The Effect Of Next Generation Accountable Care Organizations On Medicare Expenditures.

The Next Generation Accountable Care Organization (NGACO) model (active during 2016-21) tested the effects of high financial risk, payment mechanisms, and flexible care delivery on health care spending and value for fee-for-service Medicare beneficiaries. We used quasi-experimental methods to examine the model's effects on Medicare Parts A and B spending. Sixty-two ACOs with more than 4.2 million beneficiaries and more than 91,000 practitioners participated in the model. The model was associated with a $270 per beneficiary per year, or approximately $1.7 billion, decline in Medicare spending. After shared savings payments to ACOs were included, the model increased net Medicare spending by $56 per beneficiary per year, or $96.7 million. Annual declines in spending for the model grew over time, reflecting exit by poorer-performing NGACOs, improvement among the remaining NGACOs, and the COVID-19 pandemic. Larger declines in spending occurred among physician practice ACOs and ACOs that elected population-based payments and risk caps greater than 5 percent.

Accountable care organization initiatives to improve the cost and outcomes of specialty care.

OBJECTIVES: To assess initiatives to manage the cost and outcomes of specialty care in organizations that participate in Medicare accountable care organizations (ACOs). STUDY DESIGN: Cross-sectional analysis of 2023 ACO survey data. METHODS: Analysis of responses to a 12-question web-based survey from 101 respondents representing 174 ACOs participating in the Medicare Shared Savings Program or the Realizing Equity, Access, and Community Health ACO model in 2023. RESULTS: Improving specialist alignment was a high priority for 62% of the 101 respondents and a medium priority for 34%. Only 11% reported that employed specialists were highly aligned and 7% reported that contracted specialists were highly aligned. A subset of ACOs reported major efforts to engage specialists in quality improvement projects (38%) and to convene specialists to develop evidence-based care pathways (30%). They also reported supporting primary care physicians through providing specialist directories (44%), specialist e-consults (23%), and sharing specialist cost data (20%). The most common challenges reported were the influence of fee-for-service payment on specialist behavior (58%), lack of data to evaluate specialist performance (53%), and insufficient bandwidth or ACO resources to address specialist alignment (49%). CONCLUSIONS: Engaging specialists in accountable care is an emerging area for ACOs but one with numerous challenges. Making better data on specialist costs and outcomes available to Medicare ACOs is essential for accelerating progress.

ACO leakage among gynecologic cancer patients: Incidence, predictors, and impact on annual Medicare expenditure.

OBJECTIVE: To examine patterns of Accountable Care Organizations (ACO) leakage, the receipt of healthcare by ACO-assigned patients from institutions outside assigned ACO network, among patients with gynecologic cancer. ACO leakage was estimated as rates of patients seeking care external to their ACO assignment. Factors associated with ACO leakage were identified and cost differences within the first year of cancer diagnosis described. METHODS: Medicare 5% data (2013-2017) was used to quantify rates of leakage among gynecologic cancer patients with stable ACO assignment. Crude and multivariable adjusted risk ratios of ACO leakage risk factors were estimated using log-binomial regression models. Overall and cancer-specific spending differences by ACO leakage status were compared using Wilcoxon rank-sum test. RESULTS: Overall incidence of ACO leakage was 28.1% with highest leakage for outpatient care and uterine cancer patients. ACO leakage risk was 56% higher among Black relative to White patients, and 77% more for those in higher relative to lowest quintiles of median household income. Leakage decreased by 3% and 8% with each unit increase in ACO size and number of subspecialists, respectively. Healthcare costs were 19.5% higher for leakage patients. CONCLUSIONS: ACO leakage rates among gynecologic cancer patients was overall modest, with some regional and temporal variation, higher leakage for certain subgroups and substantially higher Medicare spending in inpatient and outpatient settings for patients with ACO leakage. These findings identify targets for further investigations and strategies to encourage oncologists to participate in ACOs and prevent increased health care costs associated with use of non-ACO providers.

Telehealth Infrastructure, Accountable Care Organization, and Medicare Payment for Patients with Alzheimer's Disease and Related Dementia Living in Socially Vulnerable Areas.

