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The article explores the use of difference-in-differences (DID) designs in health systems research, specifically in assessing the effectiveness of health system interventions. It emphasizes the importance of establishing core assumptions and addressing potential biases in order to determine causal relationships. The article also discusses the need for clear assumptions, statistical assessments, and contextualization to enhance the quality of evaluations. It mentions the increasing acceptance of causal claims in observational studies by medical journals. [Extracted from the article]

Health information exchange (HIE) is an effective way to coordinate care, but HIE between health and behavioral health providers is limited. Recent delivery reform models, including the Accountable Care Organization (ACO) and Patient Centered Medical Home (PCMH) prioritize interprofessional collaboration, but little is known about their impact on behavioral health HIE. This study explores whether delivery reform participation affects behavioral health HIE among ambulatory health providers using pooled 2015–2019 data from the National Electronic Health Record Survey, a nationally representative survey of ambulatory physicians' technology use (n = 8,703). The independent variable in this analysis was provider participation in ACO, PCMH, Hybrid ACO-PCMH, or standard care. The dependent variable was HIE with behavioral health providers. Chi square analysis estimated unweighted rates of behavioral health HIE across reform models. Logistic regression estimated the impact of delivery reform participation on rates of behavioral health HIE. Unweighted estimates indicated that Hybrid ACO-PCMH providers had the highest rates of HIE (n = 330, 33%). In the fully adjust model, rates of HIE were higher among ACO (AOR = 2.66, p <.01), PCMH (AOR = 4.73, p <.001) and Hybrid ACO-PCMH participants (AOR = 5.55, p <.001) compared to standard care, but they did not significantly vary between delivery models. Physicians infrequently engage in HIE with behavioral health providers. Compared to standard care, higher rates of HIE were found across all models of delivery reform. More work is needed to identify common elements of delivery reform models that are most effective in supporting this behavior [ABSTRACT FROM AUTHOR]

Background: Structural social determinants of health have an accumulated negative impact on physical and mental health. Evidence is needed to understand whether emerging health information technology and innovative payment models can help address such structural social determinants for patients with complex health needs, such as Alzheimer's disease and related dementias (ADRD). Objective: This study aimed to test whether telehealth for care coordination and Accountable Care Organization (ACO) enrollment for residents in the most disadvantaged areas, particularly those with ADRD, was associated with reduced Medicare payment. Methods: The study used the merged data set of 2020 Centers for Medicare and Medicaid Services Medicare inpatient claims data, the Medicare Beneficiary Summary File, the Medicare Shared Savings Program ACO, the Center for Medicare and Medicaid Service's Social Vulnerability Index (SVI), and the American Hospital Annual Survey. Our study focused on community-dwelling Medicare fee-for-service beneficiaries aged 65 years and up. Cross-sectional analyses and generalized linear models (GLM) were implemented. Analyses were implemented from November 2023 to February 2024. Results: Medicare fee-for-service beneficiaries residing in SVI Q4 (i.e., the most vulnerable areas) reported significantly higher total Medicare costs and were least likely to be treated in hospitals that provided telehealth post-discharge services or have ACO affiliation. Meanwhile, the proportion of the population with ADRD was the highest in SVI Q4 compared with other SVI levels. The GLM regression results showed that hospital telehealth post-discharge infrastructure, patient ACO affiliation, SVI Q4, and ADRD were significantly associated with higher Medicare payments. However, coefficients of interaction terms among these factors were significantly negative. For example, the average interaction effect of telehealth post-discharge and ACO, SVI Q4, and ADRD on Medicare payment was −$1,766.2 (95% confidence interval: −$2,576.4 to −$976). Conclusions: Our results suggested that the combination of telehealth post-discharge and ACO financial incentives that promote care coordination is promising to reduce the Medicare cost burden among patients with ADRD living in socially vulnerable areas. [ABSTRACT FROM AUTHOR]

