Adjusting for measured sociodemographic and clinical differences, patients in the highest tercile of opioids prescribed at the time of URS had 69% higher odds of new persistent opioid use compared to those in the lowest tercile (odds ratio, 1.69; 95% CI, 1.41-2.03). CONCLUSION: Nearly 1 in 16 opioid-naive patients develop new persistent opioid use after URS. New persistent opioid use is associated with the amount of opioid prescribed at the time of URS. Given these findings, urologists should re-evaluate their post-URS opioid prescribing patterns.

Performance in the Medicare Shared Savings Program After Accounting for Nonrandom Exit: An Instrumental Variable Analysis.

Background: Accountable care organizations (ACOs) in the Medicare Shared Savings Program (MSSP) are associated with modest savings. However, prior research may overstate this effect if high-cost clinicians exit ACOs. Objective: To evaluate the effect of the MSSP on spending and quality while accounting for clinicians' nonrandom exit. Design: Similar to prior MSSP analyses, this study compared MSSP ACO participants versus control beneficiaries using adjusted longitudinal models that accounted for secular trends, market factors, and beneficiary characteristics. To further account for selection effects, the share of nearby clinicians in the MSSP was used as an instrumental variable. Hip fracture served as a falsification outcome. The authors also tested for compositional changes among MSSP participants. Setting: Fee-for-service Medicare, 2008 through 2014. Patients: A 20% sample (97 204 192 beneficiary-quarters). Measurements: Total spending, 4 quality indicators, and hospitalization for hip fracture. Results: In adjusted longitudinal models, the MSSP was associated with spending reductions (change, -$118 [95% CI, -$151 to -$85] per beneficiary-quarter) and improvements in all 4 quality indicators. In instrumental variable models, the MSSP was not associated with spending (change, $5 [CI, -$51 to $62] per beneficiary-quarter) or quality. In falsification tests, the MSSP was associated with hip fracture in the adjusted model (-0.24 hospitalizations for hip fracture [CI, -0.32 to -0.16 hospitalizations] per 1000 beneficiary-quarters) but not in the instrumental variable model (0.05 hospitalizations [CI, -0.10 to 0.20 hospitalizations] per 1000 beneficiary-quarters). Compositional changes were driven by high-cost clinicians exiting ACOs: High-cost clinicians (99th percentile) had a 30.4% chance of exiting the MSSP, compared with a 13.8% chance among median-cost clinicians (50th percentile). Limitation: The study used an observational design and administrative data. Conclusion: After adjustment for clinicians' nonrandom exit, the MSSP was not associated with improvements in spending or quality. Selection effects-including exit of high-cost clinicians-may drive estimates of savings in the MSSP. Primary Funding Source: Horowitz Foundation for Social Policy, Agency for Healthcare Research and Quality, and National Institute on Aging.

Risk Adjustment In Medicare ACO Program Deters Coding Increases But May Lead ACOs To Drop High-Risk Beneficiaries.

The Medicare Shared Savings Program (MSSP) adjusts savings benchmarks by beneficiaries' baseline risk scores. To discourage increased coding intensity, the benchmark is not adjusted upward if beneficiaries' risk scores rise while in the MSSP. As a result, accountable care organizations (ACOs) have an incentive to avoid increasingly sick or expensive beneficiaries. We examined whether beneficiaries' exposure to the MSSP was associated with within-beneficiary changes in risk scores and whether risk scores were associated with entry to or exit from the MSSP. We found that the MSSP was not associated with consistent changes in within-beneficiary risk scores. Conversely, beneficiaries at the ninety-fifth percentile of risk score had a 21.6 percent chance of exiting the MSSP, compared to a 16.0 percent chance among beneficiaries at the fiftieth percentile. The decision not to upwardly adjust risk scores in the MSSP has successfully deterred coding increases but might discourage ACOs to care for high-risk beneficiaries in the MSSP .