Objective: To examine changes in more and less discretionary condition-specific post-acute care use (skilled nursing, inpatient rehabilitation, home health) associated with Medicare accountable care organization (ACO) implementation. Data sources: 2009-2014 Medicare fee-for-service claims. Study Design: Difference-indifference methodology comparing post-acute outcomes after hospitalization for hip fracture and stroke (where rehabilitation is fundamental to the episode of care) to pneumonia, (where it is more discretionary) for beneficiaries attributed to ACO and non-ACO providers. Principal Findings: Across all three cohorts, in the baseline period ACO patients were more likely to receive Medicare-paid post-acute care and had higher episode spending. In hip fracture patients where rehabilitation is standard of care, ACO implementation was associated with 6-8% increases in probability of admission to a skilled nursing facility or inpatient rehabilitation (compared to home without care), and a slight reduction in readmissions. In a clinical condition where rehabilitation is more discretionary, pneumonia, ACO implementation was not associated with changes in post-acute location, but episodic spending decreased 2-3%. Spending decreases were concentrated in the least complex patients. Across all cohorts, the length of stay in skilled nursing facilities decreased with ACO implementation. Conclusions: ACOs decreased spending on post-acute care by decreasing use of discretionary services. ACO implementation was associated with reduced length of stay in skilled nursing facilities, while hip fracture patients used institutional post-acute settings at higher rates. Among pneumonia patients, we observed decreases in spending, readmission days, and mortality associated with ACO implementation.
Success of the accountable care organization model may require stronger financial incentives, potentially by including downside financial risk in contracts. Using the National Survey of ACOs, we explored changes in ACO structure and contracts over time. Though the number of ACO contracts and proportion with multiple contracts has grown, the proportion of ACOs bearing downside risk increased only modestly.Accountable care organizations (ACOs) have emerged as one of the most broadly implemented value-based payment models by both public and private payers. With incentives to improve the quality of care and reduce health care spending, the ACO model has grown to include 1,011 ACOs in 2018, covering an estimated 32.7 million lives and representing 1,477 different public and commercial payment arrangements.(1) While the Centers for Medicare and Medicaid Services (CMS) has introduced new ACO programs, debates continue around the impact of the ACO model, including the contribution of downside risk, where ACOs that fail to meet their financial targets share responsibility with payers for losses.(2)We used data from the National Survey of Accountable Care Organizations, administered four times from 2012 -2018 to analyze the evolution of ACOs. Twenty eight percent of ACOs formed in 2012 initially had a contract with downside risk (Exhibit 1). The proportion of ACOs taking on downside risk at the time they formed has varied over time, in part based on Medicare program initiation (e.g. Pioneer and Next Generation ACO programs could only be joined in 2012 and 2016 respectively). In 2018, 33% of ACOs report having at least one contract with downside risk. Though the increase in the proportion of ACOs with a downside risk contract is modest, the number of ACOs has grown roughly fivefold since 2012 (1), potentially indicating that the number of ACO downside risk contracts has also grown substantially. Study Data and MethodsTo improve our understanding of the rapidly growing number of ACOs, we fielded the National Survey of ACOs to all known ACOs in 2012. We fielded Waves 2 and 3 to
Importance It is critical to develop a better understanding of the strategies provider organizations use to improve the performance of frontline clinicians and whether ACO participation is associated with differential adoption of these tools. Objectives Characterize the strategies that physician practices use to improve clinician performance and determine their association with ACOs and other payment reforms. Data Sources The National Survey of Healthcare Organizations and the National Survey of ACOs fielded 2017‐2018 (response rates = 47 percent and 48 percent). Study Design Descriptive analysis for practices participating and not participating in ACOs among 2190 physician practice respondents. Linear regressions to examine characteristics associated with counts of performance domains for which a practice used data for feedback, quality improvement, or physician compensation as dependent variables. Logistic and fractional regression to examine characteristics associated with use of peer comparison and shares of primary care and specialist compensation accounted for by performance bonuses, respectively. Principal Findings ACO‐affiliated practices feed back clinician‐level information and use it for quality improvement and compensation on more performance domains than non‐ACO‐affiliated practices. Performance measures contribute little to physician compensation irrespective of ACO participation. Conclusion ACO‐affiliated practices are using more performance improvement strategies than other practices, but base only a small fraction of compensation on quality or cost.
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