Background: Structural social determinants of health have an accumulated negative impact on physical and mental health. Evidence is needed to understand whether emerging health information technology and innovative payment models can help address such structural social determinants for patients with complex health needs, such as Alzheimer's disease and related dementias (ADRD). Objective: This study aimed to test whether telehealth for care coordination and Accountable Care Organization (ACO) enrollment for residents in the most disadvantaged areas, particularly those with ADRD, was associated with reduced Medicare payment. Methods: The study used the merged data set of 2020 Centers for Medicare and Medicaid Services Medicare inpatient claims data, the Medicare Beneficiary Summary File, the Medicare Shared Savings Program ACO, the Center for Medicare and Medicaid Service's Social Vulnerability Index (SVI), and the American Hospital Annual Survey. Our study focused on community-dwelling Medicare fee-for-service beneficiaries aged 65 years and up. Cross-sectional analyses and generalized linear models (GLM) were implemented. Analyses were implemented from November 2023 to February 2024. Results: Medicare fee-for-service beneficiaries residing in SVI Q4 (i.e., the most vulnerable areas) reported significantly higher total Medicare costs and were least likely to be treated in hospitals that provided telehealth post-discharge services or have ACO affiliation. Meanwhile, the proportion of the population with ADRD was the highest in SVI Q4 compared with other SVI levels. The GLM regression results showed that hospital telehealth post-discharge infrastructure, patient ACO affiliation, SVI Q4, and ADRD were significantly associated with higher Medicare payments. However, coefficients of interaction terms among these factors were significantly negative. For example, the average interaction effect of telehealth post-discharge and ACO, SVI Q4, and ADRD on Medicare payment was -$1,766.2 (95% confidence interval: -$2,576.4 to -$976). Conclusions: Our results suggested that the combination of telehealth post-discharge and ACO financial incentives that promote care coordination is promising to reduce the Medicare cost burden among patients with ADRD living in socially vulnerable areas.

Value-based payment models and management of newly diagnosed prostate cancer.

OBJECTIVE: To examine the effect of urologist participation in value-based payment models on the initial management of men with newly diagnosed prostate cancer. METHODS: Medicare beneficiaries with prostate cancer diagnosed between 2017 and 2019, with 1 year of follow-up, were assigned to their primary urologist, each of whom was then aligned to a value-based payment model (the merit-based incentive payment system [MIPS], accountable care organization [ACO] without financial risk, and ACO with risk). Multivariable mixed-effects logistic regression was used to measure the association between payment model participation and treatment of prostate cancer. Additional models estimated the effects of payment model participation on use of treatment in men with very high risk (i.e., >75%) of non-cancer mortality within 10 years of diagnosis (i.e., a group of men for whom treatment is generally not recommended) and price-standardized prostate cancer spending in the 12 months after diagnosis. RESULTS: Treatment did not vary by payment model, both overall (MIPS-67% [95% CI 66%-68%], ACOs without risk-66% [95% CI 66%-68%], ACOs with risk-66% [95% CI 64%-68%]). Similarly, treatment did not vary among men with very high risk of non-cancer mortality by payment model (MIPS-52% [95% CI 50%-55%], ACOs without risk-52% [95% CI 50%-55%], ACOs with risk-51% [95% CI 45%-56%]). Adjusted spending was similar across payment models (MIPS-$16,501 [95% CI $16,222-$16,780], ACOs without risk-$16,140 [95% CI $15,852-$16,429], ACOs with risk-$16,117 [95% CI $15,585-$16,649]). CONCLUSIONS: How urologists participate in value-based payment models is not associated with treatment, potential overtreatment, and prostate cancer spending in men with newly diagnosed disease.

Organizational Characteristics Associated with High Performance in Medicare's Comprehensive End-Stage Renal Disease Care Initiative.

BACKGROUND AND OBJECTIVES: Medicare plans to extend financial structures tested through the Comprehensive End-Stage Renal Disease Care (CEC) Initiative-an alternative payment model for maintenance dialysis providers-to promote high-value care for beneficiaries with kidney failure. The End-Stage Renal Disease Seamless Care Organizations (ESCOs) that formed under the CEC Initiative varied greatly in their ability to generate cost savings and improve patient health outcomes. This study examined whether organizational or community characteristics were associated with ESCOs' performance. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We used a retrospective pooled cross-sectional analysis of all 37 ESCOs participating in the CEC Initiative during 2015-2018 (n=87 ESCO-years). Key exposures included ESCO characteristics: number of dialysis facilities, number and types of physicians, and years of CEC Initiative experience. Outcomes of interest included were above versus below median gross financial savings (2.4%) and standardized mortality ratio (0.93). We analyzed unadjusted differences between high- and low-performing ESCOs and then used multivariable logistic regression to construct average marginal effect estimates for parameters of interest. RESULTS: Above-median gross savings were obtained by 23 (52%) ESCOs with no program experience, 14 (32%) organizations with 1 year of experience, and seven (16%) organizations with 2 years of experience. The adjusted likelihoods of achieving above-median gross savings were 23 (95% confidence interval, 8 to 37) and 48 (95% confidence interval, 24 to 68) percentage points higher for ESCOs with 1 or 2 years of program experience, respectively (versus none). The adjusted likelihood of achieving above-median gross savings was 1.7 (95% confidence interval, -3 to -1) percentage points lower with each additional affiliated dialysis facility. Adjusted mortality rates were lower for ESCOs located in areas with higher socioeconomic status. CONCLUSIONS: Smaller ESCOs, organizations with more experience in the CEC Initiative, and those located in more affluent areas performed better under the CEC Initiative.

