Accountable care organization initiatives to improve the cost and outcomes of specialty care.

OBJECTIVES: To assess initiatives to manage the cost and outcomes of specialty care in organizations that participate in Medicare accountable care organizations (ACOs). STUDY DESIGN: Cross-sectional analysis of 2023 ACO survey data. METHODS: Analysis of responses to a 12-question web-based survey from 101 respondents representing 174 ACOs participating in the Medicare Shared Savings Program or the Realizing Equity, Access, and Community Health ACO model in 2023. RESULTS: Improving specialist alignment was a high priority for 62% of the 101 respondents and a medium priority for 34%. Only 11% reported that employed specialists were highly aligned and 7% reported that contracted specialists were highly aligned. A subset of ACOs reported major efforts to engage specialists in quality improvement projects (38%) and to convene specialists to develop evidence-based care pathways (30%). They also reported supporting primary care physicians through providing specialist directories (44%), specialist e-consults (23%), and sharing specialist cost data (20%). The most common challenges reported were the influence of fee-for-service payment on specialist behavior (58%), lack of data to evaluate specialist performance (53%), and insufficient bandwidth or ACO resources to address specialist alignment (49%). CONCLUSIONS: Engaging specialists in accountable care is an emerging area for ACOs but one with numerous challenges. Making better data on specialist costs and outcomes available to Medicare ACOs is essential for accelerating progress.

Accountable Care Organizations and Specialists: Opportunities for Neurologists.

More than 700,000 physicians and advanced practice clinicians participate in Medicare ACOs, which is responsible for the cost and quality of care for more than 13 million beneficiaries. Nearly 40 percent of neurologists who treat Medicare patients are already in an ACO. The Centers for Medicare and Medicaid services is now implementing a strategy for value-based specialty care that promotes active ACO management of specialty services while some ACOs are starting to direct referrals to preferred specialist networks. Neurologists can benefit from engaging with ACOs through enhanced patient data, an emphasis on team-based care, care coordination support for their patients, and financial rewards for performance. Neurologists can help ACOs as the population ages, including by helping ensure appropriate use of expensive new therapies for neurologic conditions.

All-payer value-based contracting in organizations with Medicare ACOs.

OBJECTIVES: To measure the prevalence of non-Medicare value-based contracting and participation in contracts with downside risk among organizations participating in the Medicare Shared Savings Program (MSSP). STUDY DESIGN: Cross-sectional analysis of 2022 accountable care organization (ACO) survey. METHODS: The author analyzed surveys from 100 organizations participating in the MSSP that reported the number of covered lives they have in value-based contracts in traditional Medicare (ACOs), Medicare Advantage (MA), commercial payers, Medicaid managed care organizations, Medicaid, and direct-to-employer arrangements. We analyzed the distribution of covered lives across shared-savings, shared-risk, and full-risk contracts and analyzed changes between 2018 and 2022. RESULTS: Respondents reported 15.5 million covered lives in value-based contracts. All respondents have Medicare ACO contracts, and roughly 75% reported value-based contracts with commercial and MA plans. Approximately one-third reported such contracts with Medicaid managed care plans. Seventy percent of covered lives in respondents' Medicare ACO contracts included downside risk for losses compared with 51% of lives in commercial plans and 45% in MA plans. Compared with a similar 2018 survey, the proportion of respondents in value-based MA contracts doubled, and the proportion in commercial contracts rose by half. CONCLUSIONS: Organizations that participate in Medicare ACO models have substantially increased their participation in value-based contracts with other payers. They reported a higher proportion of Medicare ACO covered lives in downside risk arrangements than in commercial or MA contracts.

Challenges in predicting future high-cost patients for care management interventions.

BACKGROUND: To test the accuracy of a segmentation approach using claims data to predict Medicare beneficiaries most likely to be hospitalized in a subsequent year. METHODS: This article uses a 100-percent sample of Medicare beneficiaries from 2017 to 2018. This analysis is designed to illustrate the actuarial limitations of person-centered risk segmentation by looking at the number and rate of hospitalizations for progressively narrower segments of heart failure patients and a national fee-for-service comparison group. Cohorts are defined using 2017 data and then 2018 hospitalization rates are shown graphically. RESULTS: As the segments get narrower, the 2018 hospitalization rates increased, but the percentage of total Medicare FFS hospitalizations accounted for went down. In all three segments and the total Medicare FFS population, more than half of all patients did not have a hospitalization in 2018. CONCLUSIONS: With the difficulty of identifying future high utilizing beneficiaries, health systems should consider the addition of clinician input and 'light touch' monitoring activities to improve the prediction of high-need, high-cost cohorts. It may also be beneficial to develop systemic strategies to manage utilization and steer beneficiaries to efficient providers rather than targeting individual patients.

Characteristics of home-based care provided by accountable care organizations.