Introduction:To examine telehealth use in chronic care management and disparity reduction among the aging population. Methods:This longitudinal cohort study compared the changes in chronic care quality measures among patients with and without telehealth visits during the COVID-19 pandemic relative to patients in the previous years and by patient sociodemographic subgroup. Participants were Medicare fee-for-service beneficiaries 65 years or older from an Accountable Care Organization in the Midwest United States. Three utilization-based measures included having 2+ A1C tests, breast cancer screening, and depression screening. Three outcome-based measures included A1C control, blood pressure control, and depression diagnosis. Results:During the study period, the pandemic cohort experienced 5–17 percentage points' decrease in utilization-based measures (e.g., 2+ A1C tests 63.9% vs. 51.1%; OR [95% confidence intervals] = 0.35 [0.34–0.36]) from baseline relative to the control cohort. The outcome-based measures also significantly decreased but at smaller magnitudes (3–5 percentage points). About 51.5% patients had at least one telehealth visit. The utilization-based measures for these patients were significantly higher than those without any telehealth visit (e.g., 2+ A1C 57.1% vs. 51.1%, p < 0.01). However, the outcome-based measures were comparable. Patients from historically underserved groups had a larger decline in health care outcomes than their counterparts. Among patient with at least one telehealth visit, these disparities were no longer significant. Discussions:Telehealth was associated with less negative impact of the pandemic and better performance in chronic care management, but more for utilization-based measures and less for outcome-based measures. Telehealth was also associated with less disparities in care outcomes. [ABSTRACT FROM AUTHOR]

To examine patterns of Accountable Care Organizations (ACO) leakage, the receipt of healthcare by ACO-assigned patients from institutions outside assigned ACO network, among patients with gynecologic cancer. ACO leakage was estimated as rates of patients seeking care external to their ACO assignment. Factors associated with ACO leakage were identified and cost differences within the first year of cancer diagnosis described. Medicare 5% data (2013–2017) was used to quantify rates of leakage among gynecologic cancer patients with stable ACO assignment. Crude and multivariable adjusted risk ratios of ACO leakage risk factors were estimated using log-binomial regression models. Overall and cancer-specific spending differences by ACO leakage status were compared using Wilcoxon rank-sum test. Overall incidence of ACO leakage was 28.1% with highest leakage for outpatient care and uterine cancer patients. ACO leakage risk was 56% higher among Black relative to White patients, and 77% more for those in higher relative to lowest quintiles of median household income. Leakage decreased by 3% and 8% with each unit increase in ACO size and number of subspecialists, respectively. Healthcare costs were 19.5% higher for leakage patients. ACO leakage rates among gynecologic cancer patients was overall modest, with some regional and temporal variation, higher leakage for certain subgroups and substantially higher Medicare spending in inpatient and outpatient settings for patients with ACO leakage. These findings identify targets for further investigations and strategies to encourage oncologists to participate in ACOs and prevent increased health care costs associated with use of non-ACO providers. • Accountable care organizations (ACO) are responsible for the overall cost and quality outcomes of a patient population. • Evidence suggests that ACOs have not had a meaningful effect on costs and quality of care for patients with cancer. • Gynecologic cancer patients often receive care outside of assigned ACO limiting ability to control costs and quality of care. • Greater participation of oncologists in ACOs may prevent increased healthcare costs associated with using non-ACO providers. [ABSTRACT FROM AUTHOR]

Preventive and primary care in the postpartum year is critical for future health and may be increased by primary care focused delivery system reform including implementation of Medicaid Accountable Care Organizations (ACO). This study examined associations of Massachusetts Medicaid ACO implementation with preventive visits in the postpartum year. The Massachusetts All-Payer Claims Database was used to identify births to privately-insured or Medicaid ACO-eligible individuals from January 1, 2016 to February 28, 2019. Comparing these groups before and after implementation, a propensity score weighted difference-in-difference design was used to analyze associations of Medicaid ACO implementation with any preventive care visit and any primary care physician (PCP) preventive visit within one year postpartum, controlling for other characteristics. Analyses were performed in 2023 and 2024. Of the 110,601 births in the study population, 35.5% had any preventive care visit and 23.0% had any preventive PCP visit in the year postpartum, with higher rates of preventive visits among privately-insured individuals. In adjusted difference-in-difference analyses, relative to the pre-period, there was a 2.7 percentage point (pp) decrease (95% confidence interval [CI]: -4.3pp, -1.2pp) and 3.5 pp decrease (95% CI: -4.9pp, -2.0pp) in use of any preventive visits and any PCP preventive visits, respectively, for Medicaid-insured versus privately-insured individuals after ACO implementation. Implementation of Massachusetts Medicaid ACOs was associated with decreases in receipt of preventive visits and preventive PCP visits for Medicaid-insured individuals relative to privately-insured individuals. Medicaid ACOs should consider potential implications of primary care access in the postpartum year for health across the lifecourse. [ABSTRACT FROM AUTHOR]

