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Out-Of-Network Primary Care Is Associated With Higher Per Beneficiary Spending In Medicare ACOs.

ABSTRACT: Despite expectations that Medicare accountable care organizations (ACOs) would curb health care spending, their effect has been modest. One possible explanation is that ACOs' inability to prohibit out-of-network care limits their control over spending. To examine this possibility, we examined the association between out-of-network care and per beneficiary spending using national Medicare data for 2012-15. While there was no association between out-of-network specialty care and ACO spending, each percentage-point increase in receipt of out-of-network primary care was associated with an increase of $10.79 in quarterly total ACO spending per beneficiary. When we broke down total spending by place of service, we found that out-of-network primary care was associated with higher spending in outpatient, skilled nursing facility, and emergency department settings, but not inpatient settings. Our findings suggest an opportunity for the Medicare program to realize substantial savings, if policy makers developed explicit incentives for beneficiaries to seek more of their primary care within network.

SUBMITTER: Lin SC

PROVIDER: S-EPMC7213776 | biostudies-literature | 2020 Feb

REPOSITORIES: biostudies-literature

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Out-Of-Network Primary Care Is Associated With Higher Per Beneficiary Spending In Medicare ACOs.

Lin Sunny C SC Yan Phyllis L PL Moloci Nicholas M NM Lawton Emily J EJ Ryan Andrew M AM Adler-Milstein Julia J Hollingsworth John M JM

Health affairs (Project Hope) 20200201 2

Despite expectations that Medicare accountable care organizations (ACOs) would curb health care spending, their effect has been modest. One possible explanation is that ACOs' inability to prohibit out-of-network care limits their control over spending. To examine this possibility, we examined the association between out-of-network care and per beneficiary spending using national Medicare data for 2012-15. While there was no association between out-of-network specialty care and ACO spending, each ...[more]

PMID: 32011939

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Project description:BackgroundThe Medicare Accountable Care Organization (ACO) programs encourage integration of providers into large groups and reward provider groups for improving quality, but not explicitly for reducing health care disparities. Larger group size and better overall quality may or may not be associated with smaller disparities.ObjectiveTo examine differences in patient characteristics between provider groups sufficiently large to participate in ACO programs and smaller groups; the association between group size and racial disparities in quality; and the association between quality and disparities among larger groups.Design and participantsUsing 2009 Medicare claims for 3.1 million beneficiaries with cardiovascular disease or diabetes and linked data on provider groups, we compared racial differences in quality by provider group size, adjusting for patient characteristics. Among larger groups, we used multilevel models to estimate correlations between group performance on quality measures for white beneficiaries and black-white disparities within groups.Main measuresFour process measures of quality, hospitalization for ambulatory care-sensitive conditions (ACSCs) related to cardiovascular disease or diabetes, and hospitalization for any ACSC.Key resultsBeneficiaries served by larger groups were more likely to be white and live in areas with less poverty and more education. Larger group size was associated with smaller disparities in low-density lipoprotein (LDL) cholesterol testing and retinal exams, but not in other process measures or hospitalization for ACSCs. Among larger groups, better quality for white beneficiaries in one measure (hospitalization for ACSCs related to cardiovascular disease or diabetes) was correlated with smaller racial disparities (r?=?0.28; P?=?0.02), but quality was not correlated with disparities in other measures.ConclusionsLarger provider group size and better performance on quality measures were not consistently associated with smaller racial disparities in care for Medicare beneficiaries with cardiovascular disease or diabetes. ACO incentives rewarding better quality for minority groups and payment arrangements supporting ACO development in disadvantaged communities may be required for ACOs to promote greater equity in care.

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Dataset Information

Out-Of-Network Primary Care Is Associated With Higher Per Beneficiary Spending In Medicare ACOs.

Publications

Out-Of-Network Primary Care Is Associated With Higher Per Beneficiary Spending In Medicare ACOs.

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