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• What is the primary question addressed by this study? Would Medicare costs be reduced if Black and Hispanic ADRD patients and ADRD patients living in areas with higher social vulnerability enrolled in ACO? • What is the main finding of this study? Significant variations in Medicare costs were observed by patient's race, ethnicity, and social vulnerability of the residing area, with Black and Hispanic patients and those living in the most vulnerable areas experiencing the highest total costs. For ADRD patients residing in the areas with the highest vulnerability, the cost differences by ACO enrollment of the total Medicare costs ranged from $4,403.1 to $6,922.7 and beneficiaries' savings ranged from $114.5 to $726.6 for a 3-year post-ADRD diagnosis by patient's race and ethnicity. • What is the meaning of the finding? ACOs and emerging CMS Innovation models, such as the Guiding an Improved Dementia Experience (GUIDE) Model, should prioritize strategic resource allocation in socially vulnerable areas while emphasizing culturally competent ADRD care. This study investigated variations in Medicare payments for Alzheimer's disease and related dementia (ADRD) by race, ethnicity, and neighborhood social vulnerability, together with cost variations by beneficiaries' enrollment in Accountable Care Organizations (ACOs). We used merged datasets of longitudinal Medicare Beneficiary Summary File (2016–2020), the Social Vulnerability Index (SVI), and the Medicare Shared Savings Program (MSSP) ACO to measure beneficiary-level ACO enrollment at the diagnosis year of ADRD. We analyzed Medicare payments for patients newly diagnosed with ADRD for the year preceding the diagnosis and for the subsequent 3 years. The dataset included 742,175 Medicare fee-for-service (FFS) beneficiaries aged 65 and older with a new diagnosis of ADRD in 2017 who remained in the Medicare FFS plan from 2016 to 2020. Among those newly diagnosed, Black and Hispanic patients encountered higher total costs compared to White patients, and ADRD patients living in the most vulnerable areas experienced the highest total costs compared to patients living in other regions. These cost differences persisted over 3 years postdiagnosis. Patients enrolled in ACOs incurred lower costs across all racial and ethnic groups and SVI areas. For ADRD patients living in the areas with the highest vulnerability, the cost differences by ACO enrollment of the total Medicare costs ranged from $4,403.1 to $6,922.7, and beneficiaries' savings ranged from $114.5 to $726.6 over three years post-ADRD diagnosis by patient's race and ethnicity. Black and Hispanic ADRD patients and ADRD patients living in areas with higher social vulnerability would gain more from ACO enrollment compared to their counterparts. [ABSTRACT FROM AUTHOR]

The emergence of Accountable Care Organizations (ACOs) in the landscape of the U.S. healthcare system marks a paradigm shift in healthcare operations. The potential impact of ACOs has been a topic of intense debate. Traditional analytical approaches do not lend themselves to examining the complex phenomenon of the emergence and growth of ACOs in the healthcare network. We adopt a complex adaptive system lens to examine the growth of ACOs among physician groups and explore factors that influence this growth. We also discuss the impact of ACOs on the profit of physician groups. An agent-based model was built to simulate physician groups' ACO entrance and exit based on a set of simple rules and their complex interactions with other agents. Based on the simulation results, we derive patterns of ACO expansion and contraction, following four stages of wait-and-see, rollercoaster, fast growth, and stabilizing. Findings suggest that the growth of ACOs is sensitive to the initial state of ACO membership. When the initial size of ACO membership increases, it helps to eliminate the rollercoaster stage. In addition, the growth of the ACO varies depending on the cost–quality tradeoff. When both cost and quality objectives can be met simultaneously, the growth of ACO membership follows wait-and-see and fast growth stages followed by a different stage that we term sticky state. The impact of ACOs on physician groups’ cumulative profit varies by the service quality level of the physician group. Physician groups affiliated with insurance companies charging the lowest or the highest level of health insurance premiums are worse off with the ACO option. However, the ACO benefits physician groups affiliated with an insurance company charging a moderate level of premiums.

