Accountable Care Organization Leader Perspectives on the Medicare Shared Savings Program: A Qualitative Study.

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

Patient Experiences with and Preferences for Telemedicine Relative to In-Person Care During the COVID-19 Pandemic.

Introduction: Although telemedicine emerged during the COVID-19 pandemic as a critical mode of health care delivery, there may be differences in the perceived ease of patient-clinician communication and quality of care for telemedicine versus in-person visits, as well as variation in perceptions across patient subgroups. We examined patients' experiences with and preferences for telemedicine relative to in-person care, based on their most recent visit. Methods: We conducted a survey of 2,668 adults in a large academic health care system in November 2021. The survey captured patients' reasons for their most recent visit, perceptions on patient-clinician communication and quality of care, and attitudes toward telemedicine versus in-person care. Results: Among respondents, 552 (21%) had a telemedicine visit. Patients with telemedicine and in-person visits had similar agreement on ease of patient-clinician communication and perceived quality of the visit on average. However, for individuals 65 years of age or older, men, and those not needing urgent care, telemedicine was associated with worse perceptions of patient-clinician communication (65 years of age or older: adjusted odds ratio [aOR], 0.51; 95% confidence interval [CI], 0.31-0.85; men: aOR, 0.50; 95% CI, 0.31-0.81; urgent care: aOR 0.67; 95% CI, 0.49-0.91) and lower perceived quality (65 years of age or older, aOR 0.51; 95% CI, 0.30-0.86; men: 0.51; 95% CI, 0.32-0.83; urgent care: aOR 0.68; 95% CI, 0.49-0.93). Conclusion: Patient-perceived quality of care and patient-clinician communication were similar for telemedicine and in-person visits overall. However, among men, older adults, and those not seeking urgent care, patients using telemedicine had lower perceptions of patient-clinician communication and quality.

Variation in Procedural Denials of Medicaid Eligibility Across States Before the COVID-19 Pandemic.

This cross-sectional study examines denials of Medicaid and Children's Health Insurance Program coverage due to procedural reasons.

Many Intensive Care Units Were Overloaded While Nearby Hospitals Had Excess Capacity During The COVID-19 Pandemic.

Strained hospital capacity is associated with adverse patient outcomes. Anecdotal evidence suggests that during the COVID-19 pandemic in the US, some hospitals experienced capacity constraints while others in the same market had surplus capacity, a phenomenon known as "load imbalance." Our study evaluated the prevalence of intensive care unit load imbalance and the characteristics of hospitals most likely to be over capacity while other nearby hospitals were under capacity. Of the 290 hospital referral regions (HRRs) analyzed, 154 (53.1 percent) experienced load imbalance during the study period. HRRs experiencing the most imbalance had higher proportions of Black residents. Hospitals with the highest Medicaid patient shares and Black Medicare patient shares were significantly more likely to be over capacity, while other hospitals in their market were under capacity. Our findings highlight that hospital load imbalance was common during the COVID-19 pandemic. Policies to coordinate transfers may decrease strain during periods of high demand and ease the burden on hospitals that serve a higher proportion of patients from racial minority groups.

Realigning Reality With Intent in Funding Safety-Net Hospitals.

This Viewpoint discusses how revisiting the design and implementation of the disproportionate share hospital program represents a key policy lever for improving health equity in the US.

Variation And Changes In The Targeting Of Medicaid Disproportionate Share Hospital Payments.

Little is known about how Medicaid disproportionate share hospital payments, which are intended to support hospitals that serve low-income patients, are allocated or whether allocation patterns have changed over time. We employed alternative definitions of targeting, or the degree to which allocations were made in a manner consistent with the statutory goals and intent of the program, to examine disproportionate share hospital payment allocations in forty-nine participating states. The most recent data indicate that 57.2 percent of acute care hospitals received disproportionate share hospital payments, totaling more than $14.5 billion, in 2015. The majority of payments went to hospitals with Medicaid shares above the state-specific median (89.1 percent), hospitals with uncompensated care shares above the state-specific median (60.6 percent), or hospitals deemed as disproportionate share per statutory definitions (64.6 percent). However, among all hospitals receiving these payments, up to 31.6 percent of payments were allocated to hospitals that did not meet a given definition, and 3.2 percent went to hospitals that met none of them. These findings suggest that although the majority of the payments were targeted to hospitals serving low-income patients, opportunities exist to better align allocation with statutory goals and intent or to revise applicable statute.

Association Between Individual Primary Care Physician Merit-based Incentive Payment System Score and Measures of Process and Patient Outcomes.

