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The Hidden Roles That Management Partners Play In Accountable Care Organizations.

ABSTRACT: Accountable care organizations (ACOs) are often discussed and promoted as driven by physicians, hospitals, and other health care providers. However, because of the flexible nature of ACO contracts, management organizations may also become partners in ACOs. We used data from 2013-15 on 276 ACOs from the National Survey of Accountable Care Organizations to understand the prevalence of nonprovider management partners' involvement in ACOs, the services these partners provide, and the structure of ACOs that have such partners. We found that 37 percent of ACOs reported having a management partner, and two-thirds of these ACOs reported that the partner shared in the financial risks or rewards. Among ACOs with partners, 94 percent had data services provided by the partner, 87 percent received administrative services, 68 percent received educational services, and 66 percent received care coordination services. Half received all four of these services from their partner. ACOs with partners were more heavily primary care than other ACOs. ACOs with and without partners had similar performance on costs and quality in Medicare ACO programs. Our findings suggest that management partners play a central role in many ACOs, perhaps supplying smaller and physician-run ACOs with services or expertise perceived as necessary for ACO success.

SUBMITTER: Lewis VA

PROVIDER: S-EPMC5905409 | biostudies-literature | 2018 Feb

REPOSITORIES: biostudies-literature

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The Hidden Roles That Management Partners Play In Accountable Care Organizations.

Lewis Valerie A VA D'Aunno Thomas T Murray Genevra F GF Shortell Stephen M SM Colla Carrie H CH

Health affairs (Project Hope) 20180201 2

Accountable care organizations (ACOs) are often discussed and promoted as driven by physicians, hospitals, and other health care providers. However, because of the flexible nature of ACO contracts, management organizations may also become partners in ACOs. We used data from 2013-15 on 276 ACOs from the National Survey of Accountable Care Organizations to understand the prevalence of nonprovider management partners' involvement in ACOs, the services these partners provide, and the structure of AC ...[more]

PMID: 29401012

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Project description:ImportancePeople with complex needs account for a disproportionate amount of Medicare spending, partially because of fragmented care delivered across multiple practitioners and settings. Accountable care organization (ACO) contracts give practitioners incentives to improve care coordination to the extent that coordination initiatives reduce total spending or improve quality.ObjectiveTo assess the association between ACO-reported care management and coordination activities and quality, utilization, spending, and health care system interactions in older adults with complex needs.Design, setting, and participantsIn this cross-sectional study, survey information on care management and coordination processes from 244 Medicare Shared Savings Program ACOs in the 2017-2018 National Survey of ACOs (of 351 Medicare ACO respondents; response rate, 69%) conducted from July 20, 2017, to February 15, 2018, was linked to 2016 Medicare administrative claims data. Medicare beneficiaries 66 years or older who were defined as having complex needs because of frailty or 2 or more chronic conditions associated with high costs and clinical need were included.ExposuresBeneficiary attribution to ACO reporting comprehensive (top tertile) care management and coordination activities.Main outcomes and measuresAll-cause prevention quality indicator admissions, 30-day all-cause readmissions, acute care and critical access hospital admissions, evaluation and management visits in ambulatory settings, inpatient days, emergency department visits, total spending, post-acute care spending, health care contact days, and continuity of care (from Medicare claims).ResultsAmong 1 402 582 Medicare beneficiaries with complex conditions, the mean (SD) age was 78 (8.0) years and 55.1% were female. Compared with beneficiaries assigned to ACOs in the bottom tertile of care management and coordination activities, those assigned to ACOs in the top tertile had identical median prevention quality indicator admissions and 30-day all-cause readmissions (0 per beneficiary across all tertiles), hospitalization and emergency department visits (1.0 per beneficiary in bottom and top tertiles), evaluation and management visits in ambulatory settings (14.0 per beneficiary [interquartile range (IQR), 8.0-21.0] in both tertiles), longer median inpatient days (11.0 [IQR, 4.0-33.0] vs 10.0 [IQR, 4.0-32.0]), higher median annual spending ($14 350 [IQR, $4876-$36 119] vs $14 229 [IQR, $4805-$36 268]), lower median health care contact days (28.0 [IQR, 17.0-44.0] vs 29.0 [IQR, 18.0-45.0]), and lower continuity-of-care index (0.12 [IQR, 0.08-0.20] vs 0.13 [IQR, 0.08-0.21]). Accounting for within-patient correlation, quality, utilization, and spending outcomes among patients with complex needs attributed to ACOs were not statistically different comparing the top vs bottom tertile of care management and coordination activities.Conclusions and relevanceThe ACO self-reports of care management and coordination capacity were not associated with differences in spending or measured outcomes for patients with complex needs. Future efforts to care for patients with complex needs should assess whether strategies found to be effective in other settings are being used, and if so, why they fail to meet expectations.

