Longitudinal participation in delivery and payment reform programs among US Primary Care Organizations.

OBJECTIVE: To assess longitudinal primary care organization participation patterns in large-scale reform programs and identify organizational characteristics associated with multiprogram participation. DATA SOURCES: Secondary data analysis of national program participation data over an eight-year period (2009-2016). STUDY DESIGN: We conducted a retrospective, observational study by creating a unique set of data linkages (including Medicare and Medicaid Meaningful Use and Medicare Shared Savings Program Accountable Care Organization (MSSP ACO) participation from CMS, Patient-Centered Medical Home (PCMH) participation from the National Committee for Quality Assurance, and organizational characteristics) to measure longitudinal participation and identify what types of organizations participate in one or more of these reform programs. We used multivariate models to identify organizational characteristics that differentiate those that participate in none, one, or two-to-three programs. DATA EXTRACTION METHODS: We used Medicare claims to identify organizations that delivered primary care services (n = 56 ,287) and then linked organizations to program participation data and characteristics. PRINCIPAL FINDINGS: No program achieved more than 50% participation across the 56,287 organizations in a given year, and participation levels flattened or decreased in later years. 36% of organizations did not participate in any program over the eight-year study period; 50% participated in one; 13% in two; and 1% in all three. 14.31% of organizations participated in five or more years of Meaningful Use while 3.84% of organizations participated in five years of the MSSP ACO Program and 0.64% participated in at least five years of PCMH. Larger organizations, those with younger providers, those with more primary care providers, and those with larger Medicare patient panels were more likely to participate in more programs. CONCLUSIONS AND RELEVANCE: Primary care transformation via use of voluntary programs, each with their own participation requirements and approach to incentives, has failed to broadly engage primary care organizations. Those that have chosen to participate in multiple programs are likely those already providing high-quality care.

Dying with dementia in Medicare Advantage, Accountable Care Organizations, or traditional Medicare.

BACKGROUND/OBJECTIVE: Medicare Advantage (MA) and Accountable Care Organizations (ACOs) operate under incentives to reduce burdensome and costly care at the end of life. We compared end-of-life care for persons with dementia who are in MA, ACOs, or traditional Medicare (TM). DESIGN, SETTING, AND PARTICIPANTS: Retrospective study of decedents with dementia enrolled in MA, attributed to an ACO, or in TM. Decedents had a nursing home stay between 91 and 180 days prior to death, two or more functional impairments, and mild to severe cognitive impairment. MEASUREMENTS: Hospitalization, invasive mechanical ventilation (IMV) use, and in-hospital death in the last 30 days of life reported in Medicare billing. RESULTS: Among 370,094 persons with dementia, 93,801 (25.4%) were in MA (mean age [SD], 86.9 [7.7], 67.6% female), 39,586 (10.7%) were ACO attributed (mean age [SD], 87.2 [7.6], 67.3% female), and 236,707 (63.9%) were in TM (mean age [SD], 87.0 [7.8], 67.6% female). The proportion hospitalized in the last 30 days of life was higher among TM enrollees (27.9%) and those ACO attributed (28.1%) than among MA enrollees (20.5%, p ≤ 0.001). After adjustment for socio-demographics, cognitive and functional impairments, comorbidities, and Hospital Referral Region, adjusted odds of hospitalization in the 30 days prior to death was 0.72 (95% confidence interval [CI] 0.70-0.74) among MA enrollees and 1.05 (95% CI 1.02-1.09) among those attributed to ACOs relative to TM enrollees. Relative to TM, the adjusted odds of death in the hospital were 0.78 (95% CI 0.75-0.81) among MA enrollees and 1.02 (95% CI 0.96-1.08) for ACO participants. Dementia decedents in MA had a lower likelihood of IMV use (adjusted odds ratio 0.80, 95% CI 0.75-0.85) compared to TM. CONCLUSIONS: Among decedents with dementia, MA enrollees but not decedents in ACOs experienced less costly and potentially burdensome care compared with those with TM. Policy changes are needed for ACOs.

Effect of Community Health Workers on 30-Day Hospital Readmissions in an Accountable Care Organization Population: A Randomized Clinical Trial.