The one-year impact of accountable care networks among Washington State employees.

OBJECTIVE: To estimate the impact of a new, two-sided risk model accountable care network (ACN) on Washington State employees and their families. DATA SOURCES/STUDY SETTING: Administrative data (January 2013-December 2016) on Washington State employees. STUDY DESIGN: We compared monthly health care utilization, health care intensity as measured through proxy pricing, and annual HEDIS quality metrics between the five intervention counties to 13 comparison counties, analyzed separately by age categories (ages 0-5, 6-18, 19-26, 18-64). DATA COLLECTION/EXTRACTION METHODS: We used difference-in-difference methods and generalized estimating equations to estimate the effects after 1 year of implementation for adults and children. PRINCIPAL FINDINGS: We estimate a 1-2 percentage point decrease in outpatient hospital visits due to the introduction of ACNs (adults: -1.8, P < .01; age 0-5: -1.2, P = .07; age 6-18: -1.2, P = .06; age 19-26; -1.2, P < .01). We find changes in primary and specialty care office visits; the direction of impact varies by age. Dependents age 19-26 were also responsive with inpatient admissions declines (-0.08 percentage points, P = .02). Despite changes in utilization, there was no evidence of changes in intensity of care and mixed results in the quality measures. CONCLUSIONS: Washington's state employee ACN introduction changed health care utilization patterns in the first year but was not as successful in improving quality.

Patient Experiences of Integrated Care in Medicare Accountable Care Organizations and Medicare Advantage Versus Traditional Fee-for-Service.

BACKGROUND: Health insurance design can influence the extent to which clinical care is well-coordinated. Through alternative payment models, Medicare Advantage (MA) and Accountable Care Organizations (ACOs) have the potential to improve integration relative to traditional fee-for-service (FFS) Medicare. OBJECTIVE: To characterize patient experiences of integrated care within Medicare and identify whether MA or ACO beneficiaries perceive greater integration than FFS beneficiaries. DESIGN: Retrospective cross-sectional analysis of the 2015 Medicare Current Beneficiary Survey. SUBJECTS: Nationally representative sample of 11,978 Medicare beneficiaries. MEASURES: Main outcomes included 8 previously derived domains of patient-perceived integrated care (PPIC), measured on a scale of 1-4. RESULTS: The final sample was 55% female with a mean (SD) age of 71.1 (11.3). In unadjusted analyses, we observed considerable variation across PPIC domains in the full sample, but little variation across subsamples defined by coverage type within a given PPIC domain. In linear models adjusting for a rich set of patient characteristics, we observe no significant benefits of ACOs nor MA relative to FFS, a finding which is robust to alternative specifications and adjustment for multiple comparisons. We similarly observed no benefits in subgroup analyses restricted to states with relatively high market penetration of ACOs or MA. CONCLUSIONS: Despite characteristics of ACOs and MA that theoretically promote integrated care, we find that PPIC is largely similar across coverage types in Medicare.

Medicare Accountable Care Organizations and the Adoption of New Surgical Technology.

BACKGROUND: Dissemination of new surgical technology is a major contributor to healthcare spending growth. Accountable care organization (ACO) policy aims to control spending while maintaining quality. As a result, ACOs provide incentive for hospitals to selectively adopt newer procedures with high value. STUDY DESIGN: We conducted a retrospective cohort study using a 20% sample of national Medicare claims from 2010 to 2015. We identified hospitals that performed 1 of 6 sets of procedures: abdominal aortic aneurysm repair, aortic valve replacement, carotid endarterectomy or stent, lung lobectomy, colectomy, and prostatectomy. We identified hospitals participating in a Medicare Shared Savings Program ACO and a set of matched non-ACO control hospitals. We used a difference-in-differences approach to compare rate of surgical treatment and use of newer surgical technology for each set of procedures in ACO and non-ACO hospitals. RESULTS: We included 707 ACO-hospitals and 1,770 control hospitals. ACO hospitals performed surgery for carotid stenosis at a lower rate than non-ACO hospitals. There was no difference in the rate of surgical treatment for all other procedure sets. ACO hospitals were less likely to use an endovascular approach for abdominal aortic aneurysm repair (85.2% vs 88.2%, p < 0.001) and more likely to use a minimally invasive approach for lung lobectomy (42.2% vs 34.7%, p = 0.004) than non-ACO hospitals. In difference-in-differences analysis, ACO participation was not associated with any significant difference in use of surgical care for any of the 6 procedure sets, nor with any significant difference in use of newer surgical technology. CONCLUSIONS: Despite ACO policy incentives to selectively adopt newer surgical technology, ACO participation was not associated with differences in rate of surgery or use of newer surgical technology for 6 major surgical procedures.

