Financial Performance of Accountable Care Organizations: A 5-Year National Empirical Analysis.

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.

Association of ACO Shared Savings Success and Serious Illness Spending.

EXECUTIVE SUMMARY: Accountable care organizations (ACOs) need confidence in their return on investment to implement changes in care delivery that prioritize seriously ill and high-cost Medicare beneficiaries. The objective of this study was to characterize spending on seriously ill beneficiaries in ACOs with Medicare Shared Savings Program (MSSP) contracts and the association of spending with ACO shared savings. The population included Medicare fee-for-service beneficiaries identified with serious illness (N = 2,109,573) using the Medicare Master Beneficiary Summary File for 100% of ACO-attributed beneficiaries linked to MSSP beneficiary files (2014-2016). Lower spending for seriously ill Medicare beneficiaries and risk-bearing contracts in ACOs were associated with achieving ACO shared savings in the MSSP. For most ACOs, the seriously ill contribute approximately half of the spending and constitute 8%-13% of the attributed population. Patient and geographic (county) factors explained $2,329 of the observed difference in per beneficiary per year spending on seriously ill beneficiaries between high- and low-spending ACOs. The remaining $12,536 may indicate variation as a result of potentially modifiable factors. Consequently, if 10% of attributed beneficiaries were seriously ill, an ACO that moved from the worst to the best quartile of per capita serious illness spending could realize a reduction of $1,200 per beneficiary per year for the ACO population overall. Though the prevalence and case mix of seriously ill populations vary across ACOs, this association suggests that care provided for seriously ill patients is an important consideration for ACOs to achieve MSSP shared savings.

Prospective or retrospective ACO attribution matters for seriously ill patients.

OBJECTIVES: Since 2019, the Medicare Shared Savings Program (MSSP) has allowed accountable care organizations (ACOs) to choose either retrospectively or prospectively attributed ACO populations. To understand how ACOs' choice of attribution method affects incentives for care among seriously ill Medicare beneficiaries, this study compares beneficiary characteristics and Medicare per capita expenditures between prospective and retrospective ACO populations. STUDY DESIGN: This retrospective, cross-sectional analysis describes survival, patient characteristics, and Medicare spending for Medicare fee-for-service beneficiaries identified with serious illness (n = 1,600,629) using 100% Medicare Master Beneficiary Summary and MSSP beneficiary files (2014-2016). METHODS: We used generalized linear models with ACO and year fixed effects to estimate the average within-ACO difference between potential retrospective and prospective ACO populations. RESULTS: Dying in the first 90 days of the performance year was associated with reduced odds of retrospective ACO attribution (odds ratio [OR], 0.24; 95% CI, 0.24-0.25) relative to beneficiaries surviving 270 days or longer. Similarly, hospice use was associated with reduced odds of retrospective assignment (OR, 0.80; 95% CI, 0.79-0.80). Among ACOs that did not achieve shared savings, average per capita Medicare expenditures (after truncation) were $2459 (95% CI, $2192-$2725) higher for prospective vs retrospective ACO populations. The difference was $834 (95% CI, $402-$1266) greater per capita among ACOs that achieved shared savings. CONCLUSIONS: The difference in survival and spending for ACO populations captured by prospective vs retrospective attribution methods means that ACOs may need to employ different care management strategies to improve performance depending on their attribution method.

Accountable care organizations are increasingly led by physician groups rather than hospital systems.

Because hospitals and health systems sponsored the majority of new accountable care organizations (ACOs) from 2010 to 2015, they influenced priorities and strategies of the policies designed to drive ACO adoption. In recent years, however, the majority of new ACOs have been sponsored by physician groups. This shift means that policies need to be developed with the characteristic strengths and weaknesses of physician-led ACOs in mind. Using data from the Leavitt Partners ACO database, we analyzed the types of providers becoming ACOs over time to look at their numbers and market potential. Because the market potential for further growth of physician group-led ACOs is much stronger than for hospital- or health system-led ACOs, policy makers need to create programs and policies that facilitate physician-led ACOs' success by helping them develop the capacity to take on risk, finance investments in high-value healthcare, and partner with other organizations to provide the full spectrum of care.