OBJECTIVES: To describe the use of home-based services in accountable care organizations (ACOs). STUDY DESIGN: Cross-sectional analysis of 2019 ACO survey. METHODS: We analyzed surveys completed by 151 ACOs describing the characteristics of home-based care programs serving high-need, high-cost patients. We linked survey results to publicly available information about ACO characteristics, governance, and risk model participation. RESULTS: Twenty-five percent of respondent ACOs had formal home-based care programs, 25% offered occasional home visits, and 17% were actively developing new programs. Home-based primary care was the most common program type. Half of programs were established within the past 3 years. The programs utilized multidisciplinary care teams, but two-thirds had fewer than 500 visits annually. Funding sources included direct billing for services, health system subsidies, and ACO shared savings. A majority of respondents expressed interest in expanding services but were concerned about their ability to demonstrate a return on investment (ROI), which was reported as a major or moderate challenge by three-quarters of respondents. CONCLUSIONS: ACOs deliver a diverse array of home-visit services including primary care, acute medical care, palliative care, care transitions, and interventions to address social determinants of health. Many services provided are not billable, and therefore ACO leaders are hesitant to fund expansions without strong evidence of ROI. Expanding Medicare ACO home-visit waivers to all risk-bearing ACOs and covering integrated telehealth services would improve the financial viability of these programs.

Accountable Care Organizations during Covid-19: Routine care for older adults with multiple chronic conditions.

The COVID-19 pandemic threatens the health and well-being of older adults with multiple chronic conditions. To date, limited information exists about how Accountable Care Organizations (ACOs) are adapting to manage these patients. We surveyed 78 Medicare ACOs about their concerns for these patients during the pandemic and strategies they are employing to address them. ACOs expressed major concerns about disruptions to necessary care for this population, including the accessibility of social services and long-term care services. While certain strategies like virtual primary and specialty care visits were being used by nearly all ACOs, other services such as virtual social services, home medication delivery, and remote lab monitoring were far less commonly accessible. ACOs expressed that support for telehealth services, investment in remote monitoring capabilities, and funding for new, targeted care innovation initiatives would help them better care for vulnerable patients during this pandemic.

Early Impact Of CareFirst's Patient-Centered Medical Home With Strong Financial Incentives.

In 2011 CareFirst BlueCross BlueShield, a large mid-Atlantic health insurance plan, implemented a payment and delivery system reform program. The model, called the Total Care and Cost Improvement Program, includes enhanced payments for primary care, significant financial incentives for primary care physicians to control spending, and care coordination tools to support progress toward the goal of higher-quality and lower-cost patient care. We conducted a mixed-methods evaluation of the initiative's first three years. Our quantitative analyses used spending and utilization data for 2010-13 to compare enrollees who received care from participating physician groups to similar enrollees cared for by nonparticipating groups. Savings were small and fully shared with providers, which suggests no significant effect on total spending (including bonuses). Our qualitative analysis suggested that early in the program, many physicians were not fully engaged with the initiative and did not make full use of its tools. These findings imply that this and similar payment reforms may require greater time to realize significant savings than many stakeholders had expected. Patience may be necessary if payer-led reform is going to lead to system transformation.

Effects of accountable care and payment reform on substance use disorder treatment: evidence from the initial 3 years of the alternative quality contract.

BACKGROUND AND AIMS: Global payment and accountable care reform efforts in the United States may connect more individuals with substance use disorders (SUD) to treatment. We tested whether such changes instituted under an Alternative Quality Contract (AQC) model within the Blue Cross Blue Shield of Massachusetts' (BCBSMA) insurer increased care for individuals with SUD. DESIGN: Difference-in-differences design comparing enrollees in AQC organizations with a comparison group of enrollees in organizations not participating in the AQC. SETTING: Massachusetts, USA. PARTICIPANTS: BCBSMA enrollees aged 13-64 years from 2006 to 2011 (3 years prior to and after implementation) representing 1 333 534 enrollees and 42 801 SUD service users. MEASUREMENTS: Outcomes were SUD service use and spending and SUD performance metrics. Primary exposures were enrollment into an AQC provider organization and whether the AQC organization did or did not face risk for behavioral health costs. FINDINGS: Enrollees in AQC organizations facing behavioral health risk experienced no change in the probability of using SUD services (1.64 versus 1.66%; P = 0.63), SUD spending ($2807 versus $2700; P = 0.34) or total spending ($12 631 versus $12 849; P = 0.53), or SUD performance metrics (identification: 1.73 versus 1.76%, P = 0.57; initiation: 27.86 versus 27.02%, P = 0.50; engagement: 11.19 versus 10.97%, P = 0.79). Enrollees in AQC organizations not at risk for behavioral health spending experienced a small increase in the probability of using SUD services (1.83 versus 1.66%; P = 0.003) and the identification performance metric (1.92 versus 1.76%; P = 0.007) and a reduction in SUD medication use (11.84 versus 14.03%; P = 0.03) and the initiation performance metric (23.76 versus 27.02%; P = 0.005). CONCLUSIONS: A global payment and accountable care model introduced in Massachusetts, USA (in which a health insurer provided care providers with fixed prepayments to cover most or all of their patients' care during a specified time-period, incentivizing providers to keep their patients healthy and reduce costs) did not lead to sizable changes in substance use disorder service use during the first 3 years following its implementation.

Risk contracting and operational capabilities in large medical groups during national healthcare reform.

