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Overcoming silos in health care systems through meso-level organisations - a case study of health reforms in New South Wales, Australia. THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2024; 44:101013. [PMID: 38384947 PMCID: PMC10879775 DOI: 10.1016/j.lanwpc.2024.101013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 11/24/2023] [Accepted: 01/09/2024] [Indexed: 02/23/2024]
Abstract
Fragmented care delivery is a barrier to improving health system performance worldwide. Investment in meso-level organisations is a potential strategy to improve health system integration, however, its effectiveness remains unclear. In this paper, we provide an overview of key international and Australian integrated care policies. We then describe Collaborative Commissioning - a novel health reform policy to integrate primary and hospital care sectors in New South Wales (NSW), Australia and provide a case study of a model focussed on older person's care. The policy is theorised to achieve greater integration through improved governance (local stakeholders identifying as part of one health system), service delivery (communities perceive new services as preferable to status quo) and incentives (efficiency gains are reinvested locally with progressively higher value care achieved). If effectively implemented at scale, Collaborative Commissioning has potential to improve health system performance in Australia and will be of relevance to similar reform initiatives in other countries.
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Practice Site Heterogeneity within and between Medicaid Accountable Care Organizations. Healthcare (Basel) 2024; 12:266. [PMID: 38275548 PMCID: PMC10815263 DOI: 10.3390/healthcare12020266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 01/06/2024] [Accepted: 01/13/2024] [Indexed: 01/27/2024] Open
Abstract
The existing literature has considered accountable care organizations (ACOs) as whole entities, neglecting potentially important variations in the characteristics and experiences of the individual practice sites that comprise them. In this observational cross-sectional study, our aim is to characterize the experience, capacity, and process heterogeneity at the practice site level within and between Medicaid ACOs, drawing on the Massachusetts Medicaid and Children's Health Insurance Program (MassHealth), which launched an ACO reform effort in 2018. We used a 2019 survey of a representative sample of administrators from practice sites participating in Medicaid ACOs in Massachusetts (n = 225). We quantified the clustering of responses by practice site within all 17 Medicaid ACOs in Massachusetts for measures of process change, previous experience with alternative payment models, and changes in the practices' ability to deliver high-quality care. Using multilevel logistic models, we calculated median odds ratios (MORs) and intraclass correlation coefficients (ICCs) to quantify the variation within and between ACOs for each measure. We found greater heterogeneity within the ACOs than between them for all measures, regardless of practice site and ACO characteristics (all ICCs ≤ 0.26). Our research indicates diverse experience with, and capacity for, implementing ACO initiatives across practice sites in Medicaid ACOs. Future research and program design should account for characteristics of practice sites within ACOs.
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Integration on the Frontlines of Medicaid Accountable Care Organizations and Associations With Perceived Care Quality, Health Equity, and Satisfaction. Med Care Res Rev 2023; 80:519-529. [PMID: 37232171 DOI: 10.1177/10775587231173474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Amid enthusiasm about accountable care organizations (ACOs) in Medicaid, little is known about the primary care practices engaging in them. We leverage a survey of administrators within a random sample (stratified by ACO) of 225 practices joining Massachusetts Medicaid ACOs (64% response rate; 225 responses). We measure the integration of processes with distinct entities: consulting clinicians, eye specialists for diabetes care, mental/behavioral care providers, and long-term and social services agencies. Using multivariable regression, we examine organizational correlates of integration and assess integration's relationships with care quality improvement, health equity, and satisfaction with the ACO. Integration varied across practices. Clinical integration was positively associated with perceived care quality improvement; social service integration was positively associated with addressing equity; and mental/behavioral and long-term service integration were positively associated with ACO satisfaction (all p < .05). Understanding differences in integration at the practice level is vital for sharpening policy, setting expectations, and supporting improvement in Medicaid ACOs.