ACO Serious Illness Care: Survey And Case Studies Depict Current Challenges And Future Opportunities.

Care for people living with serious illness is suboptimal for many reasons, including underpayment for key services (such as care coordination and social supports) in fee-for-service reimbursement. Accountable care organizations (ACOs) have potential to improve serious illness care because of their widespread dissemination, strong financial incentives for care coordination in downside-risk models, and flexibility in shared savings spending. Through a national survey we found that 94 percent of ACOs at least partially identify their seriously ill beneficiaries, yet only 8-21 percent have widely implemented serious illness initiatives such as advance care planning or home-based palliative care. We selected six diverse ACOs with successful programs for case studies and interviewed fifty-three leaders and front-line personnel. Cross-cutting themes include the need for up-front investment beyond shared savings to build serious illness infrastructure and workforce; supporting the business case for organizational buy-in; how ACO contract specifications affect savings for serious illness populations; and using data and health information technology to manage populations. We discuss the implications of the recent Medicare ACO regulatory overhaul and other policies related to serious illness quality measures, risk adjustment, attribution methods, supporting rural ACOs, and enhancing timely data access.

Accountable Care Organizations' Performance in Depression: Lessons for Value-Based Payment and Behavioral Health.

Value-based payment initiatives, such as the Medicare Shared Savings Program (MSSP), offer the possibility of using financial incentives to drive improvements in mental health and substance use outcomes. In the past 2 years, Accountable Care Organizations (ACOs) participating in the MSSP began to publicly report on one behavioral health outcome-Depression Remission at Twelve Months, which may indicate how value-based payment incentives have impacted mental health and substance use, and if reforms are needed. For ACOs that meaningfully reported performance on the depression remission measure in 2017, the median rate of depression remission at 12 months was 8.33%. A recent meta-analysis found that the average rate of spontaneous depression remission at 12 months absent treatment was approximately 53%. Although a number of factors likely explain these results, the current ACO design does not appear to incentivize improved behavioral health outcomes. Four changes in value-based payment incentive design may help to drive better outcomes: (1) making data collection easier, (2) increasing the salience of incentives, (3) building capacity to implement new interventions, and (4) creating safeguards for inappropriate treatment or reporting.

Why Do Accountable Care Organizations Leave The Medicare Shared Savings Program?

The ability of accountable care organizations (ACOs) to continue reducing costs and improving quality depends on understanding what affects their survival. We examined such factors for survival in the Medicare Shared Savings Program (MSSP) of 624 ACOs between performance years 2013 and 2017 (1,849 ACO-years). Overall, ACO exits from the MSSP decreased after ACOs' third year. Shared-savings bonus payment achievement, more care coordination, higher financial performance benchmarks, market-level Medicare cost growth, lower-risk patients, and contracts with upside-only risk were associated with longer survival. Quality scores, postacute care spending, organizational traits, and most market-context characteristics had no significant association with survival, which indicates that diverse organizations and markets can be successful. Put in context with the recently finalized MSSP rule from December 2018, our findings suggest that while new flexibilities for low-revenue ACOs likely reduce uncertainty for some, MSSP ACOs may need more than the new period of one to three years to prepare for downside risk. Policy makers should offer more support to ACOs (especially those with higher-risk patients) for building organizational competencies and should consider how benchmarking policy can fairly assess ACOs from regions with differing levels of cost growth.

Patient-centered care innovations by accountable care organizations: Lessons from leaders.

