Medicare Payments and ACOs for Dementia Patients Across Race and Social Vulnerability.

OBJECTIVES: This study investigated variations in Medicare payments for Alzheimer's disease and related dementia (ADRD) by race, ethnicity, and neighborhood social vulnerability, together with cost variations by beneficiaries' enrollment in Accountable Care Organizations (ACOs). METHODS: We used merged datasets of longitudinal Medicare Beneficiary Summary File (2016-2020), the Social Vulnerability Index (SVI), and the Medicare Shared Savings Program (MSSP) ACO to measure beneficiary-level ACO enrollment at the diagnosis year of ADRD. We analyzed Medicare payments for patients newly diagnosed with ADRD for the year preceding the diagnosis and for the subsequent 3 years. The dataset included 742,175 Medicare fee-for-service (FFS) beneficiaries aged 65 and older with a new diagnosis of ADRD in 2017 who remained in the Medicare FFS plan from 2016 to 2020. RESULTS: Among those newly diagnosed, Black and Hispanic patients encountered higher total costs compared to White patients, and ADRD patients living in the most vulnerable areas experienced the highest total costs compared to patients living in other regions. These cost differences persisted over 3 years postdiagnosis. Patients enrolled in ACOs incurred lower costs across all racial and ethnic groups and SVI areas. For ADRD patients living in the areas with the highest vulnerability, the cost differences by ACO enrollment of the total Medicare costs ranged from $4,403.1 to $6,922.7, and beneficiaries' savings ranged from $114.5 to $726.6 over three years post-ADRD diagnosis by patient's race and ethnicity. CONCLUSIONS: Black and Hispanic ADRD patients and ADRD patients living in areas with higher social vulnerability would gain more from ACO enrollment compared to their counterparts.

Kidney Disease Population Health Management in the Era of Accountable Care: A Conceptual Framework for Optimizing Care Across the CKD Spectrum.

Since its passage in 2010, the Affordable Care Act has led to the creation of numerous accountable care organizations that face the challenge of transforming the traditional care delivery model to provide more patient-centered, high-quality, and low-cost care. Complex patients, including those with chronic kidney disease (CKD), present the most challenges and opportunities. CKD is a condition with significant morbidity, mortality, and cost and thought to be partly secondary to known gaps in care delivery. Successful population management for CKD requires consideration of the needs of patients at all phases of the disease. In this article, we offer a comprehensive framework for a population-based approach to CKD and examples of programs we are implementing in each area. These initiatives include the development and implementation of an electronic nephrology consult (e-consult) platform, CKD quality metrics, CKD registry, CKD collaborative care agreement, multidisciplinary care clinic for advanced CKD, end-stage renal disease care coordinator program, shared decision-making tools for renal replacement, CKD education videos, and a tablet-based CKD patient-reported outcome measures tool.

Asynchronous vascular consultation via electronic methods: A feasibility pilot.

Management of chronic disease often requires multidisciplinary clinical efforts and specialist care. With the emergence of Accountable Care Organizations (ACOs), health care systems are incentivized to evaluate methods of information exchange between generalists and specialists in order to provide value while preserving quality. Our objective was to evaluate patient and referring provider satisfaction and outcomes of asynchronous electronic consultations in vascular care in a large tertiary academic medical center. Referring providers were offered a vascular 'e-consult' option through an electronic referral management system. We conducted chart review to understand the downstream effects and surveyed patients and referring providers to assess satisfaction. From 24 March 2014 to 1 March 2015, 54 e-consults were completed. Additional testing and recommendations were made in 49/54 (90.7%) e-consults, including lower-extremity venous duplex ultrasonography with reflux testing, duplex ultrasonography of the carotid artery, computed tomography, magnetic resonance imaging, non-invasive physiology arterial studies, laboratory tests, medications, compression stockings, and sequential lymphedema compression therapy. Referring providers were compliant with recommendations in 40/49 (81.6%) of e-consults. A total of 17/54 (31.5%) patients were surveyed with a median patient satisfaction score of 13.7/15 (91.3%) (SD ± 6.4). The program was associated with high referring provider satisfaction, with 87.0% finding the e-consult very helpful and 80.0% stating it averted the need for a traditional visit. Our experience suggests that e-consults are an effective way to provide vascular care in some patients and are associated with high patient and provider satisfaction. E-consults may therefore be an efficient method of care delivery for vascular patients within an ACO.

A Few Thoughts about ACO Antitrust Issues from a Local Enforcement Perspective.