Importance: Value-based care within accountable care organizations (ACOs) has magnified the importance of reducing preventable hospital readmissions. Community health worker (CHW) interventions may address patients' unmet psychosocial and clinical care needs but have been underused in inpatient and postdischarge care. Objective: To determine if pairing hospitalized patients with ACO insurance with CHWs would reduce 30-day readmission rates. Design, Setting, and Participants: This randomized clinical trial was conducted in 6 general medicine hospital units within 1 academic medical center in Boston, Massachusetts. Participants included adults hospitalized from April 1, 2017, through March 31, 2019, who had ACO insurance and were at risk for 30-day readmission based on a hospital readmission algorithm. The main inclusion criterion was frequency of prior nonelective hospitalizations (≥2 in the past 3 months or ≥3 in the 12 months prior to enrollment). Data were analyzed from February 1, 2018, through March 3, 2021. Intervention: CHWs met with intervention participants prior to discharge and maintained contact for 30 days postdischarge to assist participants with clinical access and social resources via telephone calls, text messages, and field visits. CHWs additionally provided psychosocial support and health coaching, using motivational interviewing, goal-setting, and other behavioral strategies. The control group received usual care, which included routine care from primary care clinics and any outpatient referrals made by hospital case management or social work at the time of discharge. Main Outcomes and Measures: The primary outcome was 30-day hospital readmissions. Secondary outcomes included 30-day missed primary care physician or specialty appointments. Results: A total of 573 participants were enrolled, and 550 participants (mean [SD] age, 70.1 [15.7] years; 266 [48.4%] women) were included in analysis, with 277 participants randomized to the intervention group and 273 participants randomized to the control group. At baseline, participants had a mean (SD) of 3 (0.8) hospitalizations in the prior 12 months. There were 432 participants (78.5%) discharged home and 127 participants (23.1%) discharged to a short rehabilitation stay prior to returning home. Compared with participants in the control group, participants in the intervention group were less likely to be readmitted within 30 days (odds ratio [OR], 0.44; 95% CI, 0.28-0.90) and to miss clinic appointments within 30 days (OR, 0.56; 95% CI, 0.38-0.81). A post hoc subgroup analysis showed that compared with control participants, intervention participants discharged to rehabilitation had a reduction in readmissions (OR, 0.09; 95% CI, 0.03-0.31), but there was no significant reduction for those discharged home (OR, 0.68; 95% CI, 0.41-1.12). Conclusions and Relevance: This randomized clinical trial found that pairing ACO-insured inpatient adults with CHWs reduced readmissions and missed outpatient visits 30 days postdischarge. The effect was significant for those discharged to short-term rehabilitation but not for those discharged home. Trial Registration: ClinicalTrials.gov Identifier: NCT03085264.

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.

The Effects of Accountable Care Organizations Forming Preferred Skilled Nursing Facility Networks on Market Share, Patient Composition, and Outcomes.

BACKGROUND: Through participation in payment reforms such as bundled payment and accountable care organizations (ACOs), hospitals are increasingly financially responsible for health care use and adverse health events occurring after hospital discharge. To improve management and coordination of postdischarge care, ACO hospitals are establishing a closer relationship with skilled nursing facilities (SNFs) through the formation of preferred SNF networks. RESEARCH DESIGN: We evaluated the effects of preferred SNF network formation on care patterns and outcomes. We included 10 ACOs that established preferred SNF networks between 2014 and 2015 in the sample. We first investigated whether hospitals "steer" patients to preferred SNFs by examining the percentage of patients sent to preferred SNFs within each hospital before and after network formation. We then used a difference-in-difference model with SNF fixed effects to evaluate the changes in patient composition and outcomes of preferred SNF patients from ACO hospitals after network formation relative to patients from other hospitals. RESULTS: We found that preferred network formation was not associated with higher market share or better outcomes for preferred SNF patients from ACO hospitals. However, we found a small increase in the average number of Elixhauser comorbidities for patients from ACO hospitals after network formation, relative to patients from non-ACO hospitals. CONCLUSIONS: After preferred SNF network formation, there is some evidence that ACO hospitals sent more complex patients to preferred SNFs, but there was no change in the volume of patients received by these SNFs. Furthermore, preferred network formation was not associated with improvement in patient outcomes.

The Effect of Medicare Shared Savings Program on Readmissions and Variations by Race/Ethnicity and Payer Status (December 9, 2020).