Although there is a widespread belief that ACOs must be patient-centered to be successful, evidence to guide them in achieving that goal has been lacking. This case report examines four ACO innovators in patient-centered care that together represent urban, suburban and rural populations with a broad range of economic, racial, ethnic and geographic diversity. Seven patient-centeredness strategies emerged: transform primary care practices into patient-centered medical homes; move upstream to address social and economic issues; use both high-tech and high-touch to identify and engage high-risk patients; practice a whole-person orientation; optimize patient-reported measures; treat patients like valued customers; and incorporate patient voices into governance and operations. Exemplars prioritized direct care interventions perceived as central to financial and clinical success, and organizational maturity played a role. Activities that decreased the traditional system's authority, such as incorporating patient voices, were less popular. Local practice factors were important, and a mixture of mission and margin energized front-line staff in implementing patient-centered care as "the right thing to do." Unresolved questions remain that are related to the impact of individual and multiple interventions and how successful interventions can be disseminated widely. In order for patient-centeredness innovations to enable transformation, providers, payers and policymakers alike must consciously adopt strategies that nurture it.

Preventable Hospital Admissions and 30-Day All-Cause Readmissions: Does Hospital Participation in Accountable Care Organizations Improve Quality of Care?

This study evaluates quality performance of hospitals participating in Medicare Shared Savings and Pioneer Accountable Care Organization (ACO) programs relative to nonparticipating hospitals. Overall, 198 ACO participating and 1210 propensity score matched, nonparticipating hospitals were examined in a difference-in-difference analysis, using data from 17 states in the years 2010-2013. The authors studied preventable hospitalizations for conditions sensitive to high-quality ambulatory care-chronic obstructive pulmonary disease (COPD) and asthma, chronic heart failure (CHF), complications of diabetes-and 30-day all-cause readmissions potentially influenced by hospital care. A decrease was found in preventable hospitalizations for COPD and asthma and for diabetes complications for ACO participating hospitals, but no significant differences for preventable CHF hospitalizations and 30-day readmissions. Mixed results may be attributable to insufficient incentives for ACO participating hospitals to decrease 30-day readmissions, whereas disease-focused initiatives may have a beneficial effect on preventable hospitalizations for COPD and asthma and complications of diabetes.

Assessing Provider Partnerships For Accountable Care Organizations.

PURPOSE: Understand current provider approaches to the evaluation of various partnerships under accountable care contracts and create a framework to help accountable care organizations (ACOs) better assess their partnerships. DESIGN: Study included (1) an in-depth literature review of materials describing high-value health care organizations as a foundation for draft framework development, (2) an expert panel convened to evaluate the framework and help prioritize provider types to evaluate, and (3) interviews with representatives of ACOs and entities representing various types of health care providers. METHODOLOGY: Authors created a draft partnership framework derived from the literature review for expert panel feedback. An updated draft framework was then shared with active ACO leaders prior to qualitative interviews. All interviews were transcribed and coded using a mixed-methods analysis platform. RESULTS: We found little research that took a comprehensive view of health care provider competencies and characteristics and by extension few resources to help ACOs fill competency gaps through partnerships. The ACOs interviewed were all actively engaged in provider partnerships and were learning and establishing best practices for provider partnerships. CONCLUSIONS: Accountable care offers incentives for entities to improve the cost and quality of health care. To accomplish this in an effective way, ACOs must recognize the needs of their assigned populations and work to provide comprehensive care management across the spectrum of provider types. Accomplishing this will also require ACOs to create novel partnership arrangements and learn how to manage populations most effectively. ACOs need a framework for evaluating potential partners that will help risk-bearing providers establish the partnerships that will enable them to achieve their goals. This paper makes specific recommendations on how state and federal policy could facilitate better and more effective provider partnerships.

Optimization of Medication Use at Accountable Care Organizations.

