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Implementation of a pilot accountable care organization payment model and the use of discretionary and nondiscretionary cardiovascular care.

ABSTRACT: Accountable care organizations (ACOs) seek to reduce growth in healthcare spending while ensuring high-quality care. We hypothesized that accountable care organization implementation would selectively limit the use of discretionary cardiovascular care (defined as care occurring in the absence of indications such as myocardial infarction or stroke), while maintaining high-quality care, such as nondiscretionary cardiovascular imaging and procedures.The intervention group was composed of fee-for-service Medicare patients (n=819 779) from 10 groups participating in a Medicare pilot accountable care organization, the Physician Group Practice Demonstration (PGPD). Matched controls were patients (n=934 621) from nonparticipating groups in the same regions. We compared use of cardiovascular care before (2002-2004) and after (2005-2009) PGPD implementation, studying both discretionary and nondiscretionary carotid and coronary imaging and procedures. Our main outcome measure was the difference in the proportion of patients treated with imaging and procedures among patients of PGPD practices compared with patients in control practices, before and after PGPD implementation (difference-in-difference). For discretionary imaging, the difference-in-difference between PGPD practices and controls was not statistically significant for discretionary carotid imaging (0.17%; 95% confidence interval, -0.51% to 0.85%; P=0.595) or discretionary coronary imaging (-0.19%; 95% confidence interval, -0.73% to 0.35%; P=0.468). Similarly, the difference-in-difference was also minimal for discretionary carotid revascularization (0.003%; 95% confidence interval, -0.008% to 0.002%; P=0.705) and coronary revascularization (-0.02%; 95% confidence interval, -0.11% to 0.07%; P=0.06). The difference-in-difference associated with PGPD implementation was also essentially 0 for nondiscretionary cardiovascular imaging or procedures.Implementation of a pilot accountable care organization did not limit the use of discretionary or nondiscretionary cardiovascular care in 10 large health systems.

SUBMITTER: Colla CH

PROVIDER: S-EPMC4244758 | biostudies-literature | 2014 Nov

REPOSITORIES: biostudies-literature

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Implementation of a pilot accountable care organization payment model and the use of discretionary and nondiscretionary cardiovascular care.

Colla Carrie H CH Goodney Philip P PP Lewis Valerie A VA Nallamothu Brahmajee K BK Gottlieb Daniel J DJ Meara Ellen E

Circulation 20141020 22

<h4>Background</h4>Accountable care organizations (ACOs) seek to reduce growth in healthcare spending while ensuring high-quality care. We hypothesized that accountable care organization implementation would selectively limit the use of discretionary cardiovascular care (defined as care occurring in the absence of indications such as myocardial infarction or stroke), while maintaining high-quality care, such as nondiscretionary cardiovascular imaging and procedures.<h4>Methods and results</h4>Th ...[more]

PMID: 25421044

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Project description:ImportanceAccountable care contracts hold physician groups financially responsible for the quality and cost of health care delivered to patients. Focusing on clinically vulnerable patients, those with serious conditions who are responsible for the greatest proportion of spending, may result in the largest effects on both patient outcomes and financial rewards for participating physician groups.ObjectiveTo estimate the effect of Medicare accountable care organization (ACO) contracts on spending and high-cost institutional use for all Medicare beneficiaries and for clinically vulnerable beneficiaries.Design, setting, and participantsFor this cohort study, 2 study populations were defined: the overall Medicare population and the clinically vulnerable subgroup of Medicare beneficiaries. The overall Medicare population was based on a random 40% sample drawn from continuously enrolled fee-for-service beneficiaries with at least 1 evaluation and management visit in a calendar year. The clinically vulnerable study population included all Medicare beneficiaries 66 years or older who had at least 3 Hierarchical Condition Categories (HCCs). Beneficiaries entered the cohort during the quarter between January 2009 to December 2011 when they first had at least 3 HCCs and remained in the cohort until death. Cohort entry was restricted to the preperiod to account for potential changes in coding practices after ACO implementation. Difference-in-difference estimations were used to compare changes in health care outcomes for Medicare beneficiaries attributed to physicians in ACOs with those attributed to non-ACO physicians from January 2009 to December 2013.ExposuresMedicare ACOs beginning contracts in January 2012, April 2012, July 2012, and January 2013 through the Pioneer and Medicare Shared Savings Programs.Main outcomes and measuresTotal spending per beneficiary-quarter, spending categories, use of hospitals and emergency departments, ambulatory care sensitive admissions, and 30-day readmissions.ResultsTotal spending decreased by $34 (95% CI, -$52 to -$15) per beneficiary-quarter after ACO contract implementation across the overall Medicare population (n = 15 592 600) and decreased $114 in clinically vulnerable patients (n = 8 673 823) (95% CI, -$178 to -$50). In the overall Medicare cohort, hospitalizations and emergency department visits decreased by 1.3 and 3.0 events per 1000 beneficiaries per quarter, respectively (95% CIs: -2.1 to -0.4 and -4.8 to -1.3), and hospitalizations and emergency department visits decreased in the clinically vulnerable cohort by 2.9 and 4.1 events per 1000 beneficiaries per quarter, respectively (95% CIs: -5.2 to -0.7 and -7.1 to -1.2). Changes in total spending associated with ACOs did not vary by clinical condition of beneficiaries.Conclusions and relevanceMedicare ACO programs are associated with modest reductions in spending and use of hospitals and emergency departments. Savings were realized through reductions in use of institutional settings in clinically vulnerable patients.