Background Methods Results Conclusion One‐third of people living with dementia (PLWD) have highly fragmented care (i.e., care spread across many ambulatory providers without a dominant provider). It is unclear whether PLWD with fragmented care and their caregivers perceive gaps in communication among the providers involved and whether any such gaps are perceived as benign inconveniences or as clinically meaningful, leading to adverse events. We sought to determine the frequency of perceived gaps in communication (coordination) among providers and the frequency of self‐reported adverse events attributed to poor coordination.We conducted a cross‐sectional study in the context of a Medicare accountable care organization (ACO) in New York in 2022–2023. We included PLWD who were attributed to the ACO, had fragmented care in the past year by claims (reversed Bice‐Boxerman Index ≥0.86), and were in a pragmatic clinical trial on care management. We used an existing survey instrument to determine perceptions of care coordination and perceptions of four adverse events (repeat tests, drug–drug interactions, emergency department visits, and hospital admissions). ACO care managers collected data by telephone, using clinical judgment to determine whether each survey respondent was the patient or a caregiver. We used descriptive statistics to summarize results.Of 167 eligible PLWD, surveys were completed for 97 (58.1%). Of those, 88 (90.7%) reported having >1 ambulatory visit and >1 ambulatory provider and were thus at risk for gaps in care coordination and included in the analysis. Of those, 23 respondents were patients (26.1%) and 64 were caregivers (72.7%), with one respondent's role missing. Overall, 57% of respondents reported a problem (or “gap”) in the coordination of care and, separately, 18% reported an adverse event that they attributed to poor care coordination.Gaps in coordination of care for PLWD are reported to be very common and often perceived as hazardous. [ABSTRACT FROM AUTHOR]

The authors describe a real-world application of virtually integrated primary and behavioral health care implemented within an accountable care organization (ACO) system. Cost-of-care data from before and after a 6-month intervention were analyzed for 121 Medicaid and Child Health Plan Plus ACO members. The intervention was associated with a significant shift in the distribution of health care costs, from inpatient and emergency care to outpatient and preventive care. The program demonstrates a flexible and replicable approach to integration that can help expand effective primary care. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the effects of Medicaid Accountable Care Organizations (ACOs) on children's access to and utilization of health services. Study Setting and Design: This study employs difference‐in‐differences models comparing ACO and non‐ACO states from 2018 through 2021. Access measures are indicators for preventive and sick care sources, unmet healthcare needs, and having a personal doctor or nurse. Utilization measures are preventive and dental care, mental healthcare, specialist visits, emergency department visits, and hospital admissions. Data Sources and Analytic Sample: Secondary, de‐identified data come from the 2016–2021 National Survey of Children's Health. The sample includes children with public insurance and ranges between 21,452 and 37,177 depending on the outcome. Principal Findings: Medicaid ACO implementation was associated with an increase in children's likelihood of having a personal doctor or nurse by about 4 percentage‐points concentrated among states that implemented ACOs in 2018. Medicaid ACOs were also associated with an increase in specialist care use and decline in emergency visits by about 5 percentage‐points (the latter being concentrated among states that implemented ACOs in 2020). There were no discernable or robust associations with other pediatric outcomes. Conclusions: There is mixed evidence on the associations of Medicaid ACOs with pediatric access and utilization outcomes. Examining effects over longer periods post‐ACO implementation is important. [ABSTRACT FROM AUTHOR]

Chronic kidney disease (CKD) is common, costly, and life-limiting, requiring dialysis and transplantation in advanced stages. Although effective guideline-based therapy exists, the asymptomatic nature of CKD together with low health literacy, adverse social determinants of health, unmet behavioral health needs, and primary care providers' (PCP) limited understanding of CKD result in defects in screening and diagnosis. Care is fragmented between PCPs and specialty nephrologists, with limited time, expertise, and resources to address systemic gaps. In this article, the authors define how they classified defects in care and report the current numbers of patients exposed to these defects, both nationally and in their health system Accountable Care Organization. They describe use of the health system's three-pillar leadership model (believing, belonging, and building) to empower providers to transform CKD care. Believing entailed engaging individuals to believe defects in CKD care could be eliminated and were a collective responsibility. Belonging fostered the creation of learning communities that broke down silos and encouraged open communication and collaboration between PCPs and nephrologists. Building involved constructing a fractal management infrastructure with transparent reporting and shared accountability, which would enable success in innovation and transformation. The result is proactive and relational CKD care organized around the patient's needs in University Hospitals Systems of Excellence. Systems of excellence combine multiple domains of expertise to promote best practice guidelines and integrate care throughout the system. The authors further describe a preliminary pilot of the CKD System of Excellence in primary care. [ABSTRACT FROM AUTHOR]

