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Barriers and Facilitators to Implementation of Value-Based Care Models in New Medicaid Accountable Care Organizations in Massachusetts: A Study Protocol.

ABSTRACT: Introduction: Massachusetts established 17 new Medicaid accountable care organizations (ACOs) and 24 affiliated Community Partners (CPs) in 2018 as part of a large-scale healthcare reform effort to improve care value. The new ACOs will receive $1.8 billion dollars in state and federal funding over 5 years through the Delivery System Reform Incentive Program (DSRIP). The multi-faceted study described in this protocol aims to address gaps in knowledge about Medicaid ACOs' impact on healthcare value by identifying barriers and facilitators to implementation and sustainment of the DSRIP-funded programs. Methods and analysis: The study's four components are: (1) Document Review to characterize the ACOs and CPs; (2) Semi-structured Key Informant Interviews (KII) with ACO and CP leadership, state-level Medicaid administrators, and patients; (3) Site visits with selected ACOs and CPs; and (4) Surveys of ACO clinical teams and CP staff. The Consolidated Framework for Implementation Research's (CFIR) serves as the study's conceptual framework; its versatile menu of constructs, arranged across five domains (Intervention Characteristics, Inner Setting, Outer Setting, Characteristics of Individuals, and Processes) guides identification of barriers and facilitators across multiple organizational contexts. For example, KII interview guides focus on understanding how Inner and Outer Setting factors may impact implementation. Document Review analysis includes extraction and synthesis of ACO-specific DSRIP-funded programs (i.e., Intervention Characteristics); KIIs and site visit data will be qualitatively analyzed using thematic analytic techniques; surveys will be analyzed using descriptive statistics (e.g., counts, frequencies, means, and standard deviations). Discussion: Understanding barriers and facilitators to implementing and sustaining Medicaid ACOs with varied organizational structures will provide critical context for understanding the overall impact of the Medicaid ACO experiment in Massachusetts. It will also provide important insights for other states considering the ACO model for their Medicaid programs. Ethics and dissemination: IRB determinations were that the overall study did not constitute human subjects research and that each phase of primary data collection should be submitted for IRB review and approval. Study results will be disseminated through traditional channels such as peer reviewed journals, through publicly available reports on the mass.gov website; and directly to key stakeholders in ACO and CP leadership.

SUBMITTER: Goff SL

PROVIDER: S-EPMC8055830 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:Policy Points Maine, Massachusetts, Minnesota, and Vermont leveraged State Innovation Model awards to implement Medicaid accountable care organizations (ACOs). Flexibility in model design, ability to build on existing reforms, provision of technical assistance to providers, and access to feedback data all facilitated ACO development. Challenges included sustainability of transformation efforts and the integration of health care and social service providers. Early estimates showed promising improvements in hospital-related utilization and Vermont was able to reduce or slow the growth of Medicaid costs. These states are sustaining Medicaid ACOs owing in part to provider support and early successes in generating shared savings. The states are modifying their ACOs to include greater accountability and financial risk.ContextAs state Medicaid programs consider alternative payment models (APMs), many are choosing accountable care organizations (ACOs) as a way to improve health outcomes, coordinate care, and reduce expenditures. Four states (Maine, Massachusetts, Minnesota, and Vermont) leveraged State Innovation Model awards to create or expand Medicaid ACOs.MethodsWe used a mixed-methods design to assess achievements and challenges with ACO implementation and the impact of Medicaid ACOs on health care utilization, quality, and expenditures in three states. We integrated findings from key informant interviews, focus groups, document review, and difference-in-difference analyses using data from Medicaid claims and an all-payer claims database.FindingsStates built their Medicaid ACOs on existing health care reforms and infrastructure. Facilitators of implementation included allowing flexibility in design and implementation, targeting technical assistance, and making clinical, cost, and use data readily available to providers. Barriers included provider concerns about their ability to influence patient behavior, sustainability of provider practice transformation efforts when shared savings are reinvested into the health system and not shared with participating clinicians, and limited integration between health care and social service providers. Medicaid ACOs were associated with some improvements in use, quality, and expenditures, including statistically significant reductions in emergency department visits. Only Vermont's ACO demonstrated slower growth in total Medicaid expenditures.ConclusionsFour states demonstrated that adoption of ACOs for Medicaid beneficiaries was both possible and, for three states, associated with some improvements in care. States revised these models over time to address stakeholder concerns, increase provider participation, and enable some providers to accept financial risk for Medicaid patients. Lessons learned from these early efforts can inform the design and implementation of APMs in other Medicaid programs.