BACKGROUND: Optimized medication use involves the effective use of medications for better outcomes, improved patient experience, and lower costs. Few studies systematically gather data on the actions accountable care organizations (ACOs) have taken to optimize medication use. OBJECTIVES: To (a) assess how ACOs optimize medication use; (b) establish an association between efforts to optimize medication use and achievement on financial and quality metrics; (c) identify organizational factors that correlate with optimized medication use; and (d) identify barriers to optimized medication use. METHODS: This cross-sectional study consisted of a survey and interviews that gathered information on the perceptions of ACO leadership. The survey contained a medication practices inventory (MPI) composed of 38 capabilities across 6 functional domains related to optimizing medication use. ACOs completed self-assessments that included rating each component of the MPI on a scale of 1 to 10. Fisher's exact tests, 2-proportions tests, t-tests, and logistic regression were used to test for associations between ACO scores on the MPI and performance on financial and quality metrics, and on ACO descriptive characteristics. RESULTS: Of the 847 ACOs that were contacted, 49 provided usable survey data. These ACOs rated their own system's ability to manage the quality and costs of optimizing medication use, providing a 64% and 31% affirmative response, respectively. Three ACOs achieved an overall MPI score of 8 or higher, 45 scored between 4 and 7.9, and 1 scored between 0 and 3.9. Using the 3 score groups, the study did not identify a relationship between MPI scores and achievement on financial or quality benchmarks, ACO provider type, member volume, date of ACO creation, or the presence of a pharmacist in a leadership position. Barriers to optimizing medication use relate to reimbursement for pharmacist integration, lack of health information technology interoperability, lack of data, feasibility issues, and physician buy-in. CONCLUSIONS: Compared with 2012 data, data on ACOs that participated in this study show that they continue to build effective strategies to optimize medication use. These ACOs struggle with both notification related to prescription use and measurement of the influence optimized medication use has on costs and quality outcomes. Compared with the earlier study, these data find that more ACOs are involving pharmacists directly in care, expanding the use of generics, electronically transmitting prescriptions, identifying gaps in care and potential adverse events, and educating patients on therapeutic alternatives. ACO-level policies that facilitate practices to optimize medication use are needed. Integrating pharmacists into care, giving both pharmacists and physicians access to clinical data, obtaining physician buy-in, and measuring the impact of practices to optimize medication use may improve these practices. DISCLOSURES: This research was sponsored and funded by the National Pharmaceutical Council (NPC), an industry funded health policy research group that is not involved in lobbying or advocacy. Employees of the sponsor contributed to the research questions, determination of the relevance of the research questions, and the research design. Specifically, there was involvement in the survey and interview instruments. They also contributed to some data interpretation and revision of the manuscript. Leavitt Partners was hired by NPC to conduct research for this study and also serves a number of health care clients, including life sciences companies, provider organizations, accountable care organizations, and payers. Westrich and Dubois are employed by the NPC. Wilks, Krisle, Lunner, and Muhlestein are employed by Leavitt Partners and did not receive separate compensation. Study concept and design were contributed by Krisle, Dubois, and Muhlestein, along with Lunner and Westrich. Krisle and Muhlestein collected the data, and data interpretation was performed by Wilks, Krisle, and Muhlestein, along with Dubois and Westrich. The manuscript was written primarily by Wilks, along with Krisle and Muhlestein, and revised by Wilks, Westrich, Lunner, and Krisle. Preliminary versions of this work were presented at the following: National Council for Prescription Drug Programs Educational Summit, November 1, 2016; Academy Health 2016 Annual Research Meeting, June 27, 2016; Accountable Care Learning Collaborative Webinar, June 16, 2016; the 21st Annual PBMI Drug Benefit Conference, February 29, 2016; National Value-Based Payment and Pay for Performance Summit, February 17, 2016; National Accountable Care Congress, November 17, 2015; and American Journal of Managed Care's ACO Emerging Healthcare Delivery Coalition, Fall 2015 Live Meeting, October 15, 2015.

Patient experience and hospital profitability: Is there a link?