Establishing reliable access to dental services for publicly insured patients is an important part of achieving equitable oral health care. In 2023, an oral health screening requirement was added to the MassHealth Accountable Care Organization contract, which has the capacity to affect over 1.3 million members enrolled in MassHealth Accountable Care Organizations throughout the state. The goal of the oral health screening requirement is to identify MassHealth-insured patients who do not have reliable access to dental services and to provide them with resources to establish a dental home with a MassHealth-participating dentist. Primary care providers were surveyed, and results indicate a need for a care coordination mechanism to assist MassHealthinsured patients with establishing a dental home, in addition to an option to request telehealth-enabled and/ or urgent dental appointments. This report describes the oral health screening program at one MassHealth Accountable Care Organization and presents some of the data collected during the first year of its implementation, in addition to discussing how this data is being used to guide equity-focused interventions with the potential for policy implications. [ABSTRACT FROM AUTHOR]

Objective: To study diagnosis coding intensity across Medicare programs, and to examine the impacts of changes in the risk model adopted by the Centers for Medicare and Medicaid Services (CMS) for 2024. Data Sources and Study Setting: Claims and encounter data from the CMS data warehouse for Traditional Medicare (TM) beneficiaries and Medicare Advantage (MA) enrollees. Study Design: We created cohorts of MA enrollees, TM beneficiaries attributed to Accountable Care Organizations (ACOs), and TM non‐ACO beneficiaries. Using the 2019 Hierarchical Condition Category (HCC) software from CMS, we computed HCC prevalence and scores from base records, then computed incremental prevalence and scores from health risk assessments (HRA) and chart review (CR) records. Data Collection/Extraction Methods: We used CMS's 2019 random 20% sample of individuals and their 2018 diagnosis history, retaining those with 12 months of Parts A/B/D coverage in 2018. Principal Findings: Measured health risks for MA and TM ACO individuals were comparable in base records for propensity‐score matched cohorts, while TM non‐ACO beneficiaries had lower risk. Incremental health risk due to diagnoses in HRA records increased across coverage cohorts in line with incentives to maximize risk scores: +0.9% for TM non‐ACO, +1.2% for TM ACO, and + 3.6% for MA. Including HRA and CR records, the MA risk scores increased by 9.8% in the matched cohort. We identify the HCC groups with the greatest sensitivity to these sources of coding intensity among MA enrollees, comparing those groups to the new model's areas of targeted change. Conclusions: Consistent with previous literature, we find increased health risk in MA associated with HRA and CR records. We also demonstrate the meaningful impacts of HRAs on health risk measurement for TM coverage cohorts. CMS's model changes have the potential to reduce coding intensity, but they do not target the full scope of hierarchies sensitive to coding intensity. [ABSTRACT FROM AUTHOR]

The finding that the Camden Coalition's signature care-management intervention, the Camden Core Model, did not reduce readmissions was a significant moment for the organization. While disappointing, we saw it as an opportunity to learn and further innovate and move the field of complex care forward. This article highlights positive results learned through additional secondary analysis, as well as challenges confronted by community-based organizations (CBOs) endeavoring to conduct rigorous program evaluation and our strategies for addressing those challenges, including investment in internal data capacity and research partnerships. [ABSTRACT FROM AUTHOR]