OBJECTIVE: Accountable care organizations in the Medicare Shared Savings Program (MSSP) in the United States attempt to reduce cost and improve quality for their patients by improving care coordination across care settings. We examined the impact of hospital participation in the MSSP on 30-day readmissions for several groups of Medicare inpatients, and by race/ethnicity and payer status. MAIN DATA SOURCE: A 2010-2016 Medicare Provider Analysis and Review files. RESEARCH DESIGN: With propensity score matched sample of MSSP and non-MSSP-participating hospitals, patient-level linear probability models with difference-in-differences approach were used to compare the changes in readmission rates for Medicare fee-for-service patients initially admitted for ischemic stroke, hip fracture, or total joint arthroplasty in MSSP-participating hospitals with non-MSSP-participating hospitals as well as to compare the changes in disparities in readmission rates over time. PRINCIPAL FINDINGS: Hospital participation in MSSP was associated with further reduced readmission rate by 1.1 percentage points (95% confidence interval: -0.02 to 0.00, P<0.05) and 1.5 percentage points (95% confidence interval: -0.03 to 0.00, P=0.08) for ischemic stroke and hip fracture cohorts, respectively, compared with non-MSSP-participating hospitals, after the third year of hospital participation in the MSSP. There was no evidence that MSSP had an impact on racial/ethnic disparities, but increased disparity by payer status (dual vs. Medicare-only) was observed. These findings together suggest that MSSP accountable care organizations may take at least 3 years to achieve reduced readmissions and may increase disparities by payer status.

Impact of the Medicare Shared Savings Program on utilization of mental health and substance use services by eligibility and race/ethnicity.

OBJECTIVE: To assess the impact of the Medicare Shared Savings Program (MSSP) ACOs on mental health and substance use services utilization and racial/ethnic disparities in care for these conditions. DATA SOURCES: Five percent random sample of Medicare claims from 2009 to 2016. STUDY DESIGN: We compared Medicare beneficiaries in MSSP ACOs to non-MSSP beneficiaries, stratifying analyses by Medicare eligibility (disability vs age 65+). We estimated difference-in-difference models of MSSP ACOs on mental health and substance use visits (outpatient and inpatient), medication fills, and adequate care for depression adjusting for age, sex, race/ethnicity, region, and chronic medical and behavioral health conditions. To examine the differential impact of MSSP on our outcomes by race/ethnicity, we used a difference-in-difference-in-differences (DDD) design. DATA COLLECTION/EXTRACTION METHODS: Not applicable. PRINCIPAL FINDINGS: MSSP ACOs were associated with small reductions in outpatient mental health (Coeff: -0.012, P < .001) and substance use (Coeff: -0.001, P < .01) visits in the disability population, and in adequate care for depression for both the disability- and age-eligible populations (Coeff: -0.028, P < .001; Coeff: -0.012, P < .001, respectively). MSSP ACO's were also associated with increases in psychotropic medications (Coeff: 0.007 and Coeff: 0.0213, for disability- and age-eligible populations, respectively, both P < .001) and reductions in inpatient mental health stays (Coeff:-0.004, P < .001, and Coeff:-0.0002, P < .01 for disability- and age-eligible populations, respectively) and substance use-related stays for disability-eligible populations (Coeff:-0.0005, P<.05). The MSSP effect on disparities varied depending on type of service. CONCLUSIONS: We found small reductions in outpatient and inpatient stays and in rates of adequate care for depression associated with MSSP ACOs. As MSSP ACOs are placed at more financial risk for population-based treatment, it will be important to include more robust behavioral health quality measures in their contracts and to monitor disparities in care.

Impact of a commercial accountable care organization on prescription drugs.

OBJECTIVE: To determine the long-run impact of a commercial accountable care organization (ACO) on prescription drug spending, utilization, and related quality of care. DATA SOURCES/STUDY SETTING: California Public Employees' Retirement System (CalPERS) health maintenance organization (HMO) member enrollment data and pharmacy benefit claims, including both retail and mail-order generic and brand-name prescription drugs. STUDY DESIGN: We applied a longitudinal retrospective cohort study design and propensity-weighted difference-in-differences regression models. We examined the relative changes in outcome measures between two ACO cohorts and one non-ACO cohort before and after the ACO implementation in 2010. The ACO directed provider prescribing patterns toward generic substitution for brand-name prescription drugs to maximize shared savings in pharmacy spending. DATA COLLECTION/EXTRACTION METHODS: The study sample included members continuously enrolled in a CalPERS commercial HMO from 2008 through 2014 in the Sacramento area. PRINCIPAL FINDINGS: The cohort differences in baseline characteristics of 40 483 study participants were insignificant after propensity-weighting adjustment. The ACO enrollees had no significant differential changes in either all or most of the five years of the ACO operation for the following measures: (1) average total spending and (2) average total scripts filled and days supplied on either generic or brand-name prescription drugs, or the two combined; (3) average generic shares of total prescription drug spending, scripts filled or days supplied; (4) annual rates of 10 outpatient process quality of care metrics for medication prescribing or adherence. CONCLUSIONS: Participation in the commercial ACO was associated with negligible differential changes in prescription drug spending, utilization, and related quality of care measures. Capped financial risk-sharing and increased generics substitution for brand names are not enough to produce tangible performance improvement in ACOs. Measures to increase provider financial risk-sharing shares and lower brand-name drug prices are needed.

