The Effects of Medicare Accountable Organizations on Inpatient Mortality Rates.
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ABSTRACT:
SUBMITTER: Cutler E
PROVIDER: S-EPMC6156189 | biostudies-literature | 2018 Jan-Dec
REPOSITORIES: biostudies-literature
Publications
The Effects of Medicare Accountable Organizations on Inpatient Mortality Rates.
Cutler Eli E Karaca Zeynal Z Henke Rachel R Head Michael M Wong Herbert S HS
Inquiry : a journal of medical care organization, provision and financing 20180101
Studies have linked Accountable Care Organizations (ACOs) to improved primary care, but there is little research on how ACOs affect care in other settings. We examined whether Medicare ACOs have improved hospital quality of care, specifically focusing on preventable inpatient mortality. We used 2008-2014 Healthcare Cost and Utilization Project hospital discharge data from 34 states' Medicare ACO and non-ACO hospitals in conjunction with data from the American Hospital Association Annual Survey a ...[more]
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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.
| S-EPMC4963149 | biostudies-literature
Project description:BackgroundSurgical care among older adults is costly. While Medicare accountable care organizations (ACOs) are designed around primary care, there are reasons to believe that participation may also affect spending on surgery. This study examines the impact that Medicare ACO alignment has on spending for inpatient and outpatient surgical care.Study designWe conducted a retrospective cohort study using national Medicare claims (2008 through 2015). Among a 20% random sample of beneficiaries, we identified adults 65 years of age and older enrolled in fee-for-service Medicare, distinguishing between those aligned and unaligned with a Medicare ACO. We then measured payments for surgical services made on their behalf. Finally, we fit multivariable regression models to evaluate the association between ACO alignment and spending for inpatient and outpatient surgical care.ResultsWe identified 37,249,845 beneficiary-year observations, of which 2,950,188 (7.9%) were aligned with a Medicare ACO. After adjustment for patient factors, ACO alignment was associated with $181 [95% confidence interval (CI), -$243 to -$118; P <0.001] lower spending per beneficiary-year. ACO alignment was associated with 2.9% fewer inpatient surgical episodes per year [incidence rate ratio (IRR), 0.97; 95% CI, 0.96 to 0.98; P <0.001] but 2.3% more outpatient episodes per year (IRR, 1.02; 95% CI, 1.02 to 1.03; P <0.001). Among inpatient surgical episodes, average payments were $956 lower for ACO aligned beneficiaries (95%CI -$1218 to -$694, P <0.001).Conclusions and relevanceACO alignment was associated with savings on surgical care. These savings resulted from increased outpatient surgery and reduced use of inpatient surgery as well as reduced spending per inpatient surgical episode. Greater focus on surgical care may improve the ability of ACOs to control healthcare spending.
| S-EPMC7561039 | biostudies-literature
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.).
| S-EPMC4239654 | biostudies-literature
Project description:Background/objectiveMedicare Advantage (MA) and Accountable Care Organizations (ACOs) operate under incentives to reduce burdensome and costly care at the end of life. We compared end-of-life care for persons with dementia who are in MA, ACOs, or traditional Medicare (TM).Design, setting, and participantsRetrospective study of decedents with dementia enrolled in MA, attributed to an ACO, or in TM. Decedents had a nursing home stay between 91 and 180 days prior to death, two or more functional impairments, and mild to severe cognitive impairment.MeasurementsHospitalization, invasive mechanical ventilation (IMV) use, and in-hospital death in the last 30 days of life reported in Medicare billing.ResultsAmong 370,094 persons with dementia, 93,801 (25.4%) were in MA (mean age [SD], 86.9 [7.7], 67.6% female), 39,586 (10.7%) were ACO attributed (mean age [SD], 87.2 [7.6], 67.3% female), and 236,707 (63.9%) were in TM (mean age [SD], 87.0 [7.8], 67.6% female). The proportion hospitalized in the last 30 days of life was higher among TM enrollees (27.9%) and those ACO attributed (28.1%) than among MA enrollees (20.5%, p ≤ 0.001). After adjustment for socio-demographics, cognitive and functional impairments, comorbidities, and Hospital Referral Region, adjusted odds of hospitalization in the 30 days prior to death was 0.72 (95% confidence interval [CI] 0.70-0.74) among MA enrollees and 1.05 (95% CI 1.02-1.09) among those attributed to ACOs relative to TM enrollees. Relative to TM, the adjusted odds of death in the hospital were 0.78 (95% CI 0.75-0.81) among MA enrollees and 1.02 (95% CI 0.96-1.08) for ACO participants. Dementia decedents in MA had a lower likelihood of IMV use (adjusted odds ratio 0.80, 95% CI 0.75-0.85) compared to TM.ConclusionsAmong decedents with dementia, MA enrollees but not decedents in ACOs experienced less costly and potentially burdensome care compared with those with TM. Policy changes are needed for ACOs.