Project description:Importance:Several state Medicaid reforms are under way, but the relative performance of different approaches is unclear. Objective:To compare the performance of Oregon's and Colorado's Medicaid Accountable Care Organization (ACO) models. Design, Setting, and Participants:Oregon initiated its Medicaid transformation in 2012, supported by a $1.9 billion investment from the federal government, moving most Medicaid enrollees into 16 Coordinated Care Organizations, which managed care within a global budget. Colorado initiated its Medicaid Accountable Care Collaborative in 2011, creating 7 Regional Care Collaborative Organizations that received funding to coordinate care with providers and connect Medicaid enrollees with community services. Data spanning July 1, 2010, through December 31, 2014 (18 months before intervention and 24 months after intervention, treating 2012 as a transition year) were analyzed for 452?371 Oregon and 330?511 Colorado Medicaid enrollees, assessing changes in outcomes using difference-in-differences analyses of regional focus, primary care homes, and care coordination. Oregon's Coordinated Care Organization model was more comprehensive in its reform goals and in the imposition of downside financial risk. Exposures:Regional focus, primary care homes, and care coordination in Medicaid ACOs. Main Outcomes and Measures:Performance on claims-based measures of standardized expenditures and utilization for selected services, access, preventable hospitalizations, and appropriateness of care. Results:In a total of 782?882 Medicaid enrollees, 45.0% were male, with mean (SD) age 16.74 (14.41) years. Standardized expenditures for selected services declined in both states during the 2010-2014 period, but these decreases were not significantly different between the 2 states. Oregon's model was associated with reductions in emergency department visits (-6.28 per 1000 beneficiary-months; 95% CI, -10.51 to -2.05) and primary care visits (-15.09 visits per 1000 beneficiary-months; 95% CI, -26.57 to -3.61), improvements in acute preventable hospital admissions (-1.01 admissions per 1000 beneficiary-months; 95% CI, -1.61 to -0.42), 3 of 4 measures of access (well-child visits, ages 3-6 years, 2.69%; 95% CI, 1.20% to 4.19%; adolescent well-care visits, 6.77%; 95% CI, 5.22% to 8.32%; and adult access to preventive ambulatory care, 1.26%; 95% CI, 0.28% to 2.25%), and 1 of 4 measures of appropriateness of care (avoidance of head imaging for uncomplicated headache, 2.59%; 95% CI, 1.35% to 3.83%). Conclusions and Relevance:Two years into implementation, Oregon's and Colorado's Medicaid ACO models exhibited similar performance on standardized expenditures for selected services. Oregon's model, marked by a large federal investment and movement to global budgets, was associated with improvements in some measures of utilization, access, and quality, but Colorado's model paralleled Oregon's on several other metrics.

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:IntroductionA multitude of HRSN interventions are undergoing testing in the U.S., with the CMS Accountable Health Communities (AHC) Model as the largest. HRSN interventions typically include screening for social needs, referral to community resources, and patient navigation to ensure needs are met. There is currently a paucity of evidence on implementation of HRSN interventions. The Consolidated Framework for Implementation Research (CFIR) is a determinant framework widely used to plan and assess implementation. To the authors knowledge, there are no published studies assessing CFIR constructs for HRSN intervention implementation in the U.S. In the Assessment step of the Strengthening Peer AHC Navigation (SPAN) model, a between-site qualitative assessment methodology was used to examine implementation within and between AHC bridge organizations (BOs) within six ERIC implementation strategies identified by the authors based on AHC Model requirements.ObjectiveOur aim was to identify and present between-site barriers and facilitators to AHC Model implementation strategies.DesignA multi-site qualitative analysis methodology was used. CFIR determinants were linked to six Expert Recommendations for Implementing Change (ERIC) strategies: staff training, identify and prepare champions, facilitation, community resource engagement (alignment through advisory boards and working groups), data systems, and quality monitoring and assurance. Interviews were analyzed using thematic content analysis in NVivo 12 (QSR International).SettingFive health-related bridge organizations participating in the AHC Model.ResultsFifty-eight interviews were completed with 34 staff and 24 patients or patient proxies. Facilitators were identified across five of the six ERIC strategies. Barriers were identified across all six. While organizations found the AHC Model compatible and facilitators to implementation included previous experience, meeting patient needs and resources, and leadership engagement and support, a number of barriers presented challenges to implementation. Issues with adequate staff training, staff skills to resolve HRSN, including patient communication and boundary spanning, setting staff goals, beneficiary caseloads and measurement of progress, data infrastructure (including EHR), available resources to implement and differences in perceptions between clinical delivery site (CDS), and CSP of how to measure and resolve HRSN.Conclusions and relevanceThe conduct of a pre-implementation readiness assessment benefited from identifying CFIR determinants linked to various ERIC implementation strategies.

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Barriers and Facilitators to Implementation of Value-Based Care Models in New Medicaid Accountable Care Organizations in Massachusetts: A Study Protocol.

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