Importance: The Medicare Merit-based Incentive Payment System (MIPS) influences reimbursement for hundreds of thousands of US physicians, but little is known about whether program performance accurately captures the quality of care they provide. Objective: To examine whether primary care physicians' MIPS scores are associated with performance on process and outcome measures. Design, Setting, and Participants: Cross-sectional study of 80 246 US primary care physicians participating in the MIPS program in 2019. Exposures: MIPS score. Main Outcomes and Measures: The association between physician MIPS scores and performance on 5 unadjusted process measures, 6 adjusted outcome measures, and a composite outcome measure. Results: The study population included 3.4 million patients attributed to 80 246 primary care physicians, including 4773 physicians with low MIPS scores (≤30), 6151 physicians with medium MIPS scores (>30-75), and 69 322 physicians with high MIPS scores (>75). Compared with physicians with high MIPS scores, physicians with low MIPS scores had significantly worse mean performance on 3 of 5 process measures: diabetic eye examinations (56.1% vs 63.2%; difference, -7.1 percentage points [95% CI, -8.0 to -6.2]; P < .001), diabetic HbA1c screening (84.6% vs 89.4%; difference, -4.8 percentage points [95% CI, -5.4 to -4.2]; P < .001), and mammography screening (58.2% vs 70.4%; difference, -12.2 percentage points [95% CI, -13.1 to -11.4]; P < .001) but significantly better mean performance on rates of influenza vaccination (78.0% vs 76.8%; difference, 1.2 percentage points [95% CI, 0.0 to 2.5]; P = .045] and tobacco screening (95.0% vs 94.1%; difference, 0.9 percentage points [95% CI, 0.3 to 1.5]; P = .001). MIPS scores were inconsistently associated with risk-adjusted patient outcomes: compared with physicians with high MIPS scores, physicians with low MIPS scores had significantly better mean performance on 1 outcome (307.6 vs 316.4 emergency department visits per 1000 patients; difference, -8.9 [95% CI, -13.7 to -4.1]; P < .001), worse performance on 1 outcome (255.4 vs 225.2 all-cause hospitalizations per 1000 patients; difference, 30.2 [95% CI, 24.8 to 35.7]; P < .001), and did not have significantly different performance on 4 ambulatory care-sensitive admission outcomes. Nineteen percent of physicians with low MIPS scores had composite outcomes performance in the top quintile, while 21% of physicians with high MIPS scores had outcomes in the bottom quintile. Physicians with low MIPS scores but superior outcomes cared for more medically complex and socially vulnerable patients, compared with physicians with low MIPS scores and poor outcomes. Conclusions and Relevance: Among US primary care physicians in 2019, MIPS scores were inconsistently associated with performance on process and outcome measures. These findings suggest that the MIPS program may be ineffective at measuring and incentivizing quality improvement among US physicians.

Structural Racial Disparities in the Allocation of Disproportionate Share Hospital Payments.

This cross-sectional study examines the allocation of Medicare and Medicaid Disproportionate Share Hospital payments by race.

Lobbying Expenditures in the US Health Care Sector, 2000-2020.

This cross-sectional study uses publicly available, nonpartisan data to evaluate trends in lobbying expenditures across health care industries.

Access to Primary and Specialty Health Care in the California State Prison Population During the COVID-19 Pandemic.

This cross-sectional study examines trends in referrals for and timely delivery of primary and specialty health care among individuals incarcerated in California state prisons during the COVID-19 pandemic.

In Medicaid Managed Care Networks, Care Is Highly Concentrated Among A Small Percentage Of Physicians.

States have increasingly outsourced the provision of Medicaid services to private managed care plans. To ensure that plans maintain access to care, many states set network adequacy standards that require plans to contract with a minimum number of physicians. In this study we used data from the period 2015-17 for four states to assess the level of Medicaid participation among physicians listed in the provider network directories of each managed care plan. We found that about one-third of outpatient primary care and specialist physicians contracted with Medicaid managed care plans in our sample saw fewer than ten Medicaid beneficiaries in a year. Care was highly concentrated: 25 percent of primary care physicians provided 86 percent of the care, and 25 percent of specialists, on average, provided 75 percent of the care. Our findings suggest that current network adequacy standards might not reflect actual access; new methods are needed that account for beneficiaries' preferences and physicians' willingness to serve Medicaid patients.

Association Between Patient Social Risk and Physician Performance Scores in the First Year of the Merit-based Incentive Payment System.