Accountable care organizations (ACOs), joint ventures of commercial insurers and various groups of medical providers such as physicians, specialists, and hospitals whose development in California has been quickened by the Affordable Care Act, carry with them both promise and pitfalls. On the positive side of the ledger, ACOs may improve the quality of medical care even as they lower the costs of that care. On the negative side of the ledger, ACOs may lead to a gain in market power for their participations, allowing those participants to increase the prices they charge to commercial insurers. It is thus a key question for antitrust enforcers to figure out how to separate the sheep from the goats. This article, representing our personal views as state antitrust enforcers in the California attorney general's office, offers our reflection on a number of ACO articles and studies in this special issue through the prism of this key question and sets out a number of additional issues that we believe warrant study in conjunction with ACOs.

Estimates of ACO savings in the presence of provider and beneficiary selection.

BACKGROUND: Medicare's accountable care organizations (ACOs)-designed to improve quality and lower spending-were associated with growing savings in previous studies. However, savings estimates may be biased by beneficiary sorting among providers based on healthcare needs and by providers opting into the program based on anticipated gains. METHODS: Using Medicare administrative claims (2009-2014), we compared annual spending changes after provider organizations joined ACOs to changes in non-ACOs (controls). To address provider selection, using novel data to identify non-ACO organizations, we restricted controls to comparably large provider organizations. To address beneficiary selection, we (a) estimated within-organization (including non-ACO comparison organizations) spending changes, (b) estimated within-beneficiary spending changes, (c) incorporated beneficiaries without qualifying healthcare expenses, and (d) used a fixed beneficiary ACO assignment using the pre-ACO period. RESULTS: Each year, 19% of Medicare beneficiaries switched provider organizations. Spending was higher for switchers than stayers ($3163, p < .001) and grew more the next year ($2004; p < .001). Starting from a baseline regression modeled on previous ACO evaluations, estimated savings varied widely as we sequentially introduced methods to address selection. Combining methods, however, generated more stable estimated ACO savings of $46 (p = .022), averaged across cohorts. CONCLUSIONS: When implementing a comprehensive suite of methods to adjust for provider and beneficiary selection, we estimated ACO savings that grew over time. Our estimates are in line with, but smaller than, previous estimates in the literature. Implementing piecemeal adjustments produced misleading results. IMPLICATIONS: Our results confirm the importance of selection for savings estimates and for provider organizations managing costs and quality. Attribution rules that consider multiple years may help mitigate the impact of beneficiary churn for providers and payers. Implementing payment reform by randomizing early participants, or implementing fully across selected markets, may better serve efforts to evaluate and improve payment models. LEVEL OF EVIDENCE: Level 3.

Engaging Primary Care Providers to Reduce Unwanted Clinical Variation and Support ACO Cost and Quality Goals: A Unique Provider-Payer Collaboration.

This project was undertaken to reduce unneeded variation among practicing primary care clinicians participating in an accountable care organization (ACO) and to raise quality and reduce costs. This real-world, quasi-controlled experiment compared ACO target improvements between 3 participating geographic regions and members within the ProHealth ACO against nonparticipating regions and members. The authors used a novel care standardization initiative to engage participating providers. This was a 2-year longitudinal study with 6 rounds of serially measured provider care decisions and customized individual and group improvement feedback. Participating providers cared for online patient simulations as they would actual patients, and their care decisions were scored against evidence-based guidelines. This approach generated significant increases in evidence-based quality scores (+27%) and reductions in unneeded testing (-55%) in the patient simulations. Improvements in the online simulated patients correlated with improvements in patient-level ACO quality measures, which showed gains above and beyond the quasi-control group. Reductions calculated for spending on unneeded tests and specialist referrals exceeded $4.8 million. This study found that supporting practicing physicians in ACOs with evidence-based feedback significantly improved care and cost-efficiency.

Morehouse Choice Accountable Care Organization and Education System (MCACO-ES): Integrated Model Delivering Equitable Quality Care.