Project description:ImportanceMany of the quality measures used to assess accountable care organization (ACO) performance in the Medicare Shared Savings Program (MSSP) focus on disease control and medication use among patients with cardiovascular disease and diabetes. To date, the association between participation in the MSSP by provider organizations and medication use or adherence among their patients with cardiovascular disease or diabetes has not been described.ObjectiveTo assess the association between exposure to the MSSP and changes in the use of and adherence to common antihypertensive, lipid-lowering, and hypoglycemic medications.Design, setting, and participantsFee-for-service Medicare claims from January 1, 2009, to December 31, 2014, were used to conduct difference-in-differences comparisons of changes for ACO-attributed beneficiaries from before the start of ACO contracts to 2014 with concurrent changes for beneficiaries attributed to local non-ACO providers (control group). A random 20% sample of Medicare beneficiaries contributing 4 482 168 to 10 849 224 beneficiary-years for analysis from 2009 to 2014, depending on the drug class, was examined. Differential changes were estimated separately for cohorts of ACOs entering the MSSP in 2012, 2013, and 2014. Data analysis was conducted from November 1, 2016, to April 5, 2017.ExposuresPatient attribution to an ACO after entry into the MSSP.Main outcomes and measuresAny use (at least 1 prescription fill) and proportion of days covered (PDC), a standard claims-based measure of adherence, assessed for each of 6 drug classes: statins, angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers, β-blockers, thiazide diuretics, calcium channel blockers, and metformin.ResultsDifferences in patient characteristics between the MSSP and control group were generally small after geographic adjustment and changed minimally from the precontract period to 2014. There were no significant differential changes in medication use from the precontract period to 2014 for any cohort of MSSP ACOs in any drug class, except for a slight differential increase in the use of thiazides among beneficiaries with hypertension in the 2013 entry cohort (adjusted differential change, 0.5 percentage point; 95% CI, 0.1-0.8 percentage points; or 1.5% of the overall percentage using thiazides [33.4%], P = .01). Similarly, there were no significant differential changes in PDC among beneficiaries with at least 1 prescription fill, except for slight differential increases in the PDC for β-blockers in the 2012 entry cohort (adjusted differential change, 0.3 percentage point; 95% CI, 0.1-0.5 percentage points; or 0.4% of the mean PDC [82.3%], P = .003) and for metformin in the 2012 and 2013 cohorts (adjusted differential change, 0.5 percentage point; 95% CI, 0.1-0.9 percentage points; or 0.6% of the mean PDC [78.2%], P = .01 for both).Conclusions and relevanceExposure to the MSSP has not been associated with meaningful changes in medication use or adherence among patients with cardiovascular disease and diabetes.