Importance: The US Merit-based Incentive Payment System (MIPS) is a major Medicare value-based payment program aimed at improving quality and reducing costs. Little is known about how physicians' performance varies by social risk of their patients. Objective: To determine the relationship between patient social risk and physicians' scores in the first year of MIPS. Design, Setting, and Participants: Cross-sectional study of physicians participating in MIPS in 2017. Exposures: Physicians in the highest quintile of proportion of dually eligible patients served; physicians in the 3 middle quintiles; and physicians in the lowest quintile. Main Outcomes and Measures: The primary outcome was the 2017 composite MIPS score (range, 0-100; higher scores indicate better performance). Payment rates were adjusted -4% to 4% based on scores. Results: The final sample included 284 544 physicians (76.1% men, 60.1% with ≥20 years in practice, 11.9% in rural location, 26.8% hospital-based, and 24.6% in primary care). The mean composite MIPS score was 73.3. Physicians in the highest risk quintile cared for 52.0% of dually eligible patients; those in the 3 middle risk quintiles, 21.8%; and those in the lowest risk quintile, 6.6%. After adjusting for medical complexity, the mean MIPS score for physicians in the highest risk quintile (64.7) was lower relative to scores for physicians in the middle 3 (75.4) and lowest (75.9) risk quintiles (difference for highest vs middle 3, -10.7 [95% CI, -11.0 to -10.4]; highest vs lowest, -11.2 [95% CI, -11.6 to -10.8]; P < .001). This relationship was found across specialties except psychiatry. Compared with physicians in the lowest risk quintile, physicians in the highest risk quintile were more likely to work in rural areas (12.7% vs 6.4%; difference, 6.3 percentage points [95% CI, 6.0 to 6.7]; P < .001) but less likely to care for more than 1000 Medicare beneficiaries (9.4% vs 17.8%; difference, -8.3 percentage points [95% CI, -8.7 to -8.0]; P < .001) or to have more than 20 years in practice (56.7% vs 70.6%; difference, -13.9 percentage points [95% CI, -14.4 to -13.3]; P < .001). For physicians in the highest risk quintile, several characteristics were associated with higher MIPS scores, including practicing in a larger group (mean score, 82.4 for more than 50 physicians vs 46.1 for 1-5 physicians; difference, 36.2 [95% CI, 35.3 to 37.2]; P < .001) and reporting through an alternative payment model (mean score, 79.5 for alternative payment model vs 59.9 for reporting as individual; difference, 19.7 [95% CI, 18.9 to 20.4]; P < .001). Conclusions and Relevance: In this cross-sectional analysis of physicians who participated in the first year of the Medicare MIPS program, physicians with the highest proportion of patients dually eligible for Medicare and Medicaid had significantly lower MIPS scores compared with other physicians. Further research is needed to understand the reasons underlying the differences in physician MIPS scores by levels of patient social risk.

Household Immigration Status Had Differential Impact On Medicaid Enrollment In Expansion And Nonexpansion States.

Recent research has shown that concern about the apprehension and deportation of undocumented immigrants can affect how members of their households who are eligible for public benefits choose to participate in public programs. The extent to which this "chilling effect" broadly affects adults' Medicaid enrollment nationally remains unclear, in part because of the difficulty of isolating undocumented immigrants in survey data. In this study we identified households that likely included undocumented immigrants and then examined whether gains in health care coverage due to the expansion of Medicaid eligibility under the Affordable Care Act (ACA) were dampened for eligible people living in households with mixed immigration status. We found no significant differences in coverage gains for people in mixed- relative to non-mixed-status households in expansion states. Coverage gains were significantly lower, however, for people in mixed-status households relative to those in non-mixed-status households in nonexpansion states. These findings suggest that household immigration status may have dampened the "woodwork effect," whereby the ACA enhanced knowledge about program availability, in turn increasing Medicaid enrollment in nonexpansion states among people previously eligible for the program but not enrolled in it.

Medicaid Expansion and Health Plan Quality in Medicaid Managed Care.

OBJECTIVE: To assess the effect of the 2014 Medicaid expansion on Medicaid managed care plan quality. DATA SOURCES: Three composite measures of plan-level quality constructed from the Health Care Effectiveness Data and Information Set. STUDY SETTING: One hundred and sixty-three plans in 27 Medicaid expansion states and 100 plans in 14 nonexpansion states. STUDY DESIGN: Quasi-experimental difference-in-differences (DID) analysis, comparing quality before (2011-13) and after (2014-15) Medicaid expansion in states that elected to expand Medicaid eligibility and those that did not. PRINCIPAL FINDINGS: Mean plan enrollment increased from 130,533 to 274,259 in expansion states and from 105,449 to 148,194 in nonexpansion states. The proportion of enrollees receiving recommended preventive care increased from 62.6 to 65.2 percent in expansion states and from 59.3 to 62.5 percent in nonexpansion states (adjusted DID: -0.7 percentage points [95% CI -2.2, 0.7]). The proportion of enrollees receiving recommended chronic disease care management increased from 65.4 to 66.0 percent in expansion states and from 62.5 to 63.1 percent in nonexpansion states (adjusted DID: 1.1 percentage points [95% CI -0.5, 2.6]). We observed similar patterns for the receipt of recommended maternity care. CONCLUSIONS: Medicaid expansion increased enrollment in managed care plans, but it did not result in erosion of quality.