This project was undertaken to reduce unneeded variation among practicing primary care clinicians participating in an accountable care organization (ACO) and to raise quality and reduce costs. This real-world, quasi-controlled experiment compared ACO target improvements between 3 participating geographic regions and members within the ProHealth ACO against nonparticipating regions and members. The authors used a novel care standardization initiative to engage participating providers. This was a 2-year longitudinal study with 6 rounds of serially measured provider care decisions and customized individual and group improvement feedback. Participating providers cared for online patient simulations as they would actual patients, and their care decisions were scored against evidence-based guidelines. This approach generated significant increases in evidence-based quality scores (+27%) and reductions in unneeded testing (-55%) in the patient simulations. Improvements in the online simulated patients correlated with improvements in patient-level ACO quality measures, which showed gains above and beyond the quasi-control group. Reductions calculated for spending on unneeded tests and specialist referrals exceeded $4.8 million. This study found that supporting practicing physicians in ACOs with evidence-based feedback significantly improved care and cost-efficiency. [ABSTRACT FROM AUTHOR]

Background: Accountable care organizations (ACOs) are being implemented rapidly across the Unites States. Previous studies indicated an increasing number of hospitals have participated in ACOs. However, little is known about how ACO participation could influence hospitals' performance. Purpose: This study aims to examine the impact of Medicare ACO participation on hospitals' patient experience. Methodology/Approach: Difference-in-difference analyses were conducted to compare 10 patient experience measures between hospitals participating in Medicare ACOs and those not participating. Results: In general, hospitals participating in Pioneer ACOs had significantly improved scores on nursing communication and doctor communication. Shared Savings Program (SSP) ACO participation did not show significant improvement of patient experience. Subgroup analyses indicate that, for hospitals in the middle and top tertile groups in terms of baseline experience, Pioneer ACO and SSP ACO participation was associated with better patient experience. For hospitals in the bottom tertile, Pioneer ACO and SSP ACO participation had no association with patient experience. Conclusion: ACO participation improved some aspects of patient experience among hospitals with prior good performance. However, hospitals with historically poor performance did not benefit from ACO participation. Practice Implications: Prior care coordination and quality improvement experience position Medicare ACOs for greater success in terms of patient experience. Hospital leaders need to consider the potential negative consequences of ACO participation and the hospital's preparedness for care coordination. [ABSTRACT FROM AUTHOR]

Background and Objectives: MRI is commonly used in the pediatric population and often requires sedation or general anesthesia to complete. This study used data from a pediatric accountable care organization (ACO) to investigate trends in MRI utilization and in the requirement for anesthesia to complete MRI examinations.Methods: The Partners for Kids (PFK) ACO claims database was queried for MRI examination encounters involving patients 0 to 18 years old from 2009 to 2014, with utilization expressed as encounters per 10,000 PFK members-months. Data were limited to 2011 to 2014 to ensure consistent billing of anesthesia services. Encounters were classified according to the presence of procedure codes for anesthesia or sedation.Results: MRI utilization was approximately constant over the study period at 11 to 12 encounters per 10,000 member-months. The need for anesthesia increased from 21% to 28% of encounters over 2011 to 2014. The latter increase was shared across 1- to 6-year-old, 7- to 12-year-old, and 12- to 18-year-old subgroups. In multivariable regression analysis of monthly utilization, increasing need for anesthesia could not be attributed to secular trends in patient demographics or types of examinations ordered. Paid cost data were available for outpatient MRIs, and MRIs with sedation accounted for an increasing share of these costs (from 22% in 2011 to 33% in 2014).Conclusion: There was an increasing need for anesthesia services to complete MRI examinations in this pediatric population, resulting in increasing cost of MRI examinations and presenting a challenge to ACO cost containment. [ABSTRACT FROM AUTHOR]

