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Changes in Postacute Care in the Medicare Shared Savings Program.

ABSTRACT: Importance:Postacute care is thought to be a major source of wasteful spending. The extent to which accountable care organizations (ACOs) can limit postacute care spending has implications for the importance and design of other payment models that include postacute care. Objective:To assess changes in postacute care spending and use of postacute care associated with provider participation as ACOs in the Medicare Shared Savings Program (MSSP) and the pathways by which they occurred. Design, Setting, and Participants:With the use of fee-for-service Medicare claims from a random 20% sample of beneficiaries with 25?544?650 patient-years, 8?395?426 hospital admissions, and 1?595?352 stays in skilled nursing facilities (SNFs) from January 1, 2009, to December 31, 2014, difference-in-difference comparisons of beneficiaries served by ACOs with beneficiaries served by local non-ACO health care professionals (control group) were performed before vs after entry into the MSSP. Differential changes were estimated separately for cohorts of ACOs entering the MSSP in 2012, 2013, and 2014. Exposures:Patient attribution to an ACO in the MSSP. Main Outcomes and Measures:Postacute spending, discharge to a facility, length of SNF stays, readmissions, use of highly rated SNFs, and mortality, adjusted for patient characteristics. Results:For the 2012 cohort of 114 ACOs, participation in the MSSP was associated with an overall reduction in postacute spending (differential change in 2014 for ACOs vs control group, -$106 per beneficiary [95% CI, -$176 to -$35], or -9.0% of the precontract unadjusted mean of $1172; P?=?.003) that was driven by differential reductions in acute inpatient care, discharges to facilities rather than home (-0.6 percentage points [95% CI, -1.1 to 0.0], or -2.7% of the unadjusted precontract mean of 22.6%; P?=?.03), and length of SNF stays (-0.60 days per stay [95% CI, -0.99 to -0.22], or -2.2% of the precontract unadjusted mean of 27.07 days; P?=?.002). Reductions in use of SNFs and length of stay were largely due to within-hospital or within-SNF changes in care specifically for ACO patients. Participation in the MSSP was associated with smaller significant reductions in SNF spending in 2014 for the 2013 ACO cohort (-$27 per beneficiary [95% CI, -$49 to -$6], or -3.3% of the precontract unadjusted mean of $813; P?=?.01) but not in the 2013 or 2014 cohort's first year of participation (-$13 per beneficiary [95% CI, -$33 to $6]; P?=?.19; and $4 per beneficiary [95% CI, -$15 to $24]; P?=?.66). Estimates were similar for ACOs with and without financial ties to hospitals. Participation in the MSSP was not associated with significant changes in 30-day readmissions, use of highly rated SNFs, or mortality. Conclusions and Relevance:Participation in the MSSP has been associated with significant reductions in postacute spending without ostensible deterioration in quality of care. Spending reductions were more consistent with clinicians working within hospitals and SNFs to influence care for ACO patients than with hospital-wide initiatives by ACOs or use of preferred SNFs.

SUBMITTER: McWilliams JM

PROVIDER: S-EPMC5415671 | biostudies-literature | 2017 Apr

REPOSITORIES: biostudies-literature

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Changes in Postacute Care in the Medicare Shared Savings Program.

McWilliams J Michael JM Gilstrap Lauren G LG Stevenson David G DG Chernew Michael E ME Huskamp Haiden A HA Grabowski David C DC

JAMA internal medicine 20170401 4

<h4>Importance</h4>Postacute care is thought to be a major source of wasteful spending. The extent to which accountable care organizations (ACOs) can limit postacute care spending has implications for the importance and design of other payment models that include postacute care.<h4>Objective</h4>To assess changes in postacute care spending and use of postacute care associated with provider participation as ACOs in the Medicare Shared Savings Program (MSSP) and the pathways by which they occurred ...[more]

PMID: 28192556

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Project description:BACKGROUND:Health care providers who participate as an accountable care organization (ACO) in the voluntary Medicare Shared Savings Program (MSSP) have incentives to lower spending for Medicare patients while achieving high performance on a set of quality measures. Little is known about the extent to which early savings achieved by ACOs in the program have grown and been replicated by ACOs that entered the program in later years. ACOs that are physician groups have stronger incentives to lower spending than hospital-integrated ACOs. METHODS:Using fee-for-service Medicare claims from 2009 through 2015, we performed difference-in-differences analyses to compare changes in Medicare spending for patients in ACOs before and after entry into the MSSP with concurrent changes in spending for local patients served by providers not participating in the MSSP (control group). We estimated differential changes (i.e., the between-group difference in the change from the pre-entry period) separately for hospital-integrated ACOs and physician-group ACOs that entered the MSSP in 2012, 2013, or 2014. RESULTS:MSSP participation was associated with differential spending reductions in physician-group ACOs. These reductions grew with longer participation in the program and were significantly greater than the reductions in hospital-integrated ACOs. By 2015, the mean differential change in per-patient Medicare spending was -$474 (-4.9% of the pre-entry mean, P<0.001) for physician-group ACOs that entered in 2012, -$342 (-3.5% of the pre-entry mean, P<0.001) for those that entered in 2013, and -$156 (-1.6% of the pre-entry mean, P=0.009) for those that entered in 2014. The corresponding differential changes for hospital-integrated ACOs were -$169 (P=0.005), -$18 (P=0.78), and $88 (P=0.14), which were significantly lower than for physician-group ACOs (P<0.001). Spending reductions in physician-group ACOs constituted a net savings to Medicare of $256.4 million in 2015, whereas spending reductions in hospital-integrated ACOs were offset by bonus payments. CONCLUSIONS:After 3 years of the MSSP, participation in shared-savings contracts by physician groups was associated with savings for Medicare that grew over the study period, whereas hospital-integrated ACOs did not produce savings (on average) during the same period. (Funded by the National Institute on Aging.).

Project description: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.ContextThe 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.MethodsWe 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.FindingsMSSP 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).ConclusionsParticipation 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.

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Changes in Postacute Care in the Medicare Shared Savings Program.

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Changes in Postacute Care in the Medicare Shared Savings Program.

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