Accountable Care Hospitals and Preventable Emergency Department Visits for Rural Dementia Patients.

BACKGROUND/OBJECTIVES: This study examined urban/rural differences in the frequency of preventable emergency department (ED) visits among patients with Alzheimer's disease and related dementias (ADRD), with a focus on the variation of accountable care organization (ACO) participation status for hospitals in urban and rural areas. DESIGN: We performed a cross-sectional study using the 2015 State Emergency Department Databases, the American Hospital Association Annual Survey of Hospitals, and the Area Health Resource File. Individual-, county-, and hospital-level characteristics and state fixed effects were used for model specification. SETTING: Patients with ADRD from seven states who visited the ED and had routine discharges. PARTICIPANTS: Our sample consisted of 117,196 patients with ADRD. MEASUREMENTS: The outcome was preventable ED visits classified using the New York University Emergency Department visit algorithm. We performed a multivariable logistic regression to estimate the variation of preventable ED visits by urban and rural areas. RESULTS: Rural patients with ADRD had 1.13 higher adjusted odds (P = .007) of going to the ED for a preventable visit compared with their urban counterparts. In addition, ACO-affiliated hospitals had .91 lower adjusted odds (P = .005) of preventable ED visits for ADRD patients compared with hospitals not affiliated with an ACO. Whole-county Mental Health Care Health Professional Shortage Area (HPSA) (odds ratio = 1.14; P = .002) designation was also an indicator of higher preventable ED rates. CONCLUSION: ACO delivery systems have the potential to decrease rural preventable ED visits among ADRD patients.

Accountable Care Organizations during Covid-19: Routine care for older adults with multiple chronic conditions.

The COVID-19 pandemic threatens the health and well-being of older adults with multiple chronic conditions. To date, limited information exists about how Accountable Care Organizations (ACOs) are adapting to manage these patients. We surveyed 78 Medicare ACOs about their concerns for these patients during the pandemic and strategies they are employing to address them. ACOs expressed major concerns about disruptions to necessary care for this population, including the accessibility of social services and long-term care services. While certain strategies like virtual primary and specialty care visits were being used by nearly all ACOs, other services such as virtual social services, home medication delivery, and remote lab monitoring were far less commonly accessible. ACOs expressed that support for telehealth services, investment in remote monitoring capabilities, and funding for new, targeted care innovation initiatives would help them better care for vulnerable patients during this pandemic.

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.

A new kind of gatekeeper: The increasing prevalence of Advanced Practice Nurses as case managers in US hospitals.

Case management is a representation of managed care, cost-containment organizational practices in healthcare, where managed care and its constitutive parts are situated against physician autonomy and decision-making. As a professional field, case management has evolved considerably, with the role recently taken up increasingly by Advanced Practice Nurses in various health care settings. We look at this evolution of a relatively new work task for Advanced Practice Nurses using a countervailing powers perspective, which allows us to move beyond discussions of case management effectiveness and best practices, and draw connections to trends in the social organization of healthcare, especially hospitals. We evaluated organizational (hospital-level) and environmental (county and state-level) characteristics associated with hospitals' use of Advanced Practice Nurses as case managers, using data from U.S. community acute care hospitals for 2016-2018, collected from three data sources: American Hospital Association annual survey (AHA), Centers for Medicare and Medicaid Services (CMS), and Area Resource File. Among organizational characteristics, we found that hospitals that are a part of established Accountable Care Organizations (OR = 2.55, p = 0.009; 95% CI = 1.26-5.14) and those that serve higher acuity patients, as indicated by possessing a higher Case Mix Index (OR = 1.32, p = 0.001; 95% CI = 1.13-1.55), were more likely to use Advanced Practice Nurses as case managers. Among environmental characteristics, having higher local Advanced Practice Nurses concentrations (OR = 1.24, p < 0.001; 95% CI = 1.11-1.39) was associated with hospital Advanced Practice Nurses case management service provision. Beyond the health impacts of Covid-19, its associated recession is placing families, governments and insurers under unprecedented financial stress. Governments and insurers alike are looking to reduce costs anywhere possible. This will inevitably result in increasing amounts of managed care, and decreasing reimbursements to hospitals, likely resulting in higher demand for APRN patient navigators.