BACKGROUND: Patient experience has had a direct financial impact on hospitals since value-based purchasing was instituted by the Centers for Medicare & Medicaid Services in 2013 as a method to reward or punish hospitals based on performance on various measures, including patient experience. Although other industries have shown an indirect impact of customer experience on overall profitability, that link has not been well established in the health care industry. Return-to-provider rate and perceptions of health quality have been associated with profitability in the health care industry. PURPOSE: Our aims were to assess whether, independent of a direct financial impact, a more positive patient experience is associated with increased profitability and whether a more negative patient experience is associated with decreased profitability. METHODOLOGY/APPROACH: We used a sample of 19,792 observations from 3767 hospitals over the 6-year period 2007-2012. The data were sourced from Centers for Medicare & Medicaid Services and Hospital Consumer Assessment of Healthcare Providers and Systems. Using generalized estimating equations to account for repeated measures, we fit four separate models for three dependent variables: net patient revenue, net income, and operating margin. Each model included one of the following independent variables of interest: percentage of patients who definitely recommend the hospital, percentage of patients who definitely would not recommend the hospital, percentage of patients who rated the hospital 9 or 10, and percentage of patients who rated the hospital 6 or lower. FINDINGS: We identified that a positive patient experience is associated with increased profitability and a negative patient experience is even more strongly associated with decreased profitability. PRACTICE IMPLICATIONS: Management should have greater justification for incurring costs associated with bolstering patient experience programs. Improvements in training, technology, and staffing can be justified as a way to improve not only quality but now profitability as well.

Optimization of Medication Use at Accountable Care Organizations.

BACKGROUND: Optimized medication use involves the effective use of medications for better outcomes, improved patient experience, and lower costs. Few studies systematically gather data on the actions accountable care organizations (ACOs) have taken to optimize medication use. OBJECTIVES: To (a) assess how ACOs optimize medication use; (b) establish an association between efforts to optimize medication use and achievement on financial and quality metrics; (c) identify organizational factors that correlate with optimized medication use; and (d) identify barriers to optimized medication use. METHODS: This cross-sectional study consisted of a survey and interviews that gathered information on the perceptions of ACO leadership. The survey contained a medication practices inventory (MPI) composed of 38 capabilities across 6 functional domains related to optimizing medication use. ACOs completed self-assessments that included rating each component of the MPI on a scale of 1 to 10. Fisher's exact tests, 2-proportions tests, t-tests, and logistic regression were used to test for associations between ACO scores on the MPI and performance on financial and quality metrics, and on ACO descriptive characteristics. RESULTS: Of the 847 ACOs that were contacted, 49 provided usable survey data. These ACOs rated their own system's ability to manage the quality and costs of optimizing medication use, providing a 64% and 31% affirmative response, respectively. Three ACOs achieved an overall MPI score of 8 or higher, 45 scored between 4 and 7.9, and 1 scored between 0 and 3.9. Using the 3 score groups, the study did not identify a relationship between MPI scores and achievement on financial or quality benchmarks, ACO provider type, member volume, date of ACO creation, or the presence of a pharmacist in a leadership position. Barriers to optimizing medication use relate to reimbursement for pharmacist integration, lack of health information technology interoperability, lack of data, feasibility issues, and physician buy-in. CONCLUSIONS: Compared with 2012 data, data on ACOs that participated in this study show that they continue to build effective strategies to optimize medication use. These ACOs struggle with both notification related to prescription use and measurement of the influence optimized medication use has on costs and quality outcomes. Compared with the earlier study, these data find that more ACOs are involving pharmacists directly in care, expanding the use of generics, electronically transmitting prescriptions, identifying gaps in care and potential adverse events, and educating patients on therapeutic alternatives. ACO-level policies that facilitate practices to optimize medication use are needed. Integrating pharmacists into care, giving both pharmacists and physicians access to clinical data, obtaining physician buy-in, and measuring the impact of practices to optimize medication use may improve these practices. DISCLOSURES: This research was sponsored and funded by the National Pharmaceutical Council (NPC), an industry funded health policy research group that is not involved in lobbying or advocacy. Employees of the sponsor contributed to the research questions, determination of the relevance of the research questions, and the research design. Specifically, there was involvement in the survey and interview instruments. They also contributed to some data interpretation and revision of the manuscript. Leavitt Partners was hired by NPC to conduct research for this study and also serves a number of health care clients, including life sciences companies, provider organizations, accountable care organizations, and payers. Westrich and Dubois are employed by the NPC. Wilks, Krisle, Lunner, and Muhlestein are employed by Leavitt Partners and did not receive separate compensation. Study concept and design were contributed by Krisle, Dubois, and Muhlestein, along with Lunner and Westrich. Krisle and Muhlestein collected the data, and data interpretation was performed by Wilks, Krisle, Muhlestein, along with Dubois and Westrich. The manuscript was written primarily by Wilks, along with Krisle and Muhlestein, and revised by Wilks, Westrich, Lunner, and Krisle. Preliminary versions of this work were presented at the following: National Council for Prescription Drug Programs Educational Summit, November 1, 2016; Academy Health 2016 Annual Research Meeting, June 27, 2016; Accountable Care Learning Collaborative Webinar, June 16, 2016; the 21st Annual PBMI Drug Benefit Conference, February 29, 2016; National Value-Based Payment and Pay for Performance Summit, February 17, 2016; National Accountable Care Congress, November 17, 2015; and American Journal of Managed Care's ACO Emerging Healthcare Delivery Coalition, Fall 2015 Live Meeting, October 15, 2015.