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Population turnover and leakage in commercial ACOs. THE AMERICAN JOURNAL OF MANAGED CARE 2023; 29:e104-e110. [PMID: 37104836 PMCID: PMC10542917 DOI: 10.37765/ajmc.2023.89350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
OBJECTIVES Commercial accountable care organization (ACO) contracts attempt to mitigate spending growth, but past evaluations have been limited to continuously enrolled ACO members in health maintenance organization (HMO) plans, excluding many members. The objective of this study was to examine the magnitude of turnover and leakage within a commercial ACO. STUDY DESIGN A historical cohort study using detailed information from multiple commercial ACO contracts within a large health care system between 2015 and 2019. METHODS Individuals insured through 1 of the 3 largest commercial ACO contracts during the study period, 2015-2019, were included. We examined patterns of entry and exit and the characteristics that predicted remaining in the ACO compared with leaving the ACO. We also examined predictors of the amount of care delivered in the ACO compared with outside the ACO. RESULTS Among the 453,573 commercially insured individuals in the ACO, approximately half left the ACO within the initial 24 months after entry. Approximately one-third of spending was for care occurring outside the ACO. Patients who remained in the ACO differed from those who left earlier, including being older, having a non-HMO plan, having lower predicted spending at entry, and having more medical spending for care performed within the ACO during the initial quarter of membership. CONCLUSIONS Both turnover and leakage hamper the ability of ACOs to manage spending. Modifications that address potentially intrinsic vs avoidable sources of population turnover and increase patient incentives for care within vs outside of ACOs could help address medical spending growth within commercial ACO programs.
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[10 Years Accountable Care Organizations in the USA: Impulses for Health Care Reform in Germany?]. DAS GESUNDHEITSWESEN 2022; 84:e12-e24. [PMID: 35114697 DOI: 10.1055/a-1718-3332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
GOAL OF THE STUDY An intent of the Patient Protection and Affordable Care Acts (ACA), also know as Obama Care, was to slow the expenditure growth in the public Medicare-System by shifting the accountability for health care outcomes and costs to the provider. For this purpose, provider were allowed to form networks, which would then take accountability for a defined population - Accountable Care Organizations (ACOs). Ten years after the introduction of ACOs, this paper looks at the impact of ACOs both on quality of care and costs of care to assess if ACOs can be a model of care delivery for Germany. METHODS In a mixed-method approach, a rapid review was conducted in Health System Evidence and PubMed. This was supported with further papers identified using the snowballing-technique. After screening the abstracts, we included articles containing information on cost- and/or quality impact of US-Medicare-ACOs. The findings of the rapid review were challenged with 16 ACO-experts and stakeholder in the USA. RESULTS In total, we included 60 publications which incorporated 6 reports that were either conducted directly by governmental institutions or ordered by them, along with 3 previous reviews. Among these, 31 contained information on costs of care, 18 contained information on quality of care and 11 had information on both aspects. The publications show that ACOs reduced costs of of care. Cost reductions were achieved compared to historic costs, to populations not cared for in ACOs, and counterfactuals. Quality of care stayed the same or improved. CONCLUSION ACOs contributed to slowing the cost growth in US Medicare without compromising quality of care. Thus, a transferal of this model of care to Germany should be considered. However, various policies have led to ACOs failing to unleash their full potential. Against this background, and against the background of stark differences between US Medicare and the German health care system, a critical reflection of the necessary policies underlying ACOs-like structures in Germany, needs to be undertaken.