Accountable care organizations (ACOs) are rapidly being implemented across the United States, but little is known about what environmental and organizational factors are associated with hospital participation in ACOs. Using resource dependency theory, this study examines external environmental characteristics and organizational characteristics that relate to hospital participation in Medicare ACOs. Results indicate hospitals operating in more munificent environments (as measured by income per capita: β = 0.00002, p < .05) and more competitive environments (as measured by Health Maintenance Organization penetration: β = 1.86, p < .01) are more likely to participate in ACOs. Organizational characteristics including hospital ownership, health care system membership, electronic health records implementation, hospital type, percentage of Medicaid inpatient discharge, and number of nursing home beds per 1,000 population over 65 are also related to ACO participation. Should the anticipated benefits of ACOs be realized, findings from this study can guide strategies to encourage hospitals that have not gotten involved in ACOs. [ABSTRACT FROM AUTHOR]

Management of chronic disease often requires multidisciplinary clinical efforts and specialist care. With the emergence of Accountable Care Organizations (ACOs), health care systems are incentivized to evaluate methods of information exchange between generalists and specialists in order to provide value while preserving quality. Our objective was to evaluate patient and referring provider satisfaction and outcomes of asynchronous electronic consultations in vascular care in a large tertiary academic medical center. Referring providers were offered a vascular ‘e-consult’ option through an electronic referral management system. We conducted chart review to understand the downstream effects and surveyed patients and referring providers to assess satisfaction. From 24 March 2014 to 1 March 2015, 54 e-consults were completed. Additional testing and recommendations were made in 49/54 (90.7%) e-consults, including lower-extremity venous duplex ultrasonography with reflux testing, duplex ultrasonography of the carotid artery, computed tomography, magnetic resonance imaging, non-invasive physiology arterial studies, laboratory tests, medications, compression stockings, and sequential lymphedema compression therapy. Referring providers were compliant with recommendations in 40/49 (81.6%) of e-consults. A total of 17/54 (31.5%) patients were surveyed with a median patient satisfaction score of 13.7/15 (91.3%) (SD ± 6.4). The program was associated with high referring provider satisfaction, with 87.0% finding the e-consult very helpful and 80.0% stating it averted the need for a traditional visit. Our experience suggests that e-consults are an effective way to provide vascular care in some patients and are associated with high patient and provider satisfaction. E-consults may therefore be an efficient method of care delivery for vascular patients within an ACO. [ABSTRACT FROM AUTHOR]

Accountable care organizations (ACOs), joint ventures of commercial insurers and various groups of medical providers such as physicians, specialists, and hospitals whose development in California has been quickened by the Affordable Care Act, carry with them both promise and pitfalls. On the positive side of the ledger, ACOs may improve the quality of medical care even as they lower the costs of that care. On the negative side of the ledger, ACOs may lead to a gain in market power for their participations, allowing those participants to increase the prices they charge to commercial insurers. It is thus a key question for antitrust enforcers to figure out how to separate the sheep from the goats. This article, representing our personal views as state antitrust enforcers in the California attorney general's office, offers our reflection on a number of ACO articles and studies in this special issue through the prism of this key question and sets out a number of additional issues that we believe warrant study in conjunction with ACOs. [ABSTRACT FROM AUTHOR]

Over the past thirty years the rising cost of healthcare has produced changes in reimbursement strategies. Continually, pressures are placed on the practitioners to reduce the length of the patient hospital stay and provide services in a high quality, riskfree, cost effective manner. Following the implementation of diagnostic related groups (DRGs) in the 1980s and Managed Care in the 1990s we are now faced with embracing and surviving the Affordable Health Care Act-H.R. 3590 (HHS 2013) that is linking reimbursement to quality outcomes. In short, financial constraints in the funding of health care will once more alter the patterns of delivery and challenge the practitioners to maintain superior care. As Neurodiagnostic Professionals this new reform offers another opportunity to review our process of care and the Neurodiagnostic labs role in the delivery of healthcare. For success, close examination of routine workflows, recognizing and solving existing delivery limitations, developing team care coordination, and increasing the neurodiagnostic professionals profile within the work environment will be required. Embracing your role in this overall process will most likely demand more paperwork, changing protocols, learning and implementing new policies, accepting new work schedules, implementing new quality standards, and pursuing additional education or credentials. Unlike never before more emphasis will be placed on measuring and reporting on the quality of the care we deliver in our labs, intensive care units, and operating rooms. Become “Accountable to manage costs and care. [ABSTRACT FROM AUTHOR]