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.

Value-Based Payment Reforms in Cardiovascular Care: Progress to Date and Next Steps.

In an effort to curb excessive health care spending and incentivize high-quality care, many payers have implemented value-based payment reforms designed to pay for the quality rather than the quantity of health care services. Medicare, the largest payer in the United States, has implemented numerous value-based payment policies over the past decade, many of which affect cardiovascular care. In this review, we discuss some of these major nationwide value-based payment reforms as they relate to cardiovascular care and what we may expect in the future from cardiovascular value-based policies.

Are ACOs Ready to be Accountable for Medication Use?

BACKGROUND: Accountable care organizations (ACOs) have the potential to lower costs and improve quality through incentives and coordinated care. However, the design brings with it many new challenges. One such challenge is the optimal use of pharmaceuticals. Most ACOs have not yet focused on this integral facet of care, even though medications are a critical component to achieving the lower costs and improved quality that are anticipated with this new model. OBJECTIVE: To evaluate whether ACOs are prepared to maximize the value of medications for achieving quality benchmarks and cost offsets. METHODS: During the fall of 2012, an electronic readiness self-assessment was developed using a portion of the questions and question methodology from the National Survey of Accountable Care Organizations, along with original questions developed by the authors. The assessment was tested and subsequently revised based on feedback from pilot testing with 5 ACO representatives. The revised assessment was distributed via e-mail to a convenience sample (n=175) of ACO members of the American Medical Group Association, Brookings-Dartmouth ACO Learning Network, and Premier Healthcare Alliance. RESULTS: The self-assessment was completed by 46 ACO representatives (26% response rate). ACOs reported high readiness to manage medications in a few areas, such as transmitting prescriptions electronically (70%), being able to integrate medical and pharmacy data into a single database (54%), and having a formulary in place that encourages generic use when appropriate (50%). However, many areas have substantial room for improvement with few ACOs reporting high readiness. Some notable areas include being able to quantify the cost offsets and hence demonstrate the value of appropriate medication use (7%), notifying a physician when a prescription has been filled (9%), having protocols in place to avoid medication duplication and polypharmacy (17%), and having quality metrics in place for a broad diversity of conditions (22%). CONCLUSIONS: Developing the capabilities to support, monitor, and ensure appropriate medication use will be critical to achieve optimal patient outcomes and ACO success. The ACOs surveyed have embarked upon an important journey towards this goal, but critical gaps remain before they can become fully accountable. While many of these organizations have begun adopting health information technologies that allow them to maximize the value of medications for achieving quality outcomes and cost offsets, a significant lag was identified in their inability to use these technologies to their full capacities. In order to provide further guidance, the authors have begun documenting case studies for public release that would provide ACOs with examples of how certain medication issues have been addressed by ACOs or relevant organizations. The authors hope that these case studies will help ACOs optimize the value of pharmaceuticals and achieve the "triple aim" of improving care, health, and cost. DISCLOSURES: There was no outside funding for this study, and the authors report no conflicts of interest related to the article. Concept and design were primarily from Dubois and Kotzbauer, with help from Feldman, Penso, and Westrich. Data collection was done by Feldman, Penso, Pope, and Westrich, and all authors participated in data interpretation. The manuscript was written primarily by Westrich, with help from all other authors, and revision was done primarily by Lustig and Westrich, with help from all other authors.

Association between specialist compensation and Accountable Care Organization performance.

OBJECTIVE: To determine if Medicare Shared Savings Program Accountable Care Organizations (ACOs) using cost reduction measures in specialist compensation demonstrated better performance. DATA SOURCES: National, cross-sectional survey data on ACOs (2013-2015) linked to public-use data on ACO performance (2014-2016). STUDY DESIGN: 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. PRINCIPAL FINDINGS: 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]). CONCLUSION: 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.