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Abstract
Accountable care organizations (ACO) emerge each year aiming to improve care
quality while controlling rising health care costs. This cross-sectional study
examined whether ACO arrangements within a Preferred Provider Organization and a
Health Maintenance Organization (HMO) effected patient experience. A modified
Consumer Assessment of Healthcare Providers and Systems ACO survey was used to
assess care domain differences overall and by product. The association between
ACO and non-ACO populations and items in each significant care domain, flu
vaccination, and delayed and emergency department care are explored using
multivariable logistic regression. Accountable care organizations patients were
more likely to report it was easy to get a specialist appointment (adjusted odds
ratio [AOR], 1.54; 95% CI = 1.11-2.13), less likely to report visiting the
emergency department for care (AOR, 0.70; 95% CI = 0.55-0.90) and communicating
with their provider using technology (AOR, 0.79; 95% CI = 0.65-0.96). Reported
experience differed for Access to Specialists between ACO and
non-ACO groups among overall and HMO respondents (79.4% vs 74.7% and 79.9% vs
75.5%, P < .05, respectively). The ACO patient experience
was not substantially better. Strategies incorporating satisfaction and
experience, whether linked to contracts or not, should be encouraged given ACOs
goal to optimize patient care. Survey instruments must be improved to capture
nuances of provider care and patient bond that is vital in ACO integrated
systems.
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Barriers and Facilitators to Implementation of Value-Based Care Models in New Medicaid Accountable Care Organizations in Massachusetts: A Study Protocol. Front Public Health 2021; 9:645665. [PMID: 33889558 PMCID: PMC8055830 DOI: 10.3389/fpubh.2021.645665] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 03/05/2021] [Indexed: 12/05/2022] Open
Abstract
Introduction: Massachusetts established 17 new Medicaid accountable care organizations (ACOs) and 24 affiliated Community Partners (CPs) in 2018 as part of a large-scale healthcare reform effort to improve care value. The new ACOs will receive $1.8 billion dollars in state and federal funding over 5 years through the Delivery System Reform Incentive Program (DSRIP). The multi-faceted study described in this protocol aims to address gaps in knowledge about Medicaid ACOs' impact on healthcare value by identifying barriers and facilitators to implementation and sustainment of the DSRIP-funded programs. Methods and analysis: The study's four components are: (1) Document Review to characterize the ACOs and CPs; (2) Semi-structured Key Informant Interviews (KII) with ACO and CP leadership, state-level Medicaid administrators, and patients; (3) Site visits with selected ACOs and CPs; and (4) Surveys of ACO clinical teams and CP staff. The Consolidated Framework for Implementation Research's (CFIR) serves as the study's conceptual framework; its versatile menu of constructs, arranged across five domains (Intervention Characteristics, Inner Setting, Outer Setting, Characteristics of Individuals, and Processes) guides identification of barriers and facilitators across multiple organizational contexts. For example, KII interview guides focus on understanding how Inner and Outer Setting factors may impact implementation. Document Review analysis includes extraction and synthesis of ACO-specific DSRIP-funded programs (i.e., Intervention Characteristics); KIIs and site visit data will be qualitatively analyzed using thematic analytic techniques; surveys will be analyzed using descriptive statistics (e.g., counts, frequencies, means, and standard deviations). Discussion: Understanding barriers and facilitators to implementing and sustaining Medicaid ACOs with varied organizational structures will provide critical context for understanding the overall impact of the Medicaid ACO experiment in Massachusetts. It will also provide important insights for other states considering the ACO model for their Medicaid programs. Ethics and dissemination: IRB determinations were that the overall study did not constitute human subjects research and that each phase of primary data collection should be submitted for IRB review and approval. Study results will be disseminated through traditional channels such as peer reviewed journals, through publicly available reports on the mass.gov website; and directly to key stakeholders in ACO and CP leadership.