The healthcare landscape in which independent practice of psychology is embedded has undergone significant change in the last three decades. Following on those changes, the Affordable Care Act (ACA) was passed in 2010, with a goal of increasing access, improving patient outcomes, and curbing escalating healthcare costs, while providing 32 million more Americans with health insurance coverage. The partisan political climate in Washington, DC, and the serious budget deficit facing Congress, forecast an uncertain future for the ACA. Despite these uncertainties, there is considerable agreement by public and private payers, many healthcare systems, and employers about the need to improve America's healthcare system. The ACA encourages a healthcare system transformation that includes integration of behavioral healthcare into primary care settings and it is not clear what role psychologists will have in that evolving system. Additionally, mental and behavioral health services will be included in the Medicaid expansion program and state-based health insurance exchange plans. Critical issues affecting independent practitioners in the evolving healthcare system include access to program participation in Medicaid and health insurance exchange products, payment reform, new reimbursement structures, evolving practice models, acquisition of the skills necessary to practice in team-based primary care environments, and demonstration of psychology's value to the greater healthcare system. As these issues are addressed in the legislative, legal, and regulatory arenas, it is imperative that psychology's voice is heard. The implications of these changes for psychological practice and action steps for the profession are discussed. [ABSTRACT FROM AUTHOR]

Background: Medicare's accountable care organizations (ACOs)-designed to improve quality and lower spending-were associated with growing savings in previous studies. However, savings estimates may be biased by beneficiary sorting among providers based on healthcare needs and by providers opting into the program based on anticipated gains., Methods: Using Medicare administrative claims (2009-2014), we compared annual spending changes after provider organizations joined ACOs to changes in non-ACOs (controls). To address provider selection, using novel data to identify non-ACO organizations, we restricted controls to comparably large provider organizations. To address beneficiary selection, we (a) estimated within-organization (including non-ACO comparison organizations) spending changes, (b) estimated within-beneficiary spending changes, (c) incorporated beneficiaries without qualifying healthcare expenses, and (d) used a fixed beneficiary ACO assignment using the pre-ACO period., Results: Each year, 19% of Medicare beneficiaries switched provider organizations. Spending was higher for switchers than stayers ($3163, p < .001) and grew more the next year ($2004; p < .001). Starting from a baseline regression modeled on previous ACO evaluations, estimated savings varied widely as we sequentially introduced methods to address selection. Combining methods, however, generated more stable estimated ACO savings of $46 (p = .022), averaged across cohorts., Conclusions: When implementing a comprehensive suite of methods to adjust for provider and beneficiary selection, we estimated ACO savings that grew over time. Our estimates are in line with, but smaller than, previous estimates in the literature. Implementing piecemeal adjustments produced misleading results., Implications: Our results confirm the importance of selection for savings estimates and for provider organizations managing costs and quality. Attribution rules that consider multiple years may help mitigate the impact of beneficiary churn for providers and payers. Implementing payment reform by randomizing early participants, or implementing fully across selected markets, may better serve efforts to evaluate and improve payment models., Level of Evidence: Level 3., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Since its passage in 2010, the Affordable Care Act has led to the creation of numerous accountable care organizations that face the challenge of transforming the traditional care delivery model to provide more patient-centered, high-quality, and low-cost care. Complex patients, including those with chronic kidney disease (CKD), present the most challenges and opportunities. CKD is a condition with significant morbidity, mortality, and cost and thought to be partly secondary to known gaps in care delivery. Successful population management for CKD requires consideration of the needs of patients at all phases of the disease. In this article, we offer a comprehensive framework for a population-based approach to CKD and examples of programs we are implementing in each area. These initiatives include the development and implementation of an electronic nephrology consult (e-consult) platform, CKD quality metrics, CKD registry, CKD collaborative care agreement, multidisciplinary care clinic for advanced CKD, end-stage renal disease care coordinator program, shared decision-making tools for renal replacement, CKD education videos, and a tablet-based CKD patient-reported outcome measures tool., (Copyright © 2016 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)