Accountable Care Organizations (ACOs) seek sustainable innovation through the testing of new care delivery methods that promote shared goals among value-based health care collaborators. The Morehouse Choice Accountable Care Organization and Education System (MCACO-ES), or (M-ACO) is a physician led integrated delivery model participating in the Medicare Shared Savings Program (MSSP) offered through the Centers for Medicare and Medicaid Services (CMS) Innovation Center. The MSSP establishes incentivized, performance-based payment models for qualifying health care organizations serving traditional Medicare beneficiaries that promote collaborative efficiency models designed to mitigate fragmented and insufficient access to health care, reduce unnecessary cost, and improve clinical outcomes. The M-ACO integration model is administered through participant organizations that include a multi-site community based academic practice, independent physician practices, and federally qualified health center systems (FQHCs). This manuscript aims to present a descriptive and exploratory assessment of health care programs and related innovation methods that validate M-ACO as a reliable simulator to implement, evaluate, and refine M-ACO's integration model to render value-based performance outcomes over time. A part of the research approach also includes early outcomes and lessons learned advancing the framework for ongoing testing of M-ACO's integration model across independently owned, rural, and urban health care locations that predominantly serve low-income, traditional Medicare beneficiaries, (including those who also qualify for Medicaid benefits (also referred to as "dual eligibles"). M-ACO seeks to determine how integration potentially impacts targeted performance results. As a simulator to test value-based innovation and related clinical and business practices, M-ACO uses enterprise-level data and advanced analytics to measure certain areas, including: 1) health program insight and effectiveness; 2) optimal implementation process and workflows that align primary care with specialists to expand access to care; 3) chronic care management/coordination deployment as an effective extender service to physicians and patients risk stratified based on defined clinical and social determinant criteria; 4) adoption of technology tools for patient outreach and engagement, including a mobile application for remote biometric monitoring and telemedicine; and 5) use of structured communication platforms that enable practitioner engagement and ongoing training regarding the shift from volume to value-based care delivery.

MRI Utilization and the Associated Use of Sedation and Anesthesia in a Pediatric ACO.

BACKGROUND AND OBJECTIVES: MRI is commonly used in the pediatric population and often requires sedation or general anesthesia to complete. This study used data from a pediatric accountable care organization (ACO) to investigate trends in MRI utilization and in the requirement for anesthesia to complete MRI examinations. METHODS: The Partners for Kids (PFK) ACO claims database was queried for MRI examination encounters involving patients 0 to 18 years old from 2009 to 2014, with utilization expressed as encounters per 10,000 PFK members-months. Data were limited to 2011 to 2014 to ensure consistent billing of anesthesia services. Encounters were classified according to the presence of procedure codes for anesthesia or sedation. RESULTS: MRI utilization was approximately constant over the study period at 11 to 12 encounters per 10,000 member-months. The need for anesthesia increased from 21% to 28% of encounters over 2011 to 2014. The latter increase was shared across 1- to 6-year-old, 7- to 12-year-old, and 12- to 18-year-old subgroups. In multivariable regression analysis of monthly utilization, increasing need for anesthesia could not be attributed to secular trends in patient demographics or types of examinations ordered. Paid cost data were available for outpatient MRIs, and MRIs with sedation accounted for an increasing share of these costs (from 22% in 2011 to 33% in 2014). CONCLUSION: There was an increasing need for anesthesia services to complete MRI examinations in this pediatric population, resulting in increasing cost of MRI examinations and presenting a challenge to ACO cost containment.

Analyzing Determinants of Hospitals' Accountable Care Organizations Participation: A Resource Dependency Theory Perspective.

Accountable care organizations (ACOs) are rapidly being implemented across the United States, but little is known about what environmental and organizational factors are associated with hospital participation in ACOs. Using resource dependency theory, this study examines external environmental characteristics and organizational characteristics that relate to hospital participation in Medicare ACOs. Results indicate hospitals operating in more munificent environments (as measured by income per capita: ß = 0.00002, p < .05) and more competitive environments (as measured by Health Maintenance Organization penetration: ß = 1.86, p < .01) are more likely to participate in ACOs. Organizational characteristics including hospital ownership, health care system membership, electronic health records implementation, hospital type, percentage of Medicaid inpatient discharge, and number of nursing home beds per 1,000 population over 65 are also related to ACO participation. Should the anticipated benefits of ACOs be realized, findings from this study can guide strategies to encourage hospitals that have not gotten involved in ACOs.

US Value-Based Healthcare Policy and Its Role of Pharmacists: Contribution of Pharmacist in Accountable Care Organization (ACO) / 社会薬学

In the United States, the concepts of “Pay For Performance” and “Value-Based Health Care” were introduced, and it has been taken up as the way forward for the American health care systems. As one of the measures, an Accountable Care Organization (ACO) was included in the federal Affordable Care Act, and are being promoted for the purpose of balancing cost savings and good quality assurance in the healthcare field. In this manuscript, we provide an overview of the system of ACO, which is one of the value-based health care systems and was introduced with the aim of balancing cost savings and good quality assurance of medical care, and also focus on the role of pharmacists in ACO and summarize their roles they are executing and expected. Furthermore, we discuss on what we should learn from the United States in considering the ideal medical care systems in Japan.