Project description:Importance:Despite rapid diffusion of Accountable Care Organizations (ACOs), whether ACO enrollment results in observable changes in cancer screening remains unknown. Objective:To determine whether Medicare Shared Savings Program (MSSP) ACO enrollment changes the appropriateness of screening for breast, colorectal, and prostate cancers. Design, Setting, and Participants:For this population-based analysis of Medicare beneficiaries, we used Medicare data from 2007 through 2014 and evaluated changes in screening associated with ACO enrollment using differences-in-differences (DD) analyses. We then performed difference-in-difference-in-differences (DDD) analyses to determine whether observed changes in cancer screening associated with ACO enrollment were different across strata of appropriateness, defined using age (65-74 years vs ≥75 years) and predicted survival (top vs bottom quartile). Main Outcomes and Measures:Rates of breast, colorectal, and prostate cancer screening measured yearly as a proportion of eligible Medicare beneficiaries undergoing relevant screening services. Results:Among Medicare beneficiaries, comprising 39 218 652 person-years before MSSP enrollment and 17 252 345 person-years after MSSP enrollment, breast cancer screening declined among both ACO (42.7% precontract, 38.1% postcontract) and non-ACO (37.3% precontract, 34.1% postcontract) populations. The adjusted rate of decline (DD) in the ACO population exceeded the non-ACO population by 0.79% (P < .001). This decline was most pronounced among elderly women (-2.1%), with minimal observed change among younger women (-0.26%). Baseline colorectal cancer screening rates were lower than those for breast cancer among both ACO (10.1% precontract, 10.3% postcontract) and non-ACO (9.2% precontract, 9.1% postcontract) populations. We observed an adjusted 0.24% (P = .03) increase in screening associated with ACO enrollment, most pronounced among younger Medicare beneficiaries (0.36%). For breast and colorectal cancer, we observed statistically significant differences in estimates of effect between age strata, suggesting that the ACO effect on cancer screening is mediated by age (DDD for both P < .001). Prostate cancer screening declined among ACO (35.1% precontract, 28.5% postcontract) and non-ACO (31.2% precontract, 25.7% postcontract) populations. The adjusted rate of decline in the ACO population exceeded that of the non-ACO population by 1.2%. We observed no difference in estimate of effect between age strata, suggesting that the ACO-mediated changes in prostate cancer screening are similar among younger and elderly men. Results characterizing appropriateness with predicted survival mirrored those when stratified by age. Conclusions and Relevance:Medicare Shared Savings Program ACO enrollment is associated with more appropriate breast and colorectal screening, although the magnitude of the observed ACO effect is modest in the early ACO experience.

Project description:ObjectiveTo 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 settingCalifornia 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 designWe 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 methodsThe study sample included members continuously enrolled in a CalPERS commercial HMO from 2008 through 2014 in the Sacramento area.Principal findingsThe 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.ConclusionsParticipation 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.

Project description:BACKGROUND:While early evidence suggests that Medicare accountable care organizations (ACOs) may reduce post-acute care (PAC) utilization for attributed beneficiaries, whether these effects spill over to all beneficiaries admitted to hospitals participating in ACOs stray is unknown. OBJECTIVE:The objective of this study was to evaluate whether changes in PAC use and Medicare spending spill over to all beneficiaries admitted to hospitals participating in the Medicare Shared Savings Program (MSSP). DESIGN:Observational study using a difference-in-differences design comparing changes in PAC utilization and spending among beneficiaries admitted to ACO-participating hospitals before and after the start of the ACO contracts, compared to those admitted to non-ACO hospitals. SETTING:A total of 233 hospitals participate in MSSP ACOs and 3103 non-ACO hospitals. PARTICIPANTS:A national sample of 11,683,573 Medicare beneficiaries experiencing 26,503,086 hospital admissions from 2010 to 2013. EXPOSURE:Admission to a hospital participating in an MSSP ACO. MAIN MEASURES:The probability of discharge and Medicare payments to inpatient rehabilitation facilities (IRF), skilled nursing facilities (SNF), and home health agencies (HHA). KEY RESULTS:For beneficiaries admitted to hospitals that joined an ACO, the likelihood of being discharged to PAC did not change after the hospital joined the ACO compared with non-ACO hospitals over the same period (differential change in probability of discharge to any PAC was 0.000 (P?=?0.89), SNF was 0.000 (P?=?0.73), IRF was 0.000 (P?=?0.96), and HHA was 0.001 (P?=?0.57)). Payments reduced significantly for PAC overall (-?$130.41, P?=?0.03), but not for any individual PAC type alone. These results were consistent in samples that were conditional on discharge to any PAC, across conditions with high PAC use nationally, and among ACO-participating hospitals that also had a PAC participant. CONCLUSIONS:Hospital participation in an ACO did not result in spillovers in PAC utilization or payments to all beneficiaries, even when considering high PAC-use conditions and ACO hospitals that also have an ACO-participating PAC.

Dataset Information

Implementation of a pilot accountable care organization payment model and the use of discretionary and nondiscretionary cardiovascular care.

Publications

Implementation of a pilot accountable care organization payment model and the use of discretionary and nondiscretionary cardiovascular care.

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