| S-EPMC8497397 | biostudies-literature
Project description:BackgroundAccountable care organizations' (ACOs') focus on formal clinical integration to improve outcomes overlooks actual patterns of provider interactions around shared patients.ObjectiveTo determine whether such informal clinical integration relates to a health system's performance in an ACO.Research designWe analyzed national Medicare data (2008-2014), identifying beneficiaries who underwent coronary artery bypass grafting (CABG). After determining which physicians delivered care to them, we aggregated across episodes to construct physician networks for each health system. We used network analysis to measure each system's level of informal clinical integration (defined by cross-specialty ties). We fit regression models to examine the association between a health system's CABG mortality rate and ACO participation, conditional on informal clinical integration.SubjectsBeneficiaries age 66 and older undergoing CABG.MeasuresNinety-day CABG mortality.ResultsOver the study period, 3385 beneficiaries were treated in 161 ACO-participating health systems. The remaining 49,854 were treated in 875 nonparticipating systems or one of the 161 ACO-participating systems before the ACO start date. ACO systems with higher levels of informal clinical integration had lower CABG mortality rates than nonparticipating ones (2.8% versus 5.5%; P<0.01); however, there was no difference based on ACO participation for health systems with lower to relatively moderate informal clinical integration. Regression results corroborate this finding (coefficient for interaction between ACO participation and informal clinical integration level is -0.25; P=0.01).ConclusionsFormal clinical integration through ACO participation may be insufficient to improve outcomes. Health systems with higher informal clinical integration may benefit more from ACO participation.
| S-EPMC6421077 | biostudies-literature
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.
| S-EPMC4992435 | biostudies-literature
Project description:ObjectiveTo evaluate the effect of Accountable Care Organizations (ACOs) on the use of vertebroplasty and arthroscopic partial meniscectomy, 2 procedures for which randomized controlled trials suggest similar outcomes to sham surgery and therefore may provide low value. Medicare Shared Savings Program ACOs aim to improve quality and decrease health care spending. Reducing the use of potentially low-value procedures can accomplish both of these goals.MethodsWe performed a retrospective cohort study of patients who underwent potentially low-value orthopedic procedures (vertebroplasty and partial meniscectomy) and a control (hip fracture) from 2010 to 2015 using a 20% sample of national Medicare claims. We performed an interrupted time-series analysis using linear spline models to evaluate the count of each procedure per 1000 patients, stratified by ACO participation.ResultsWe identified 76 256 patients who underwent arthroscopic partial meniscectomy, 44 539 patients who underwent vertebroplasty, and 50 760 patients who underwent hip fracture admission. Arthroscopic partial meniscectomy rates decreased, vertebroplasty rates remained stable, and hip fracture rates increased for both groups during the study period, with similar trends among ACO and non-ACO patients. After January 1, 2013, ACO and non-ACO populations had similar trends for vertebroplasty (ACO incidence rate ratio [IRR] = 1.15 [1.08-1.23] vs non-ACO IRR = 1.11 [1.05-1.16]), meniscectomy (ACO IRR = 1.06 [1.01-1.12] vs non-ACO IRR = 1.03 [0.99-1.07]), and hip fracture (ACO IRR = 1.08 [1.01-1.14] vs non-ACO IRR = 1.08 [1.03-1.13]).ConclusionsACOs were not associated with a reduction in the frequency of vertebroplasty and arthroscopic partial meniscectomy.
| S-EPMC6503656 | biostudies-literature
Project description:BackgroundDissemination of new surgical technology is a major contributor to healthcare spending growth. Accountable care organization (ACO) policy aims to control spending while maintaining quality. As a result, ACOs provide incentive for hospitals to selectively adopt newer procedures with high value.Study designWe conducted a retrospective cohort study using a 20% sample of national Medicare claims from 2010 to 2015. We identified hospitals that performed 1 of 6 sets of procedures: abdominal aortic aneurysm repair, aortic valve replacement, carotid endarterectomy or stent, lung lobectomy, colectomy, and prostatectomy. We identified hospitals participating in a Medicare Shared Savings Program ACO and a set of matched non-ACO control hospitals. We used a difference-in-differences approach to compare rate of surgical treatment and use of newer surgical technology for each set of procedures in ACO and non-ACO hospitals.ResultsWe included 707 ACO-hospitals and 1,770 control hospitals. ACO hospitals performed surgery for carotid stenosis at a lower rate than non-ACO hospitals. There was no difference in the rate of surgical treatment for all other procedure sets. ACO hospitals were less likely to use an endovascular approach for abdominal aortic aneurysm repair (85.2% vs 88.2%, p < 0.001) and more likely to use a minimally invasive approach for lung lobectomy (42.2% vs 34.7%, p = 0.004) than non-ACO hospitals. In difference-in-differences analysis, ACO participation was not associated with any significant difference in use of surgical care for any of the 6 procedure sets, nor with any significant difference in use of newer surgical technology.ConclusionsDespite ACO policy incentives to selectively adopt newer surgical technology, ACO participation was not associated with differences in rate of surgery or use of newer surgical technology for 6 major surgical procedures.
