ACOs Serving High Proportions Of Racial And Ethnic Minorities Lag In Quality Performance

Abstract

Accountable care organizations (ACOs) are intended, in part, to improve health care quality. However, little is known about how such reforms may affect disparities or how providers serving disadvantaged patients perform under Medicare ACO contracts. We analyzed racial and ethnic disparities in health care outcomes among ACOs—the relationship between the share of an ACO’s patients that are racial and ethnic minorities and the ACO’s performance. Using data from Medicare and from a national survey of ACOs, we found that a higher proportion of minority patients is associated with worse quality performance on 26 of 33 Medicare ACO performance measures. However, ACOs serving a high share of minority patients were similar to other ACOs on most observable characteristics and capabilities, including provider composition, services, and clinical capabilities. Our findings suggest that ACOs with a high share of minority patients may struggle in quality performance under ACO contracts, especially during their early years of participation—reinforcing or potentially exacerbating current inequities. Policymakers must consider how to refine ACO programs to encourage participation of providers serving minority patients and appropriately reward performance.

Promoting Health Equity through De-Implementation Research

“…For example, there are racial and ethnic disparities in the use of electronic patient portals, 22 and accountable care organizations with higher proportions of racial and ethnic minorities appear to have poorer track records in achieving quality targets. 23 This could lead to de-implementation strategies exacerbating-not attenuating-disparities in overuse. But researchers can anticipate and measure this, and seek ways to address it, such as building in strategies to expand use of an electronic patient portal among patients from racial and ethnic subgroups, or to ensure equitable distribution of patients across accountable care organizations.…”

Could Pay-for-Performance Worsen Health Disparities?

“…ACOs will face the same challenges as any P4P program, dealing with the same issues of already poorer quality in low-income and minority populations. 13 This race-and income-based differential access to the care coordination provided by ACOs with better resources could potentially exacerbate disparities in certain parts of the country. In a private insurance ACO, a greater increase in process measures was found among lowincome versus higher-income groups, with no significant difference in outcome measures.…”

Organizational Attributes Associated With Medicare ACO Quality Performance

“…Since the beginning of the program, the number of ACOs operating in rural America has increased considerably . As CMS releases ACO performance data, it is critical to evaluate how rural ACOs’ performance compares to that of urban ACOs and what organizational attributes are associated with ACO performance to inform policy and practice . This paper contributes such knowledge by evaluating associations between geographic, structural, and service‐provision attributes of MSSP ACOs and the ACOs’ quality performance.…”

“…Yet, to date, only a few studies have explored factors associated with MSSP ACOs’ quality performance. Research has shown that ACOs serving higher proportions of minorities had poorer performance on 25 of the 36 individual or composite quality measures during their first performance year . Several qualitative studies dived into ACO‐level factors and strategies that might contribute to high performance on cost savings and quality.…”

“…Research has shown that ACOs serving higher proportions of minorities had poorer performance on 25 of the 36 individual or composite quality measures during their first performance year. 6 Several qualitative studies dived into ACO-level factors and strategies that might contribute to high performance on cost savings and quality. For example, in a comparison of selected high-versus low-performing ACOs, researchers found that collaboration with local hospitals, prior experience with providing cost-effective care, physician leadership focusing on improving performance, sophisticated use of information systems, effective feedback to physicians, and embedded care coordinators were important factors that distinguished high-performing MSSP ACOs from their counterparts.…”