Search

Importance: The Pioneer Accountable Care Organization (ACO) Model aims to drive health care organizations to reduce expenditures while improving quality for fee-for-service (FFS) Medicare beneficiaries., Objective: To determine whether FFS beneficiaries aligned with Pioneer ACOs had smaller increases in spending and utilization than other FFS beneficiaries while retaining similar levels of care satisfaction in the first 2 years of the Pioneer ACO Model., Design, Setting, and Participants: Participants were FFS Medicare beneficiaries aligned with 32 ACOs (n = 675,712 in 2012; n = 806,258 in 2013) and a comparison group of alignment-eligible beneficiaries in the same markets (n = 13,203,694 in 2012; n = 12,134,154 in 2013). Analyses comprised difference-in-differences multivariable regression with Oaxaca-Blinder reweighting to model expenditure and utilization outcomes over a 2-year performance period (2012-2013) and 2-year baseline period (2010-2011) as well as adjusted analyses of Consumer Assessment of Healthcare Providers & Systems (CAHPS) survey responses among random samples of beneficiaries in Pioneer ACOs (n = 13,097), FFS (n = 116,255), or Medicare Advantage (n = 203,736) for 2012 care., Exposures: Beneficiary alignment with a Pioneer ACO in 2012 or 2013., Main Outcomes and Measures: Medicare spending, utilization, and CAHPS domain scores., Results: Total spending for beneficiaries aligned with Pioneer ACOs in 2012 or 2013 increased from baseline to a lesser degree relative to comparison populations. Differential changes in spending were approximately -$35.62 (95% CI, -$40.12 to -$31.12) per-beneficiary-per-month (PBPM) in 2012 and -$11.18 (95% CI, -$15.84 to -$6.51) PBPM in 2013, which amounted to aggregate reductions in increases of approximately -$280 (95% CI, -$315 to -$244) million in 2012 and -$105 (95% CI, -$148 to -$61) million in 2013. Inpatient spending showed the largest differential change of any spending category (-$14.40 [95% CI, -$17.31 to -$11.49] PBPM in 2012; -$6.46 [95% CI, -$9.26 to -$3.66] PBPM in 2013). Changes in utilization of physician services, emergency department, and postacute care followed a similar pattern. Compared with other Medicare beneficiaries, ACO-aligned beneficiaries reported higher mean scores for timely care (77.2 [ACO] vs 71.2 [FFS] vs 72.7 [MA]) and for clinician communication (91.9 [ACO] vs 88.3 [FFS] vs 88.7 [MA])., Conclusions and Relevance: In the first 2 years of the Pioneer ACO Model, beneficiaries aligned with Pioneer ACOs, as compared with general Medicare FFS beneficiaries, exhibited smaller increases in total Medicare expenditures and differential reductions in utilization of different health services, with little difference in patient experience.

Objective: To examine the relationship between primary care physicians' (PCPs) payment arrangements and the total costs and intensity of care for specific episodes of care for Medicare beneficiaries., Data Sources/study Setting: We combined data from the 2004 to 2005 Community Tracking Study Physician Survey on PCP compensation methods with administrative data from the Medicare program for beneficiaries to whom these physicians provided services over the time period 2004-2006., Study Design: Cross-sectional analysis of physician survey data linked to Medicare claims., Principal Findings: The 2,211 PCP respondents included 937 internists and 1,274 family or general physicians who were linked to more than 250,000 Medicare enrollees. Most physicians (62 percent) had been in practice for 11 or more years and 87 percent were board certified. The total spending models show that for both employed physicians and owners, those in highly capitated practice environments had the lowest risk adjusted spending per beneficiary, whereas those receiving just productivity payments had the highest spending. These physicians also had lower intensity of care for episodes of care., Conclusions: Physicians in highly capitated practices had the lowest total costs and intensity of care, suggesting that these physicians develop an overall approach to care that also applies to their FFS patients., (© Health Research and Educational Trust.)

Medicare's decision-making processes leave policies on provider payment vulnerable to "micromanagement" by Congress and the White House. If they continue as they are, they could jeopardize delivery system changes central to current health reform proposals. Ad hoc intervention in response to pressure from narrow interests can result in policies that do not serve the broader priorities of beneficiaries and taxpayers and that are unsound economically. Establishing a new Medicare policy board, as proposed by the Obama administration and Congress; transforming the Medicare agency into an independent agency or new department; and conducting analyses of congressionally proposed payment policy changes before they are voted on could further insulate payment decisions from political interference.

Background: Primary care physicians are expected to coordinate care for their patients., Objective: To assess the number of physician peers providing care to the Medicare patients of a primary care physician., Design: Cross-sectional analysis of claims data., Setting: Fee-for-service Medicare in 2005., Participants: 2284 primary care physicians who responded to the 2004 to 2005 Community Tracking Study Physician Survey., Measurements: Primary patients for each physician were defined as beneficiaries for whom the physician billed for more evaluation and management visits than any other physician in 2005. The number of physician peers for each physician was the sum of other unique physicians that the index physician's primary patients visited plus other unique physicians who served as the primary physician for each of the index physician's nonprimary patients during 2005., Results: The typical primary care physician has 229 (interquartile range, 125 to 340) other physicians working in 117 (interquartile range, 66 to 175) practices with which care must be coordinated, equivalent to an additional 99 physicians and 53 practices for every 100 Medicare beneficiaries managed by the primary care physician. When only the 31% of a primary care physician's primary patients who had 4 or more chronic conditions was considered, the median number of peers involved was still substantial (86 physicians in 36 practices). The number of peers varied with geographic region, practice type, and reliance on Medicaid revenues., Limitations: Estimates are based only on fee-for-service Medicare patients and physician peers, and the number of peers is therefore probably an underestimate. The modest response rate of the Community Tracking Study Physician Survey may bias results in unpredictable directions., Conclusion: In caring for his or her own primary and nonprimary patients during a single year, each primary care physician potentially must coordinate with a large number of individual physician colleagues who also provide care to these patients., Funding: National Institute on Aging, American Medical Group Association, and the Robert Wood Johnson Foundation.