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Can governments push providers to collaborate? A comparison of hospital network reforms in France and the United States. Health Policy 2020; 124:1100-1107. [DOI: 10.1016/j.healthpol.2020.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 06/12/2020] [Accepted: 07/09/2020] [Indexed: 10/23/2022]
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Association between specialist compensation and Accountable Care Organization performance. Health Serv Res 2020; 55:722-728. [PMID: 32715464 DOI: 10.1111/1475-6773.13323] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To determine if Medicare Shared Savings Program Accountable Care Organizations (ACOs) using cost reduction measures in specialist compensation demonstrated better performance. DATA SOURCES National, cross-sectional survey data on ACOs (2013-2015) linked to public-use data on ACO performance (2014-2016). STUDY DESIGN We compared characteristics of ACOs that did and did not report use of cost reduction measures in specialist compensation and determined the association between using this approach and ACO savings, outpatient spending, and specialist visit rates. PRINCIPAL FINDINGS Of 160 ACOs surveyed, 26 percent reported using cost reduction measures to help determine specialist compensation. ACOs using cost reduction in specialist compensation were more often physician-led (68.3 vs 49.6 percent) and served higher-risk patients (mean Hierarchical Condition Category score 1.09 vs 1.05). These ACOs had similar savings per beneficiary year (adjusted difference $82.6 [95% CI -77.9, 243.1]), outpatient spending per beneficiary year (-24.0 [95% CI -248.9, 200.8]), and specialist visits per 1000 beneficiary years (369.7 [95% CI -9.3, 748.7]). CONCLUSION Incentivizing specialists on cost reduction was not associated with ACO savings in the short term. Further work is needed to determine the most effective approach to engage specialists in ACO efforts.
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Five-year Impact of a Commercial Accountable Care Organization on Health Care Spending, Utilization, and Quality of Care. Med Care 2020; 57:845-854. [PMID: 31348124 DOI: 10.1097/mlr.0000000000001179] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Accountable Care Organizations (ACOs) have proliferated after the passage of the Affordable Care Act in 2010. Few longitudinal ACO studies with continuous enrollees exist and most are short term. OBJECTIVE The objective of this study was to evaluate the long-term impact of a commercial ACO on health care spending, utilization, and quality outcomes among continuously enrolled members. RESEARCH DESIGN Retrospective cohort study design and propensity-weighted difference-in-differences approach were applied to examine performance changes in 2 ACO cohorts relative to 1 non-ACO cohort during the commercial ACO implementation in 2010-2014. SUBJECTS A total of 40,483 continuously enrolled members of a commercial health maintenance organization from 2008 to 2014. MEASURES Cost, use, and quality metrics for various type of services in outpatient and inpatient settings. RESULTS The ACO cohorts had (1) increased inpatient and outpatient total spending in the first 2 years of ACO operation, but insignificant differential changes for the latter 3 years; (2) decreased outpatient spending in the latter 2 years through reduced primary care visits and lowered spending on specialists, testing, and imaging; (3) no differential changes in inpatient hospital spending, utilization, and quality measures for most of the 5 years; (4) favorable results for several quality measures in preventive and diabetes care domains in at least one of the 5 years. CONCLUSIONS The commercial ACO improved outpatient process quality measures modestly and slowed outpatient spending growth by the fourth year of operation, but had a negligible impact on inpatient hospital cost, use, and quality measures.
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Physician practices in Accountable Care Organizations are more likely to collect and use physician performance information, yet base only a small proportion of compensation on performance data. Health Serv Res 2019; 54:1214-1222. [PMID: 31742688 PMCID: PMC6863236 DOI: 10.1111/1475-6773.13238] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
IMPORTANCE It is critical to develop a better understanding of the strategies provider organizations use to improve the performance of frontline clinicians and whether ACO participation is associated with differential adoption of these tools. OBJECTIVES Characterize the strategies that physician practices use to improve clinician performance and determine their association with ACOs and other payment reforms. DATA SOURCES The National Survey of Healthcare Organizations and the National Survey of ACOs fielded 2017-2018 (response rates = 47 percent and 48 percent). STUDY DESIGN Descriptive analysis for practices participating and not participating in ACOs among 2190 physician practice respondents. Linear regressions to examine characteristics associated with counts of performance domains for which a practice used data for feedback, quality improvement, or physician compensation as dependent variables. Logistic and fractional regression to examine characteristics associated with use of peer comparison and shares of primary care and specialist compensation accounted for by performance bonuses, respectively. PRINCIPAL FINDINGS ACO-affiliated practices feed back clinician-level information and use it for quality improvement and compensation on more performance domains than non-ACO-affiliated practices. Performance measures contribute little to physician compensation irrespective of ACO participation. CONCLUSION ACO-affiliated practices are using more performance improvement strategies than other practices, but base only a small fraction of compensation on quality or cost.