OBJECTIVES: First, to analyze the relationship between value-based payment (VBP) program participation and documentation burden among office-based physicians. Second, to analyze the relationship between specific VBP programs (eg, accountable care organizations [ACOs]) and documentation burden. STUDY DESIGN: Retrospective analyses of US office-based physicians in 2019 and 2021. METHODS: We used cross-sectional data from the National Electronic Health Records Survey to measure VBP program participation and our outcomes of reported electronic health record (EHR) documentation burden. We used ordinary least squares regression models adjusting for physician and practice characteristics to estimate the relationship between participation in any VBP program and EHR burden outcomes. We also estimated the relationship between participation in 6 distinct VBP programs and our outcomes to decompose the aggregate relationship into program-specific estimates. RESULTS: In adjusted analyses, participation in any VBP program was associated with 10.5% greater probability of reporting more than 1 hour per day of after-hours documentation time (P = .01), which corresponded to an estimated additional 11 minutes per day (P = .03). Program-specific estimates illustrated that ACO participation drove the aggregate relationship, with ACO participants reporting greater after-hours documentation time (18 additional minutes per day; P < .001), more difficulty documenting (30.6% more likely; P < .001), and more inappropriateness of time spent documenting (21.7% more likely; P < .001). CONCLUSIONS: Office-based physicians participating in ACOs report greater documentation burden across several measures; the same is not true for other VBP programs. Although many ACOs relax documentation requirements for reimbursement, documentation for quality reporting and risk adjustment may lead to a net increase in burden, especially for physicians exposed to numerous programs and payers. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Previous studies in the ambulatory care setting have shown inconsistent results in regard to, or with respect to pharmacist telephonic transitions of care (TOC) encounters and reduction in 30-day readmission rates. No studies that have been completed within an accountable care organization (ACO) evaluating the impact of telephonic TOC encounters performed by a pharmacist have been identified. The objective of this study was to analyze the impact of clinical pharmacy telephonic TOC encounters on readmission rates within a primary care-based ACO. In this retrospective chart review, data for those who had a pharmacist telephonic TOC encounter and those who had an attempt were collected. The primary outcome of this study was allcause 30-day readmission rate. Secondary outcomes included 30-day readmission rate for targeted disease states, time to readmission, and readmission reason the same as previous discharge reason. For subjects who received a telephonic TOC encounter, pharmacist intervention type and provider acceptance of intervention(s) were described. For the final analysis, 154 encounters were included, 83 encounters in the telephonic TOC encounter group, and 71 did not receive a telephonic TOC encounter. The 30-day readmission rates were similar among those who received a telephonic TOC encounter and those who did not: the difference was not significant (15.7% vs. 28.2%; P = 0.059). There was also no statistical difference in the secondary outcomes. Even so, the results of this study suggest that performing a pharmacist telephonic TOC encounter in a primary care-based ACO setting has the potential to reduce 30-day readmission rates and further research appears to be warranted in this important area of practice. [ABSTRACT FROM AUTHOR]

Objective Data Sources Study Setting Study Design Data Collection/Extraction Methods Principal Findings Conclusions To investigate the relationship between physician–hospital integration within accountable care organizations (ACOs) and inpatient care utilization and expenditure.The primary data were Massachusetts All‐Payer Claims Database (2009–2013).Fifteen provider organizations that entered a commercial ACO contract with a major private payer in Massachusetts between 2009 and 2013.Using an instrumental variable approach, the study compared inpatient care delivery between patients of ACOs demonstrating high versus low integration. We measured physician–hospital integration within ACOs by the proportion of primary care physicians in an ACO who billed for outpatient services with a place‐of‐service code indicating employment or practice ownership by a hospital. The study sample comprised non‐elderly adults who had continuous insurance coverage and were attributed to one of the 15 ACOs. Outcomes of interest included total medical expenditure during an episode of inpatient care, length of stay (LOS) of the index hospitalization, and 30‐day readmission. An inpatient episode was defined as 30, 45, and 60 days from the admission date.Not applicable.The study examined 33,535 admissions from patients served by the 15 ACOs. Average medical expenditure within 30 days of admission was $24,601, within 45 days was $26,447, and within 60 days was $28,043. Average LOS was 3.5 days, and 5.4% of patients were readmitted within 30 days. Physician–hospital integration was associated with a 10.6% reduction in 30‐day expenditure (95% CI, −15.1% to −5.9%). Corresponding estimates for 45 and 60 days were − 9.7% (95%CI, −14.2% to −4.9%) and − 9.6% (95%CI, −14.3% to −4.7%). Integration was associated with a 15.7% decrease in LOS (95%CI, −22.6% to −8.2%) but unrelated to 30‐day readmission rate.Our instrumental variable analysis shows physician–hospital integration with ACOs was associated with reduced inpatient spending and LOS, with no evidence of elevated readmission rates. [ABSTRACT FROM AUTHOR]

OBJECTIVES: High-need Medicare beneficiaries require elevated levels of care and coordination to manage their conditions. We evaluated the extent to which high-need beneficiaries enrolled in Medicare Advantage (MA) or traditional Medicare (TM) accountable care organizations (ACOs) relative to TM non-ACOs. STUDY DESIGN: Using Medicare claims and MA encounter data, we identified 3 groups of high-need beneficiaries: (1) individuals younger than 65 years with a disability or end-stage kidney disease, (2) frail individuals, and (3) older individuals with major complex or multiple noncomplex chronic conditions. For comparison, we included non--high- need beneficiaries in the analysis, including those with minor complex chronic conditions. METHODS: Descriptive analysis of Medicare enrollment patterns and beneficiary characteristics of high-need and other beneficiaries between 2016 and 2019. RESULTS: In 2019, high-need beneficiaries accounted for 18 million or 32% of enrollees in TM and MA, an increase of approximately 1 million since 2016, driven by growth in MA. A larger share of beneficiaries in TM ACOs was high need (38%) compared with MA (24%). Although the total count of high-need beneficiaries in TM remained stable from 2016 to 2019, ACOs saw an increase of almost 1.5 million high-need beneficiaries (39% increase), and TM non-ACOs saw a decrease of 1.9 million (23% decrease). CONCLUSIONS: We found that high-need beneficiaries were more likely to be in TM non-ACOs than in MA through 2019. However, an increasing number of these beneficiaries are enrolling in MA or aligned with a TM ACO. A projected increase in the population of older adults will increase the economic burden of caring for high-need individuals. [ABSTRACT FROM AUTHOR]

