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Medicare Accountable Care Organization Enrollment and Appropriateness of Cancer Screening.

ABSTRACT: 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.

SUBMITTER: Resnick MJ

PROVIDER: S-EPMC5876897 | biostudies-literature |

REPOSITORIES: biostudies-literature

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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:ImportanceAlthough Medicare accountable care organizations (ACOs) account for half of program expenditures, whether ACOs are associated with surgical spending warrants further study.ObjectiveTo assess whether greater beneficiary-hospital ACO alignment was associated with lower surgical episode costs.Design, setting, and participantsThis retrospective cohort study was conducted between 2020 and 2022 using US Medicare data from a 20% random sample of beneficiaries. Individuals 18 years of age and older and without kidney failure who had a surgical admission between 2008 and 2015 were included. For each study year, distinction was made between beneficiaries assigned to an ACO and those who were not, as well as between admissions to ACO-participating and nonparticipating hospitals.ExposuresTime-varying binary indicators for beneficiary ACO assignment and hospital ACO participation and an interaction between them.Main outcomes and measuresNinety-day, price-standardized total episode payments. Multivariable 2-way fixed-effects models were estimated.ResultsDuring the study period, 2 797 337 surgical admissions (6% of which involved ACO-assigned beneficiaries) occurred at 3427 hospitals (17% ACO participating). Total Medicare payments for 90-day surgical episodes were lowest when ACO-assigned beneficiaries underwent surgery at a hospital participating in the same ACO as the beneficiary ($26 635 [95% CI, $26 426-$26 844]). The highest payments were for unassigned beneficiaries treated at participating hospitals ($27 373 [95% CI, $27 232-$27 514]) or nonparticipating hospitals ($27 303 [95% CI, $27 291-$27 314]). Assigned beneficiaries treated at hospitals participating in a different ACO and assigned beneficiaries treated at nonparticipating hospitals had similar payments (for participating hospitals, $27 003 [95% CI, $26 739-$27 267] and for nonparticipating hospitals, $26 928 [95% CI, $26 796-$27 059]). A notable factor in the observed differences in surgical episode costs was lower spending on postacute care services.Conclusions and relevanceIn this cohort study evaluating hospital and beneficiary ACO alignment and surgical spending, savings were noted for beneficiaries treated at hospitals in the same ACO. Allowing ACOs to encourage or require surgical procedures in their own hospitals could lower Medicare spending on surgery.

Project description:BACKGROUND:Accountable care organizations (ACOs) were established to improve care and outcomes for beneficiaries requiring highly coordinated, complex care. The objective of this study was to evaluate the association between hospital ACO participation and the outcomes of major surgical oncology procedures. METHODS:This was a retrospective cohort study of Medicare beneficiaries older than 65 years who were undergoing a major surgical resection for colorectal, bladder, esophageal, kidney, liver, ovarian, pancreatic, lung, or prostate cancer from 2011 through 2013. A difference-in-differences analysis was implemented to compare the postimplementation period (January 2013 through December 2013) with the baseline period (January 2011 through December 2012) to assess the impact of hospital ACO participation on 30-day mortality, complications, readmissions, and length of stay (LOS). RESULTS:Among 384,519 patients undergoing major cancer surgery at 106 ACO hospitals and 2561 control hospitals, this study found a 30-day mortality rate of 3.4%, a readmission rate of 12.5%, a complication rate of 43.8%, and a prolonged LOS rate of 10.0% in control hospitals and similar rates in ACO hospitals. Secular trends were noted, with reductions in perioperative adverse events in control hospitals between the baseline and postimplementation periods: mortality (percentage-point reduction, 0.1%; P?=?.19), readmissions (percentage-point reduction, 0.4%; P?=?.001), complications (percentage-point reduction, 1.0%; P?<?.001), and prolonged LOS (percentage-point reduction, 1.1%; P?<?.001). After accounting for these secular trends, this study identified no significant effect of hospital participation in an ACO on the frequency of perioperative outcomes (difference-in-differences estimator P values, .24-.72). CONCLUSIONS:Early hospital participation in the Medicare Shared Savings Program ACO program was not associated with greater reductions in adverse perioperative outcomes for patients undergoing major cancer surgery in comparison with control hospitals. Cancer 2016. © 2016 American Cancer Society. Cancer 2016;122:2739-2746. © 2016 American Cancer Society.