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Evidence and Implications Behind a National Decline in Primary Care Visits. J Gen Intern Med 2019; 34:2260-2263. [PMID: 31243711 PMCID: PMC6816587 DOI: 10.1007/s11606-019-05104-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 04/24/2019] [Accepted: 05/17/2019] [Indexed: 10/26/2022]
Abstract
Primary care is the foundation of the health care system and the basis for new payment and delivery reforms in the USA. Yet since 2008, primary care visit rates dropped by 6-25% across a range of populations in five sources of national survey and administrative data. We hypothesize three likely mechanisms behind the decline: decreases in patients' ability, need, or desire to seek primary care; changes in primary care practice such as greater use of teams and non-face-to-face care; and replacement of in-person primary care visits with alternatives such as specialist, retail clinic, and commercial telemedicine visits. These mechanisms require further investigation. In the meantime, the trend prompts us to optimize the primary care visit and embrace the growth of alternatives while preserving the fundamental benefits of primary care.
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Health Information Technology and Accountable Care Organizations: A Systematic Review and Future Directions. EGEMS 2019; 7:24. [PMID: 31328131 PMCID: PMC6625537 DOI: 10.5334/egems.261] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background: Since the inception of Accountable Care Organizations (ACOs), many have acknowledged the potential synergy between ACOs and health information technology (IT) in meeting quality and cost goals. Objective: We conducted a systematic review of the literature in order to describe what research has been conducted at the intersection of health IT and ACOs and identify directions for future research. Methods: We identified empirical studies discussing the use of health IT via PubMed search with subsequent snowball reference review. The type of health IT, how health IT was included in the study, use of theory, population, and findings were extracted from each study. Results: Our search resulted in 32 studies describing the intersection of health IT and ACOs, mainly in the form of electronic health records and health information exchange. Studies were divided into three streams by purpose; those that considered health IT as a factor for ACO participation, health IT use by current ACOs, and ACO performance as a function of health IT capabilities. Although most studies found a positive association between health IT and ACO participation, studies that address the performance of ACOs in terms of their health IT capabilities show more mixed results. Conclusions: In order to better understand this emerging relationship between health IT and ACO performance, we propose future research should consider more quasi-experimental studies, the use of theory, and merging health, quality, cost, and health IT use data across ACO member organizations.
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Aggregating Claims Data Across Payers: Approaches, Challenges, and Lessons Learned From the Comprehensive Primary Care Initiative. Am J Med Qual 2019; 35:29-36. [DOI: 10.1177/1062860619843350] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The Comprehensive Primary Care (CPC) initiative fueled the emergence of new organizational alliances and financial commitments among payers and primary care practices to use data for performance improvement. In most regions of the country, practices received separate confidential feedback reports of claims-based measures from multiple payers, which varied in content and provided an incomplete picture of a practice’s patient panel. Over CPC’s last few years, participating payers in several regions resisted the tendency to guard data as a proprietary asset, instead working collaboratively to produce aggregated performance feedback for practices. Aggregating claims data across payers is a potential game changer in improving practice performance because doing so potentially makes the data more accessible, comprehensive, and useful. Understanding lessons learned and key challenges can help other initiatives that are aggregating claims or clinical data across payers for primary care practices or other types of providers.