Background: Hospitalizations for bacterial pneumonia and chronic obstructive pulmonary disease (COPD) occur frequently, but many are potentially avoidable., Objective: To examine associations between elderly patients' usual physician and practice characteristics, and the risk of hospitalization for bacterial pneumonia and COPD., Research Design: Time-to-event analysis of Medicare claims from 2000 (baseline year) through 2001-2002 (follow-up years) for beneficiaries whose usual physician participated in the 2000-2001 Community Tracking Study Physician Survey., Subjects: A total of 509,613 patients and 5764 physicians for pneumonia hospitalizations; subset of 91,318 beneficiaries with an antecedent diagnosis of COPD and 5074 physicians for COPD hospitalizations., Measures: Hospitalizations for bacterial pneumonia or COPD occurring in 2001-2002., Results: Beneficiaries whose usual physician had been in practice for >10 years (vs. 5% Medicaid revenue (vs. 0-5%, P < 0.0001), or reported more (vs. less) difficulty securing ancillary services (P < 0.01 for bacterial pneumonia and P = 0.05 for COPD). Patient socioeconomic status, previous respiratory hospitalizations, and comorbidities had the strongest associations with hospitalization., Conclusions: Given that physicians who report limited access to ancillary services and high Medicaid case volume have patients who experience higher rates of admission for COPD and pneumonia, additional resources and quality improvement interventions targeting these providers should be priorities.

Background: Two assumptions underpin the implementation of pay for performance in Medicare: that with the use of claims data, patients can be assigned to a physician or to a practice that will have primary responsibility for their care, and that a meaningful fraction of the care physicians deliver is for patients for whom they have primary responsibility., Methods: We analyzed Medicare claims from 2000 through 2002 for 1.79 million fee-for-service beneficiaries treated by 8604 respondents to the Community Tracking Study Physician Survey in 2000 and 2001. In separate analyses, we assigned each patient to the physician or primary care physician with whom the patient had had the most visits. We determined the number of physicians and practices seen annually, the percentage of care received from the assigned physician or practice, the stability of assignments over time, and the percentage of physicians' Medicare patients who were their assigned patients., Results: Beneficiaries saw a median of two primary care physicians and five specialists working in four different practices. A median of 35% of beneficiaries' visits each year were with their assigned physicians; for 33% of beneficiaries, the assigned physician changed from one year to another. On the basis of all visits to any physician, a primary care physician's assigned patients accounted for a median of 39% of the physician's Medicare patients and 62% of Medicare visits. For medical specialists, the respective percentages were 6% and 10%. On the basis of visits to primary care physicians only, 79% of beneficiaries could be assigned to a physician, and a median of 31% of beneficiaries' visits were with that assigned primary care physician., Conclusions: In fee-for-service Medicare, the dispersion of patients' care among multiple physicians will limit the effectiveness of pay-for-performance initiatives that rely on a single retrospective method of assigning responsibility for patient care., (Copyright 2007 Massachusetts Medical Society.)

Background: Withdrawals of health plans from Medicare have affected more than 1.6 million beneficiaries. Some plans claim that providing higher quality care raises costs, lowers profits, and spurs withdrawal because plans cannot sustain high quality care under current payment levels., Objective: To assess whether higher performance by Medicare health plans on quality indicators was associated with withdrawal., Design: Retrospective cohort study., Subjects: Taking each county where a contract was active as a unit of analysis, Medicare managed care plans active in 2310 contract-county combinations in 1997 were studied and followed for 3 years., Measures: Independent variables were scores on six indicators from the Health Plan Employer Data and Information Set (HEDIS) for each contract, collapsed into two summary measures: clinical and ambulatory care access. Separate Cox proportional hazards regressions were used for each indicator, and each summary measure, to assess the association of HEDIS performance with our outcome measure, time-to-withdrawal from Medicare. Multiple potential confounders were adjusted for., Results: Of 2310 managed care contract-county combinations, 877 (38%) withdrew. The proportion of contract-counties with high scores on the summary clinical quality measure that withdrew was one-fifth that for low scorers (4.2% vs. 20.5%). For summary ambulatory care access performance, the corresponding ratio was two-fifths (12.8% vs. 32.0%). Lower payments were associated with higher withdrawal risk, but also higher clinical and ambulatory care access quality performance. In separate multivariable analyses controlling for confounders, both high clinical performance (HR, 0.18; 95% CI, 0.08-0.42) and high ambulatory care access performance (HR, 0.53; 95% CI, 0.27-1.07) were independently associated with lower withdrawal risk., Conclusions: Health plans continuing to provide care to Medicare beneficiaries have higher average performance on HEDIS clinical and ambulatory care access measures than plans that withdrew.