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. Context As 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. Methods We 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. Findings States 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. Conclusions Four 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.

The healthcare system's rapid shift toward value-based payment poses unique quality measurement challenges and new foci for researchers and policy makers. Quality measures that use sex-specific criteria may inappropriately include or exclude transgender individuals. More large-scale studies must be conducted to incorporate transgender individuals into measures that use sex-specific criteria, and "measure stewards" should consider the existing clinical guidelines and recommendations regarding transgender individuals when developing measures. Systems designed only for cisgender individuals will exacerbate existing transgender healthcare disparities unless they are revamped and flexible to transgender individuals' needs.

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Research Objective To address the opioid overdose epidemic, the Centers for Disease Control and Prevention (CDC) developed the Guideline for Prescribing Opioids for Chronic Pain. Recognizing that releasing a guideline alone is insufficient for transforming practice, CDC supports initiatives to promote uptake and use, including the CDC Opioid Quality Improvement (QI) Collaborative (“Collaborative”). This presentation describes a mixed‐methods analysis combining systems‐level context, individualized approaches to QI, selected implementation strategies, and preliminary outcomes from the eleven systems in the Collaborative. Study Design The Collaborative design is an observational case study of Opioid QI implementation across two cohorts totaling eleven systems. Participating health systems reported QI measure data available in their electronic health records (EHRs) for a self‐determined subset of the sixteen CDC‐developed opioid QI measures. Each system selected a minimum of five QI measures to monitor and report. We calculated odds ratios to determine whether patients were more likely to receive guideline‐concordant care at the end of their system's participation in the Collaborative than at baseline. Qualitative data included interviews conducted with a system representative at the beginning of each cohort, notes from monthly group implementation calls, monthly liaison check‐in calls, and documents provided by systems. Population Studied The Collaborative consists of eleven health systems, including over 120 practices representing urban, rural and frontier areas and serving underserved and tribal populations. Systems volunteered to participate, received an honorarium and engaged in the Collaborative for a minimum of 18 months. The baseline measure data reflects approximately 10,000 patients on long‐term opioid therapy (LTOT) across the systems. Principal Findings The QI efforts varied based on contextual factors, including: having QI team members in leadership roles, systems' experiences with past QI efforts, availability of IT staff, and external pressure to change practice. QI teams took different approaches to implementing the QI efforts, including selecting “easy wins” first for proof of concept before implementing more difficult QI activities, allowing each clinic to decide how to implement the QI activities at the local level, and heavily involving clinical staff in decisions to change workflow. Most systems used similar implementation strategies to improve practice, including developing a dashboard to audit and provide clinician feedback, providing clinician education, creating standardized treatment agreements in the EHR, using or building clinical decision support tools within the EHR, integrating the prescription drug monitoring program within the EHR, and updating opioid initiatives and workflow. Based on the preliminary outcomes, one system saw significant improvement over seven quarters in two measures of guideline‐concordant care: decreased days' supply for new opioid prescriptions to three days or l...