Effective care management by Next Generation accountable care organizations.

OBJECTIVES: The objectives of this study were to estimate the utilization and spending impact of a standardized complex care management program implemented at 5 Next Generation accountable care organizations (NGACOs) and to identify reproducible program features that influenced program effectiveness. STUDY DESIGN: In 2016 and 2017, high-risk Medicare beneficiaries aligned to 5 geographically diverse NGACOs were identified using predictive analytics for enrollment in a standardized complex care management program. We estimated the program's impact on all-cause inpatient admissions, emergency department visits, and total medical expenditures (TME) relative to a matched cohort of nonparticipants. In a subanalysis, we studied the modifying effects of intervention fidelity on program impact. METHODS: We created 1897 propensity score-matched case-control pairs based on preprogram similarities in disease profile, predictive risk score, medical cost, and utilization. Changes in outcomes 6 months post program were measured using difference-in-differences analyses. We used principal components analysis to identify program features associated with reduced inpatient admissions, classified cases according to intervention fidelity, and measured postprogram changes in TME for each subgroup. RESULTS: Program participation was associated with a 21% reduction in all-cause inpatient admissions (P = .03) and a 22% reduction in TME (P = .02) 6 months after program completion. Relative spending reductions were 2.1 times greater for high-fidelity interventions compared with overall program participation (P < .001). CONCLUSIONS: Centrally staffed complex care management programs can reduce costs and improve outcomes for high-risk Medicare beneficiaries. Integrating predictive risk stratification, evidence-based intervention design, and performance monitoring can ensure consistent outcomes.

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.

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.

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.

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

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

Association of Organizational Factors and Physician Practices' Participation in Alternative Payment Models.

Importance: Consolidation among physician practices and between hospitals and physician practices has accelerated in the past decade, resulting in higher prices in commercial markets. The resulting integration of health care across clinicians and participation in alternative payment models (APMs), which aim to improve quality while constraining spending, are cited as reasons for consolidation, but little is known about the association between integration and APM participation. Objective: To examine the association of organizational characteristics, ownership, and integration with intensity of participation in APMs among physician practices. Design, Setting, and Participants: A cross-sectional descriptive study, adjusted for sampling and nonresponse weights, was conducted in US physician practice respondents to the National Survey of Healthcare Organizations and Systems conducted between June 16, 2017, and August 17, 2018; of 2333 responses received (response rate, 46.9%) and after exclusion of ineligible and incomplete responses, the number of practices included in the analysis was 2061. Data analysis was performed from April 1, 2019, to August 31, 2019. Exposures: Self-reported physician practice characteristics, including ownership, integration (clinical, cultural, financial, and functional), care delivery capabilities, activities, and environmental factors. Main Outcomes and Measures: Participation in APMs: (1) bundled payments, (2) comprehensive primary care and medical home programs, (3) pay-for-performance programs, (4) capitated contracts with commercial health plans, and (5) accountable care organization contracts. Results: A total of 49.2% of the 2061 practices included reported participating in 3 or more APMs; most participated in pay-for-performance and accountable care organization models. Covariate-adjusted analyses suggested that operating within a health care system (odds ratio [OR] for medical group: 2.35; 95% CI, 1.70-3.25; P < .001; simple health system: 1.46; 95% CI, 1.08-1.97; P = .02; and complex health system: 1.76; 95% CI, 1.25-2.47; P = .001 relative to independent practices), greater clinical (OR, 4.68; 95% CI, 2.28-9.59; P < .001) and functional (OR, 4.24; 95% CI, 2.00-8.97; P < .001) integration, and being located in the Northeast (OR for Midwest: 0.47; 95% CI, 0.34-0.65; P < .001; South: 0.47; 95% CI, 0.34-0.66; P < .001; and West: 0.64; 95% CI, 0.46-0.91; P = .01) were associated with greater APM participation. Conclusions and Relevance: Greater APM participation appears to be supported by integration and system ownership.