Savings or Selection? Initial Spending Reductions in the Medicare Shared Savings Program and Considerations for Reform.

Policy Points Concerns have been raised about risk selection in the Medicare Shared Savings Program (MSSP). Specifically, turnover in accountable care organization (ACO) physicians and patient panels has led to concerns that ACOs may be earning shared-savings bonuses by selecting lower-risk patients or providers with lower-risk panels. We find no evidence that changes in ACO patient populations explain savings estimates from previous evaluations through 2015. We also find no evidence that ACOs systematically manipulated provider composition or billing to earn bonuses. The modest savings and lack of risk selection in the original MSSP design suggest opportunities to build on early progress. Recent program changes provide ACOs with more opportunity to select providers with lower-risk patients. Understanding the effect of these changes will be important for guiding future payment policy. CONTEXT: The Medicare Shared Savings Program (MSSP) establishes incentives for participating accountable care organizations (ACOs) to lower spending for their attributed fee-for-service Medicare patients. Turnover in ACO physicians and patient panels has raised concerns that ACOs may be earning shared-savings bonuses by selecting lower-risk patients or providers with lower-risk panels. METHODS: We conducted three sets of analyses of Medicare claims data. First, we estimated overall MSSP savings through 2015 using a difference-in-differences approach and methods that eliminated selection bias from ACO program exit or changes in the practices or physicians included in ACO contracts. We then checked for residual risk selection at the patient level. Second, we reestimated savings with methods that address undetected risk selection but could introduce bias from other sources. These included patient fixed effects, baseline or prospective assignment, and area-level MSSP exposure to hold patient populations constant. Third, we tested for changes in provider composition or provider billing that may have contributed to bonuses, even if they were eliminated as sources of bias in the evaluation analyses. FINDINGS: MSSP participation was associated with modest and increasing annual gross savings in the 2012-2013 entry cohorts of ACOs that reached $139 to $302 per patient by 2015. Savings in the 2014 entry cohort were small and not statistically significant. Robustness checks revealed no evidence of residual risk selection. Alternative methods to address risk selection produced results that were substantively consistent with our primary analysis but varied somewhat and were more sensitive to adjustment for patient characteristics, suggesting the introduction of bias from within-patient changes in time-varying characteristics. We found no evidence of ACO manipulation of provider composition or billing to inflate savings. Finally, larger savings for physician group ACOs were robust to consideration of differential changes in organizational structure among non-ACO providers (eg, from consolidation). CONCLUSIONS: Participation in the original MSSP program was associated with modest savings and not with favorable risk selection. These findings suggest an opportunity to build on early progress. Understanding the effect of new opportunities and incentives for risk selection in the revamped MSSP will be important for guiding future program reforms.

A Sleeping Giant: Community Pharmacy's Potential Is Unrivaled.

DISCLOSURES: No funding was received for the writing of this commentary. The author has nothing to disclose.

Trends in Costs of Care and Utilization for Medicaid Patients With Diabetes in Accountable Care Communities.

BACKGROUND/OBJECTIVES: Medicaid beneficiaries with diabetes have complex care needs. The Accountable Care Communities (ACC) Program is a practice-level intervention implemented by UnitedHealthcare to improve care for Medicaid beneficiaries. We examined changes in costs and utilization for Medicaid beneficiaries with diabetes assigned to ACC versus usual care practices. RESEARCH DESIGN: Interrupted time series with concurrent control group analysis, at the person-month level. The ACC was implemented in 14 states, and we selected comparison non-ACC practices from those states to control for state-level variation in Medicaid program. We adjusted the models for age, sex, race/ethnicity, comorbidities, seasonality, and state-by-year fixed effects. We examined the difference between ACC and non-ACC practices in changes in the time trends of expenditures and hospital and emergency room utilization, for the 4 largest categories of Medicaid eligibility [Temporary Assistance to Needy Families, Supplemental Security Income (without Medicare), Expansion, Dual-Eligible]. SUBJECTS/MEASURES: Eligibility and claims data from Medicaid adults with diabetes from 14 states between 2010 and 2016, before and after ACC implementation. RESULTS: Analyses included 1,200,460 person-months from 66,450 Medicaid patients with diabetes. ACC implementation was not associated with significant changes in outcome time trends, relative to comparators, for all Medicaid categories. CONCLUSIONS: Medicaid patients assigned to ACC practices had no changes in cost or utilization over 3 years of follow-up, compared with patients assigned to non-ACC practices. The ACC program may not reduce costs or utilization for Medicaid patients with diabetes.