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Organizational influences on healthcare system adoption and use of advanced health information technology capabilities. THE AMERICAN JOURNAL OF MANAGED CARE 2019; 25:e21-e25. [PMID: 30667614 PMCID: PMC6581444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
OBJECTIVES The adoption of advanced health information technology (HIT) capabilities, such as predictive analytic functions and patient access to records, remains variable among healthcare systems across the United States. This study is the first to identify characteristics that may drive this variability among health systems. STUDY DESIGN Responses from the 2017/2018 National Survey of Healthcare Organizations and Systems were used to assess the extent to which healthcare system organizational structure, electronic health record (EHR) standardization, and resource allocation practices were associated with use of 5 advanced HIT capabilities. Of 732 systems surveyed, 446 responded (60.9%), 425 (58.1%) met sample inclusion criteria, and 389 (53.1%) reported consistent EHR use. METHODS Measures of adoption, resource allocation, and organizational structure were developed based on survey responses. Multivariate linear regression with control variables estimated the relationships. RESULTS Adoption of advanced HIT capabilities is low and variable, with a mean of 2.4 capabilities adopted and only 8.4% of systems reporting widespread adoption of all 5 capabilities. In adjusted analyses, EHR standardization (β = 0.76; P = .001) was the strongest predictor of the number of advanced capabilities adopted, and ownership and management of medical groups (β = 0.32; P = .04) was also a significant predictor. CONCLUSIONS Health systems that standardize their EHRs and that own and manage hospitals and medical groups have higher rates of advanced HIT adoption and use. System leaders looking to increase the use of advanced HIT capabilities should consider ways to better standardize their EHRs across organizations.
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Impact of Provider Participation in ACO Programs on Preventive Care Services, Patient Experiences, and Health Care Expenditures in US Adults Aged 18–64. Med Care 2018; 56:711-718. [DOI: 10.1097/mlr.0000000000000935] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Moving Organizational Culture from Volume to Value: A Qualitative Analysis of Private Sector Accountable Care Organization Development. Health Serv Res 2018; 53:4767-4788. [PMID: 30047138 DOI: 10.1111/1475-6773.13012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE The concept of shifting from volume (i.e., billing for as many patients and services as possible) to value (i.e., reducing costs while improving quality) has been a key underpinning of the development of accountable care organizations (ACOs), yet the cultural change necessary to make this shift has been previously unexplored. DATA SOURCES/STUDY SETTING Primary data collected through site visits to four private sector ACOs. STUDY DESIGN Cross-sectional, semi-structured interview study with analysis done at the ACO level to learn about ACO development. DATA COLLECTION One hundred and forty-eight interviews recorded and transcribed verbatim followed by rigorous qualitative analysis using a grounded theory approach. PRINCIPAL FINDINGS The importance of shifting organizational culture from volume to value was emphasized across sites and interviewees, particularly when defining an ACO; describing the shift in organizational focus to value; and discussing how to create value by emphasizing quality over volume. Value was viewed as more than cost-benefit, but rather encapsulated a paradigmatic cultural change in the way care is provided. CONCLUSIONS We found that moving from volume to value is central to the culture change required of an ACO. Our findings can inform future efforts that aim to create a more effective value-based health care system.
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ACOs with risk-bearing experience are likely taking steps to reduce low-value medical services. THE AMERICAN JOURNAL OF MANAGED CARE 2018; 24:e216-e221. [PMID: 30020757 PMCID: PMC6594369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
OBJECTIVES Accountable care organizations (ACOs) are groups of healthcare providers responsible for quality of care and spending for a defined patient population. The elimination of low-value medical services will improve quality and reduce costs and, therefore, ACOs should actively work to reduce the use of low-value services. We set out to identify ACO characteristics associated with implementation of strategies to reduce overuse. STUDY DESIGN Survey analysis. METHODS We used the National Survey of ACOs to determine the percentage of responding ACOs aware of the Choosing Wisely campaign and to what degree ACOs have taken steps to reduce the use of low-value services. We identified characteristics of ACOs associated with implementing low-value care-reducing strategies using 3 statistical models (stepwise and LASSO logistic regression and random forest). RESULTS Responding executives of 155 of 267 ACOs (58%) were aware of Choosing Wisely. Eighty-four of those 155 ACO leaders said that their ACOs also actively implemented strategies to reduce the use of low-value services, largely through educating physicians and stimulating shared decision making. All 3 models identified the presence of at least 1 commercial payer contract and prior joint experience pursuing risk-based payment contracts as the most important predictors of an ACO actively implementing strategies to reduce low-value care. CONCLUSIONS In the first year of implementation, just one-third of ACOs had taken steps to reduce the use of low-value medical services. Safety-net ACOs and those with little experience as a risk-bearing organization need more time and support from healthcare payers and the Choosing Wisely campaign to prioritize the reduction of overuse.