OBJECTIVES: Little is known about the scope of alternative payment models outside of Medicare. This study measures the full complement of public and private payment arrangements in large, multi-specialty group practices as a barometer of payment reform among advanced organizations. STUDY DESIGN AND METHODS: We collected information from 33 large, multi-specialty group practices about the proportion of their total revenue in 7 payment models, physician compensation strategies, and the implementation of selected performance management initiatives. We grouped respondents into 3 categories based on the proportion of their revenue in risk arrangements: risk-based (45%-100%), mixed (10%-35%), and fee-for-service (FFS) (0%-10%). We analyzed changes in contracting and operating characteristics between 2011 and 2013. RESULTS: In 2013, 68% of groups' total patient revenue was from FFS payments and 32% was from risk arrangements (unweighted average). Risk-based groups had 26% FFS revenue, whereas mixed-payment and FFS groups had 75% and 98%, respectively. Between 2011 and 2013, 9 groups increased risk contract revenue by about 15 percentage points and 22 reported few changes. Risk-based groups reported more advanced implementation of performance management strategies and were more likely to have physician financial incentives for quality and patient experience. CONCLUSIONS: The groups in this study are well positioned to manage risk-based contracts successfully, but less than one-third receive a majority of their revenue from risk arrangements. The experience of these relatively advanced groups suggests that expanding risk-based arrangements across the US health system will likely be slower and more challenging than many people assume.

Opportunities and Challenges for Payment Reform: Observations from Massachusetts.

Policy makers and private health plans are expanding their efforts to implement new payment models that will encourage providers to improve quality and deliver health care more efficiently. Over the past five years, payment reforms have progressed faster in Massachusetts than in any other state. The reasons include a major effort by Blue Cross Blue Shield of Massachusetts to implement global payment, the presence of large integrated systems willing to take on financial risk, and a supportive state policy environment. By 2014, thirty-seven percent of Massachusetts's residents enrolled in health plans were covered under risk-based payment models tied to global budgets. But the expansion of payment reform in Massachusetts slowed between 2012 and 2015 because some commercial enrollment shifted from risk-based health maintenance organization products to fee-for-service preferred provider organization (PPO) plans, and the state Medicaid program fell short of its payment reform goals. Provider groups will not fully commit to population-based clinical models if they believe it will result in large reductions in fee-for-service revenue. The use of alternative payment models will accelerate in 2016 when Blue Cross begins implementing PPO payment reforms, but it is unknown how quickly other payers will follow. Massachusetts's experience illustrates the complexity of payment reform in pluralistic health care markets and the need for complementary efforts by public and private stakeholders.

The Early Impact Of The 'Alternative Quality Contract' On Mental Health Service Use And Spending In Massachusetts.

Accountable care using global payment with performance bonuses has shown promise in controlling spending growth and improving care. This study examined how an early model, the Alternative Quality Contract (AQC) established in 2009 by Blue Cross Blue Shield of Massachusetts (BCBSMA), has affected care for mental illness. We compared spending and use for enrollees in AQC organizations that did and did not accept financial risk for mental health with enrollees not participating in the contract. Compared with BCBSMA enrollees in organizations not participating in the AQC, we found that enrollees in participating organizations were slightly less likely to use mental health services and, among mental health services users, small declines were detected in total health care spending, but no change was found in mental health spending. The declines in probability of use of mental health services and in total health spending among mental health service users attributable to the AQC were concentrated among enrollees in organizations that accepted financial risk for behavioral health. Interviews with AQC organization leaders suggested that the contractual arrangements did not meaningfully affect mental health care delivery in the program's initial years, but organizations are now at varying stages of efforts to improve mental health integration.

The impact of global budgets on pharmaceutical spending and utilization: early experience from the alternative quality contract.

In 2009, Blue Cross Blue Shield of Massachusetts implemented a global budget-based payment system, the Alternative Quality Contract (AQC), in which provider groups assumed accountability for spending. We investigate the impact of global budgets on the utilization of prescription drugs and related expenditures. Our analyses indicate no statistically significant evidence that the AQC reduced the use of drugs. Although the impact may change over time, early evidence suggests that it is premature to conclude that global budget systems may reduce access to medications.

Early experience of a safety net provider reorganizing into an accountable care organization.

Although safety net providers will benefit from health insurance expansions under the Affordable Care Act, they also face significant challenges in the postreform environment. Some have embraced the concept of the accountable care organization to help improve quality and efficiency while addressing financial shortfalls. The experience of Cambridge Health Alliance (CHA) in Massachusetts, where health care reform began six years ago, provides insight into the opportunities and challenges of this approach in the safety net. CHA's strategies include care redesign, financial realignment, workforce transformation, and development of external partnerships. Early results show some improvement in access, patient experience, quality, and utilization; however, the potential efficiencies will not eliminate CHA's current operating deficit. The patient population, payer mix, service mix, cost structure, and political requirements reduce the likelihood of financial sustainability without significant changes in these factors, increased public funding, or both. Thus the future of safety net institutions, regardless of payment and care redesign success, remains at risk.