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:Incentives for accountable care organizations (ACOs) to limit health care use and improve quality may enhance or hurt patients' experiences with care. METHODS:Using 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. RESULTS:After 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. CONCLUSIONS:In 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.).

Project description:BackgroundAccountable care organizations (ACOs) are proliferating as a solution to the cost crisis in American health care, and already involve as many as 31 million patients. ACOs hold clinicians, group practices, and in many circumstances hospitals financially accountable for reducing expenditures and improving their patients' health outcomes. The structure of health care affects the ethical issues arising in the practice of medicine; therefore, like all health care organizational structures, ACOs will experience ethical challenges. No framework exists to assist key ACO stakeholders in identifying or managing these challenges.MethodsWe conducted a structured review of the medical ACO literature using qualitative content analysis to inform identification of ethical challenges for ACOs.ResultsOur analysis found infrequent discussion of ethics as an explicit concern for ACOs. Nonetheless, we identified nine critical ethical challenges, often described in other terms, for ACO stakeholders. Leaders could face challenges regarding fair resource allocation (e.g., about fairly using ACOs' shared savings), protection of professionals' ethical obligations (especially related to the design of financial incentives), and development of fair decision processes (e.g., ensuring that beneficiary representatives on the ACO board truly represent the ACO's patients). Clinicians could perceive threats to their professional autonomy (e.g., through cost control measures), a sense of dual or conflicted responsibility to their patients and the ACO, or competition with other clinicians. For patients, critical ethical challenges will include protecting their autonomy, ensuring privacy and confidentiality, and effectively engaging them with the ACO.DiscussionACOs are not inherently more or less "ethical" than other health care payment models, such as fee-for-service or pure capitation. ACOs' nascent development and flexibility in design, however, present a time-sensitive opportunity to ensure their ethical operation, promote their success, and refine their design and implementation by identifying, managing, and conducting research into the ethical issues they might face.

Project description:In 2012, a total of 32 organizations entered the Pioneer accountable care organization (ACO) program, in which providers can share savings with Medicare if spending falls below a financial benchmark. Performance differences associated with characteristics of Pioneer ACOs have not been well described.In a difference-in-differences analysis of Medicare fee-for-service claims, we compared Medicare spending for beneficiaries attributed to Pioneer ACOs (ACO group) with other beneficiaries (control group) before (2009 through 2011) and after (2012) the start of Pioneer ACO contracts, with adjustment for geographic area and beneficiaries' sociodemographic and clinical characteristics. We estimated differential changes in spending for several subgroups of ACOs: those with and those without clear financial integration between hospitals and physician groups, those with higher and those with lower baseline spending, and the 13 ACOs that withdrew from the Pioneer program after 2012 and the 19 that did not.Adjusted Medicare spending and spending trends were similar in the ACO group and the control group during the precontract period. In 2012, the total adjusted per-beneficiary spending differentially changed in the ACO group as compared with the control group (-$29.2 per quarter, P=0.007), consistent with a 1.2% savings. Savings were significantly greater for ACOs with baseline spending above the local average, as compared with those with baseline spending below the local average (P=0.05 for interaction), and for those serving high-spending areas, as compared with those serving low-spending areas (P=0.04). Savings were similar in ACOs with financial integration between hospitals and physician groups and those without, as well as in ACOs that withdrew from the program and those that did not.Year 1 of the Pioneer ACO program was associated with modest reductions in Medicare spending. Savings were greater for ACOs with higher baseline spending than for those with lower baseline spending and were unrelated to withdrawal from the program. (Funded by the National Institute on Aging and others.).

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The Hidden Roles That Management Partners Play In Accountable Care Organizations.

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The Hidden Roles That Management Partners Play In Accountable Care Organizations.

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