| S-EPMC8030123 | biostudies-literature
Project description:ObjectiveTo understand the current role of urologists in Medicare Shared Savings Program (MSSP) Accountable Care Organizations (ACOs) and the organizational characteristics of ACOs with participating urologists.Materials and methodsUsing 2012-2013 Medicare data and the National Provider Identifier Database, we classified each urologist in the U.S. and Puerto Rico as either an MSSP ACO participant or nonparticipating provider. We then examined the distribution of ACO-participating urologists across the U.S. and among the first 220 MSSP ACOs. We also compared the characteristics of ACOs with and without participating urologists.ResultsAmong 11,084 identified urologists, 1118 (10%) were MSSP ACO participants. ACO-participating urologists practiced more frequently in the Northeast and Midwest (P < .001), and were more commonly female (10% vs 8%, P = .003). At an organizational level, only 110 (50%) of the initial MSSP ACOs included at least one urologist; among this group, the number of participating urologists ranged from 1 to 55. ACOs with one or more participating urologist were larger organizations, with respect to both the number of assigned beneficiaries and the number of providers per 1000 beneficiaries (P < .001 for each comparison). The patient populations served by ACOs with and without urologists were similar (P > .05 for each comparison).ConclusionA modest percentage of urologists participate in MSSP ACOs, although many of these organizations still lack any formal involvement by urological surgeons. Without such participation, improving the coordination, quality, and cost of urologic care for Medicare beneficiaries may be more challenging.
| S-EPMC4818669 | biostudies-literature
Project description:ImportanceThe benefits of public payment policy may extend to private populations through "spillover" effects. If cost-saving efforts in Medicare also reduce costs among commercially insured patients, Medicare payment systems could be a versatile policy tool in future reform efforts.ObjectivesTo determine whether physicians who participated in a Medicare Accountable Care Organization (ACO) reduced spending among their commercial patients.DesignThis was a retrospective, longitudinal study which was conducted using Blue Cross Blue Shield of Michigan (BCBSM) claims data from 2010 to 2015. We compared patients seen by physicians who participated in a Medicare ACO to patients whose physicians were not part of an ACO. We used a difference-in-differences (DIDs) design to test whether physician participation in an ACO was associated with reduced spending among their commercially insured patients. We also tested for heterogeneous effects: we assessed whether spillovers were larger among patients with clinical conditions (acute myocardial infarction, pneumonia, congestive heart failure) that have previously been targeted by Medicare payment programs.SettingThis was a population-based study of commercially insured patients in Michigan.ParticipantsPatients who experienced a significant clinical episode (eg, labor and delivery, acute myocardial infarction) between 2010 and 2015.ExposureOur patient-level exposure is treatment by a Medicare ACO-affiliated physician.Main outcomes and measuresMedical spending of 0-90 days and 91-365 days after a clinical episode.ResultsPatients in the exposure group (n=54,750) and in the control group (n=137,883) were similar in demographic characteristics of age, sex, and type of clinical episodes. Adjusted mean 90-day spending in the preexposure period was $21,292 among the exposure group and $21,157 among the comparison group; these means declined to $21,250 and $20,995 in the postperiod, yielding a DIDs estimate of $119 [95% confidence interval (CI), -$170 to $408]. Adjusted means for 91-365 days spending in the preperiod were $4258 among the exposure group and $4251 among the comparison group; these means rose to $4338 and $4421 in the postperiod, yielding a DIDs estimate of -$90 (95% CI, -$312 to $132). We also separately examined patients with conditions that have been targeted by other Medicare payment programs. Among these patients, 90-day spending did not differ between exposure and comparison groups (DIDs, -$223; 95% CI, -$2037 to $1591), although 91-365 days spending decreased among the exposure group with marginal statistical significance (DIDs, -$1160; 95% CI, -$2459 to $140).Conclusions and relevancePhysicians who participated in Medicare ACOs did not reduce spending among most of their commercially insured patients. Medicare policy is unlikely to confer significant spillover benefits to the commercially insured population.
| S-EPMC6417956 | biostudies-literature