Physician Consolidation: Rapid Movement From Small To Large Group Practices, 2013-15.

In the past few decades there has been a trend of physicians moving from smaller to larger group practices. We found that this trend continued in the period 2013-15. Primary care physicians have made this change at a much faster pace than specialists have.

Hospital participation in ACOs associated with other value-based program improvement.

OBJECTIVES: This paper analyzes whether hospital participation in an accountable care organization (ACO) impacts a hospital's quality improvement and cost reduction outcomes in other value-based purchasing (VBP) programs, including the Hospital Value-Based Purchasing Program (HVBP), the Hospital Readmissions Reduction Program (HRRP), and the Hospital-Acquired Conditions (HAC) Reduction Program. STUDY DESIGN: Using VBP performance data and Leavitt Partners' ACO data, 2 analyses were performed: 1) a descriptive comparison of VBP performance of hospital ACOs compared with non-ACO hospitals, and 2) a longitudinal analysis of hospitals that became part of an ACO during the second year of performance data. METHODS: In the descriptive analysis, we compared VBP scores for hospital ACOs with non-ACO hospitals. To estimate the effect that becoming an ACO had on a hospital, we evaluated the performance of hospitals that became part of an ACO to all hospitals that never became part of an ACO. RESULTS: For fiscal year 2016, hospital ACOs performed better than non-ACO hospitals for the HRRP, but not on the HVBP and the HAC Reduction Programs. Longitudinal analysis, however, reveals that results are varied, with evidence that hospitals joining ACOs did increasingly better than their peers for the HRRP, but had inconsistent results year-over-year with the HVBP. CONCLUSIONS: Despite similar goals, hospital participation in an ACO is not correlated with improved performance in all Medicare VBP programs. Organizations pursuing accountable care and also attempting to maximize Medicare VBP program performance must recognize the differences in program objectives and create strategies unique to each.

Hospitals Participating In ACOs Tend To Be Large And Urban, Allowing Access To Capital And Data.

Relationships between physicians and hospitals have changed considerably over the past decade, as hospitals and physician groups have integrated and new public and private payment policies have created financial interdependence. The extent to which accountable care organizations (ACOs) involve hospitals in their operations may prove to be vitally important, because managing hospital care is a key part of improving health care quality and lowering cost growth. Using primary data on ACO composition and capabilities paired with hospital characteristics, we found that 20 percent of US hospitals were part of an ACO in 2014. Hospitals that were in urban areas, were nonprofit, or had a smaller share of Medicare patients were more likely to participate in ACOs, compared to hospitals that were in more rural areas, were for-profit or government owned, or had a larger share of Medicare patients, respectively. Qualitative data identified the following advantages of including a hospital in an ACO: the availability of start-up capital, advanced data sharing, and engagement of providers across the care continuum. Although the 63 percent of ACOs that included hospitals offered more comprehensive services compared to ACOs without hospitals, we found no differences between the two groups in their ability to manage hospital-related aspects of patient care.

Children's Insurance Coverage and Crowd-Out Through the Recession: Lessons From Ohio.