Project description:ImportanceWasteful practices are widespread in the US health care system. It is unclear if payment models intended to improve health care efficiency, such as the Medicare accountable care organization (ACO) programs, discourage the provision of low-value services.ObjectiveTo assess whether the first year of the Medicare Pioneer ACO program was associated with a reduction in use of low-value services.Design, setting, and participantsIn a difference-in-differences analysis, we compared use of low-value services between Medicare fee-for-service beneficiaries attributed to health care provider groups that entered the Pioneer program (ACO group) and beneficiaries attributed to other health care providers (control group) before (2009-2011) vs after (2012) Pioneer ACO contracts began. Data analysis was conducted from December 1, 2014, to June 27, 2015. Comparisons were adjusted for beneficiaries' sociodemographic and clinical characteristics as well as for geography. We decomposed estimates according to service characteristics (clinical category, price, and sensitivity to patient preferences) and compared estimates between subgroups of ACOs with higher vs lower baseline use of low-value services.Main outcomes and measuresUse of, and spending on, 31 services in instances that provide minimal clinical benefit, measured as annual service counts per 100 beneficiaries and price-standardized annual service spending per 100 beneficiaries.ResultsDuring the precontract period, trends in the use of low-value services were similar for the ACO and control groups. The first year of ACO contracts was associated with a differential reduction (95% CI) of 0.8 low-value services per 100 beneficiaries for the ACO group (-1.2 to -0.4; P < .001), corresponding to a 1.9% differential reduction in service quantity (-2.9% to -0.9%) and a 4.5% differential reduction in spending on low-value services (-7.5% to -1.4%; P = .004). Differential reductions were similar for services less sensitive vs more sensitive to patient preferences and for higher- vs lower-priced services. The ACOs with higher than their markets' mean baseline levels of low-value service use experienced greater service reductions (-1.2 services per 100 beneficiaries; -1.7 to -0.7; P < .001) than did ACOs with use below the mean (-0.2 services per 100 beneficiaries, -0.6 to -0.2; P = .41; P = .003 for test of difference between subgroups).Conclusions and relevanceDuring its first year, the Pioneer ACO program was associated with modest reductions in low-value services, with greater reductions for organizations providing more low-value care. Accountable care organization-like risk contracts may be able to discourage use of low-value services even without specifying services to target.

Project description:In the Medicare Shared Savings Program (MSSP), accountable care organizations (ACOs) have financial incentives to lower spending and improve quality. We used quasi-experimental methods to assess the early performance of MSSP ACOs.Using Medicare claims from 2009 through 2013 and a difference-in-differences design, we compared changes in spending and in performance on quality measures from before the start of ACO contracts to after the start of the contracts between beneficiaries served by the 220 ACOs entering the MSSP in mid-2012 (2012 ACO cohort) or January 2013 (2013 ACO cohort) and those served by non-ACO providers (control group), with adjustment for geographic area and beneficiary characteristics. We analyzed the 2012 and 2013 ACO cohorts separately because entry time could reflect the capacity of an ACO to achieve savings. We compared ACO savings according to organizational structure, baseline spending, and concurrent ACO contracting with commercial insurers.Adjusted Medicare spending and spending trends were similar in the ACO cohorts and the control group during the precontract period. In 2013, the differential change (i.e., the between-group difference in the change from the precontract period) in total adjusted annual spending was -$144 per beneficiary in the 2012 ACO cohort as compared with the control group (P=0.02), consistent with a 1.4% savings, but only -$3 per beneficiary in the 2013 ACO cohort as compared with the control group (P=0.96). Estimated savings were consistently greater in independent primary care groups than in hospital-integrated groups among 2012 and 2013 MSSP entrants (P=0.005 for interaction). MSSP contracts were associated with improved performance on some quality measures and unchanged performance on others.The first full year of MSSP contracts was associated with early reductions in Medicare spending among 2012 entrants but not among 2013 entrants. Savings were greater in independent primary care groups than in hospital-integrated groups.

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.

Project description:BackgroundIncentives for accountable care organizations (ACOs) to limit health care use and improve quality may enhance or hurt patients' experiences with care.MethodsUsing Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey data covering 3 years before and 1 year after the start of Medicare ACO contracts in 2012 as well as linked Medicare claims, we compared patients' experiences in a group of 32,334 fee-for-service beneficiaries attributed to ACOs (ACO group) with those in a group of 251,593 beneficiaries attributed to other providers (control group), before and after the start of ACO contracts. We used linear regression and a difference-in-differences analysis to estimate changes in patients' experiences in the ACO group that differed from concurrent changes in the control group, with adjustment for the sociodemographic and clinical characteristics of the patients.ResultsAfter ACO contracts began, patients' reports of timely access to care and their primary physicians' being informed about specialty care differentially improved in the ACO group, as compared with the control group (P=0.01 and P=0.006, respectively), whereas patients' ratings of physicians, interactions with physicians, and overall care did not differentially change. Among patients with multiple chronic conditions and high predicted Medicare spending, overall ratings of care differentially improved in the ACO group as compared with the control group (P=0.02). Differential improvements in timely access to care and overall ratings were equivalent to moving from average performance among ACOs to the 86th to 98th percentile (timely access to care) and to the 82nd to 96th percentile (overall ratings) and were robust to adjustment for group differences in trends during the preintervention period.ConclusionsIn the first year, ACO contracts were associated with meaningful improvements in some measures of patients' experience and with unchanged performance in others. (Funded by the National Institute on Aging and others.).

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Medicare Accountable Care Organization Enrollment and Appropriateness of Cancer Screening.

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