For Selected Services, Blacks And Hispanics More Likely To Receive Low-Value Care Than Whites.

US minority populations receive fewer effective health services than whites. Using Medicare administrative data for 2006-11, we found no consistent, corresponding protection against the receipt of ineffective health services. Compared with whites, blacks and Hispanics were often more likely to receive the low-value services studied.

Association Between Health Plan Exit From Medicaid Managed Care and Quality of Care, 2006-2014.

Importance: State Medicaid programs have increasingly contracted with insurers to provide medical care services for enrollees (Medicaid managed care plans). Insurers that provide these plans can exit Medicaid programs each year, with unclear effects on quality of care and health care experiences. Objective: To determine the frequency and interstate variation of health plan exit from Medicaid managed care and evaluate the relationship between health plan exit and market-level quality. Design, Setting, and Participants: Retrospective cohort of all comprehensive Medicaid managed care plans (N = 390) during the interval 2006-2014. Exposures: Plan exit, defined as the withdrawal of a managed care plan from a state's Medicaid program. Main Outcomes and Measures: Eight measures from the Healthcare Effectiveness Data and Information Set were used to construct 3 composite indicators of quality (preventive care, chronic disease care management, and maternity care). Four measures from the Consumer Assessment of Healthcare Providers and Systems were combined into a composite indicator of patient experience, reflecting the proportion of beneficiaries rating experiences as 8 or above on a 0-to-10-point scale. Outcome data were available for 248 plans (68% of plans operating prior to 2014, representing 78% of beneficiaries). Results: Of the 366 comprehensive Medicaid managed care plans operating prior to 2014, 106 exited Medicaid. These exiting plans enrolled 4 848 310 Medicaid beneficiaries, with a mean of 606 039 beneficiaries affected by plan exits annually. Six states had a mean of greater than 10% of Medicaid managed care recipients enrolled in plans that exited, whereas 10 states experienced no plan exits. Plans that exited from a state's Medicaid market performed significantly worse prior to exiting than those that remained in terms of preventive care (57.5% vs 60.4%; difference, 2.9% [95% CI, 0.3% to 5.5%]), maternity care (69.7% vs 73.6%; difference, 3.8% [95% CI, 1.7% to 6.0%]), and patient experience (73.5% vs 74.8%; difference, 1.3% [95% CI, 0.6% to 1.9%]). There was no significant difference between exiting and nonexiting plans for the quality of chronic disease care management (76.2% vs 77.1%; difference, 1.0% [95% CI, -2.1% to 4.0%]). There was also no significant change in overall market performance before and after the exit of a plan: 0.7-percentage point improvement in preventive care quality (95% CI, -4.9 to 6.3); 0.2-percentage point improvement in chronic disease care management quality (95% CI, -5.8 to 6.2); 0.7-percentage point decrease in maternity care quality (95% CI, -6.4 to 5.0]); and a 0.6-percentage point improvement in patient experience ratings (95% CI, -3.9 to 5.1). Medicaid beneficiaries enrolled in exiting plans had access to coverage for a higher-quality plan, with 78% of plans in the same county having higher quality for preventive care, 71.1% for chronic disease management, 65.5% for maternity care, and 80.8% for patient experience. Conclusions and Relevance: Between 2006 and 2014, health plan exit from the US Medicaid program was frequent. Plans that exited generally had lower quality ratings than those that remained, and the exits were not associated with significant overall changes in quality or patient experience in the plans in the Medicaid market.

Evidence Suggests That The ACA's Tobacco Surcharges Reduced Insurance Take-Up And Did Not Increase Smoking Cessation.

To account for tobacco users' excess health care costs and encourage cessation, the Affordable Care Act (ACA) allowed insurers to impose a surcharge on tobacco users' premiums for plans offered on the health insurance exchanges, or Marketplaces. Low-income tax credits for Marketplace coverage were based on premiums for non-tobacco users, which means that these credits did not offset any surcharge costs. Thus, this policy greatly increased out-of-pocket premiums for many tobacco users. Using data for 2011-14 from the Behavioral Risk Factor Surveillance System, we examined the effect of tobacco surcharges on insurance status and smoking cessation in the first year of the exchanges' implementation, among adults most likely to purchase insurance from them. Relative to smokers who faced no surcharges, smokers facing medium or high surcharges had significantly reduced coverage (reductions of 4.3 percentage points and 11.6 percentage points, respectively), but no significant differences in smoking cessation. In contrast, those facing low surcharges showed significantly less smoking cessation. Taken together, these findings suggest that tobacco surcharges conflicted with a major goal of the ACA-increased financial protection-without increasing smoking cessation. States should consider these potential effects when deciding whether to limit surcharges to less than the federal maximum.