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Abstract
The accountable care organization (ACO) concept is advocated as a promising value-based payment model that could successfully realign the current payment system to financially reward improvements in quality and efficiency. Focusing on the care of hospitalized patients and controlling a substantive portion of variable hospital expenses, hospitalists are poised to play an essential role in system-level transformational change to achieve clinical integration. Especially through hospital and health system quality improvement (QI) initiatives, hospitalists can directly impact and share accountability for measures ranging from care coordination to implementation of evidence-based care and the patient and family caregiver experience. Regardless of political terrain, financial constraints in healthcare will foster continued efforts to promote formation of ACOs that aim to deliver coordinated, evidence-based, and patient-centered care. Hospitalists possess the clinical experience of caring for complex patients with multiple comorbidities and the QI skills needed to lead efforts in this new ACO era.
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Medicare Accountable Care Organizations of Diverse Structures Achieve Comparable Quality and Cost Performance. Health Serv Res 2018; 53:2303-2323. [PMID: 29388199 DOI: 10.1111/1475-6773.12829] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To examine whether an empirically derived taxonomy of Accountable Care Organizations (ACOs) is associated with quality and spending performance among patients of ACOs in the Medicare Shared Savings Program (MSSP). DATA SOURCES Three waves of the National Survey of ACOs and corresponding publicly available Centers for Medicare & Medicaid Services performance data for NSACO respondents participating in the MSSP (N = 204); SK&A Office Based Physicians Database from QuintilesIMS. STUDY DESIGN We compare the performance of three ACO types (physician-led, integrated, and hybrid) for three domains: quality, spending, and likelihood of achieving savings. Sources of performance variation within and between ACO types are compared for each performance measure. PRINCIPAL FINDINGS There is greater heterogeneity within ACO types than between ACO types. There were no consistent differences in quality by ACO type, nor were there differences in likelihood of achieving savings or overall spending per-person-year. There was evidence for higher spending on physician services for physician-led ACOs. CONCLUSIONS ACOs of diverse structures perform comparably on core MSSP quality and spending measures. CMS should maintain its flexibility and continue to support participation of diverse ACOs. Future research to identify modifiable organizational factors that account for performance variation within ACO types may provide insight as to how best to improve ACO performance based on organizational structure and ownership.
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Impact of Accountable Care Organizations on Utilization, Care, and Outcomes: A Systematic Review. Med Care Res Rev 2017; 76:255-290. [PMID: 29231131 DOI: 10.1177/1077558717745916] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Since 2010, more than 900 accountable care organizations (ACOs) have formed payment contracts with public and private insurers in the United States; however, there has not been a systematic evaluation of the evidence studying impacts of ACOs on care and outcomes across payer types. This review evaluates the quality of evidence regarding the association of public and private ACOs with health service use, processes, and outcomes of care. The 42 articles identified studied ACO contracts with Medicare ( N = 24 articles), Medicaid ( N = 5), commercial ( N = 11), and all payers ( N = 2). The most consistent associations between ACO implementation and outcomes across payer types were reduced inpatient use, reduced emergency department visits, and improved measures of preventive care and chronic disease management. The seven studies evaluating patient experience or clinical outcomes of care showed no evidence that ACOs worsen outcomes of care; however, the impact on patient care and outcomes should continue to be monitored.
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Alternative payment models lead to strategic care coordination workforce investments. Nurs Outlook 2017; 65:737-745. [DOI: 10.1016/j.outlook.2017.04.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 04/03/2017] [Accepted: 04/06/2017] [Indexed: 01/17/2023]
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