August 05, 2019 7:00 AM
Accountable care organizations seek to improve the care received
by traditional Medicare patients while holding cost growth down, but a new
study raises questions about its success.
As the Medicare system seeks to improve
the care of older adults while also keeping costs from growing too fast, a new
study suggests that one major effort may not be having as much of an impact as
hoped.
A new analysis of data from the Medicare Shared Savings Program
(MSSP) finds that high-cost physicians and high-cost patients
dropping out of the program accounted for much of the savings reported from
2008 to 2014.
After the effects of those departures
were taken into account, the Accountable Care Organizations
(ACOs) taking part in the MSSP had the same costs as physicians
in their area who were not taking part in ACOs, but also took care of other
patients with traditional Medicare coverage.
In 2014, the 338 MSSP ACO’s across the
country involved nearly 5 million Baby Boomers and older adults who received
their health care from thousands of providers. Today, that number has increased
to 518 ACOs covering nearly 11 million people.
The study also compares ACO and non-ACO
providers on measures of health care quality, finding that patients in a MSSP
ACO were not more likely to be given four proven tests for common health
problems than similar patients with the same kind of Medicare coverage who were
not part of an ACO.
The study, by a University of Michigan
team, is published in the Annals of
Internal Medicine. The authors note that the results have
greater implications for providers who voluntarily join an ACO, rather than
physicians employed by large group practices that have engaged in Medicare cost
and quality efforts for many years -- such as those at Michigan Medicine, U-M’s
academic medical center.
The findings suggest that as the
federal government continues its effort to “bend the cost curve” for Medicare
through voluntary reforms, it should take into consideration year-to-year
shifts in which providers and patients are taking part in ACOs. Otherwise, the
researchers say, “selection bias” could skew the interpretation of the
program’s effects.
ACOs can earn extra dollars from
Medicare based on their overall costs and quality averaged across all of their
providers’ patients, or can lose money if they do not meet cost or quality
goals. The Centers for Medicare and Medicaid
Services has set a goal of increasing the disincentives or
“risk” that ACOs face, so that an accurate measurement of the actual cost and
quality performance will increase in importance, say the researchers behind the
new study.
"To our surprise, we found that ACO savings
may be driven by the disproportionate exit of higher-spending clinicians out of
ACOs. " Adam Markovitz,
Ph.D.
“Our results suggest
that there is less reason for optimism about the MSSP’s effects to date than
might have been suggested by other studies,” says Andy Ryan, Ph.D., senior
author of the study and a professor at the U-M
School of Public Health. “We hope CMS will consider the implications
as it moves forward with evaluating programs aimed at improving the long-term
sustainability of the Medicare system.”
Ryan worked
with Adam Markovitz, Ph.D., who
led the analysis as part of his doctoral degree in public health. He is now
completing his medical degree at the U-M Medical School as part of the Medical Scientist Training
Program.
“At the project’s
outset, we hypothesized that early savings in this voluntary ACO program were
driven by disproportionate entry of high-performing “early adopter” clinicians
into ACOs,” says Markovitz. “To our surprise, we found that ACO savings may be
driven by the disproportionate exit of higher-spending clinicians out of ACOs.”
In all, the ACO
providers whose overall costs were in the top one percent of all providers
studied were more than twice as likely to leave a MSSP ACO than providers whose
costs fell into the middle level of spending.
Whether these
providers were encouraged to leave the ACO because of their costs, or they left
voluntarily because they were unable or unwilling to reduce the growth in cost
of their patients’ care, cannot be determined through the current study.
MSSP ACO
administrators are able to see the costs attributed to each of the providers
taking part in their ACO, so “gaming” of which providers to include could be
happening, say Ryan and Markovitz. “We would hope that if a provider shows a
trend toward low-value care, the ACO would work with them to remedy the
situation,” says Ryan.
Markovitz, Ryan and
colleagues published a paper in Health Affairs earlier
this year showing that high-cost patients were slightly more
likely to leave ACOs than lower-cost ones. They noted in that study that the
MSSP program did not adjust ACOs’ payments depending on how much more ill their
participating patients became over time – the payment was based on how sick
each patient was when their provider first joined the ACO.
While this has
apparently kept ACOs from “up-coding” patients to game the system, it also
means that ACOs may have an incentive to drop providers whose patients become
more severely ill – and therefore costlier.
That study, and this
new study, have implications for the changes being proposed for MSSP and other
value-based payment programs in Medicare.
“There need to be
more safeguards against the selective attrition of patients and providers from
ACOs that we’ve observed in our studies,” says Ryan. “As CMS encourages more
provider risk-taking, it should design its systems to support what’s working
best to improve care and efficiency.”
Markovitz also notes
that CMS could design more future Medicare innovations as true experiments –
for instance, with randomization (as in Medicare’s bundled payment plan for
joint replacement surgery) or a phased roll-out that allows researchers to
evaluate more readily whether a program truly saved money or improved quality.
Paper cited: Adam A.
Markovitz, BS; Andrew M. Ryan, PhD, et al. “Performance in the Medicare Shared
Savings Program After Accounting for Nonrandom Exit: An Instrumental Variable
Analysis” Annals of Internal Medicine. DOI: 10.7326/M18-2539
In addition to
Markovitz and Ryan, the paper’s authors include John M. Hollingsworth, MD, MS;
John Z. Ayanian, MD, MPP; Edward C. Norton, PhD; and Phyllis L. Yan, MS.
Ayanian directs, and Hollingsworth, Norton and Ryan are members of the U-M
Institute for Healthcare Policy and Innovation. Markovitz received research
support from the Horowitz Foundation for Social Policy and the Agency for
Healthcare Research and Quality.
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