OBJECTIVES: We estimated changes in children's insurance status (publicly insured, privately insured, or uninsured) and crowd-out rates during the 2007 to 2009 US recession in Ohio. METHODS: We conducted an estimate of insurance coverage from statewide, randomized telephone surveys in 2004, 2008, 2010, and 2012. We estimated crowd-out by using regression discontinuity. RESULTS: From 2004 to 2012, private insurance rates dropped from 67% to 55% and public rates grew from 28% to 40%, with no change in the uninsured rate for children. Despite a 12.0% decline in private coverage and a corresponding 12.6% increase in public coverage, we found no evidence that crowd-out increased during this period. CONCLUSIONS: Children, particularly those with household incomes lower than 400% of the federal poverty level, were enrolled increasingly in public insurance rather than private coverage. Near the Medicaid eligibility threshold, this is not from an increase in crowd-out. An alternative explanation for the increase in public coverage would be the decline in incomes for households with children.

Differences in preeclampsia rates between African American and Caucasian women: trends from the National Hospital Discharge Survey.

BACKGROUND: African Americans are at higher risk for preeclampsia compared with Caucasians, but longitudinal changes are unknown. We hypothesized that preeclampsia rates among African Americans would be higher than that of Caucasians and over time would maintain a consistent divergence. METHODS: We analyzed the annual prevalence rates and calculated prevalence odds ratios (POR) with 95% confidence intervals (95% CI) for preeclampsia comparing 4,644 African American (weighted 608,109) with 12,131 Caucasian (weighted 1,844,391) women from the National Hospital Discharge Survey (1979-2006), including all women for whom a delivery was associated with preeclampsia. We estimated the race-specific prevalence of preeclampsia while adjusting for age, geographic region, diabetes, essential hypertension, prior myocardial infarction, heart failure, benign essential hypertension complicating a pregnancy, transient hypertension, and gestational diabetes. RESULTS: There was an increasing trend in preeclampsia rates per year from 1979 to 2006 for African Americans [POR 0.76 (95% CI 0.49, 1.03)] and Caucasians [0.29 (95% CI 0.17, 0.41)]. However, there was an initial decrease in prevalence from 1979-1988 among African-Americans [-0.96 (95% CI -1.78, -0.14)] that was not seen in Caucasians [0.12 (95% CI -0.33, 0.57)]. Across all study years, preeclampsia rates remained higher for African Americans compared to Caucasians, from a POR of 0.98 (95% CI 0.96, 1.0) to POR of 1.75 (95% CI 1.73, 1.78). CONCLUSION: There was an increase in the prevalence of preeclampsia in African Americans compared to Caucasians in the most recent decade under study. This may be explained by healthcare system changes and disparities in obesity. Action is needed to reduce the trajectory of future cardiovascular disease caused by preeclampsia.

Social media: how hospitals use it, and opportunities for future use.

When used effectively, social media benefits hospitals through increased revenue, employee recruitment, and increased customer satisfaction. Although 72% of adults who use the Internet engage in social media, little is known about its prevalence among hospitals and the ways in which hospitals use it. We examined hospital characteristics associated with social media use and how U.S. hospitals use Facebook. Through analysis of websites and Facebook pages, we found that seven in 10 hospitals use social media and that 9% of hospitals with a Facebook page do not provide a link to it from their web page. The odds of social media use were greater in large, urban, nonprofit hospitals; at hospitals affiliated with universities or health systems; and at hospitals that emphasize quality metrics or educational information. Hospitals use Facebook as a dissemination strategy to educate consumers, acknowledge staff, and share news of the hospital's awards. However, the majority of hospitals do not actively engage consumers on Facebook pages. We conclude that this lack of engagement is a lost opportunity to enhance customer service, improve quality of care, and build loyalty. For hospital executives, we illustrate that Facebook is underutilized and that considerable opportunity exists for consumer engagement at a low cost. For policymakers, there is a greater use of social media by nonprofit hospitals, compared to for-profit facilities. As Facebook is most commonly used as an educational tool, it is another example of nonprofit hospitals' heightened focus on health promotion and disease prevention.