Purpose: This study aims to investigate the uptake of transradial approach (TRA) and outpatient setting for transarterial chemoembolization (TACE) and transarterial radioembolization (TARE) in the treatment of hepatocellular carcinoma (HCC) among French interventional radiology centers. Materials and Methods: This cross-sectional study was based on a 34-question survey assessing center activity, radial access, and outpatient care. The survey was developed by a working group, tested by two external experts, and distributed to active members of two French radiological societies via a web-based self-reporting questionnaire in March 2022. The survey remained open for eight weeks, with two reminder emails sent to non-responders. Only one answer per center was considered. Results: Of the 44 responding centers, 39% (17/44) performed TRA for TACE and/or TARE, with post-procedure patient comfort as main motivation. Among the 27 centers not performing TRA, 33% (9/27) reported a lack of technical experience, but all 27 intended to adopt TRA within two years. Only six centers performed TACE or TARE in an outpatient setting. Reasons limiting its implementation included TACE for HCC not being a suitable intervention (61%, 27/44) and organizational barriers (41%, 18/44). Among centers not performing outpatient TACE or TARE, 34% (13/38) said "No," 34% (13/38) said "Maybe," and 32% (12/38) said "Yes" when asked about adopting it within two years. Conclusion: French interventional radiologists have low TRA uptake for HCC treatment, but TRA adoption potential exists. Respondents were uncertain about performing TACE or TARE in an outpatient setting within a 2-year horizon. [ABSTRACT FROM AUTHOR]

This article discusses the role of Accountable Care Organizations (ACOs) in the new era of digital mental health, specifically focusing on the aging population and individuals with mental health disorders (MHD). The article highlights the high healthcare costs associated with MHD and the disparities in care for older patients with MHD. It suggests that ACOs, which provide coordinated care and are accountable for costs and quality of care, have the potential to improve mental health outcomes through integration and financial incentives. The article also explores the use of telemental health and artificial intelligence/machine learning in geriatric mental health care. It concludes by discussing policy implications for delivering equitable and efficient quality care to older adults with MHD. [Extracted from the article]

OBJECTIVE: To examine the effect of enrollee switching from a broad-network accountable care organization (ACO) health maintenance organization (HMO) to a high performance ACO-HMO with a selective narrow network and comprehensive patient navigation system on access, utilization, expenditures, and enrollee experiences. DATA SOURCES: Secondary administrative data were obtained for 2016-2020, and primary interview and survey data in 2021. STUDY DESIGN: Fixed-effects instrumental variable analyses of administrative data and regression analyses of survey data. Outcomes included access, utilization, expenditures, and enrollee experience. Background information was gathered via interviews. DATA COLLECTION/EXTRACTION METHODS: We obtained medical expenditure/enrollment and access data on continuously enrolled members in a broad-network ACO-HMO (n = 24,555), a subset of those who switched to a high-performance ACO-HMO in 2018 (n = 7664); interviews of organizational leaders (n = 13); and an enrollee survey (n = 512). PRINCIPAL FINDINGS: Health care effectiveness data and information Set (HEDIS) access measures were not different across plans. However, annual utilization dropped by 15.5 percentage points (95% CI: 18.1, 12.9) more in the high-performance ACO-HMO, with relative annual expenditures declining by $1251 (95% CI: $1461, $1042) per person per year. High-performance ACO-HMO enrollees were 10.1 percentage points (95% CI 0.001, 0.201) more likely to access primary care usually or always as soon as needed and 11.2 percentage points (95% CI 0.007, 0.217) more likely to access specialty care usually or always as soon as needed. Plan satisfaction was 7.1 percentage points (95% CI: -0.001, 0.138) higher in the high-performance ACO-HMO. Interviewees noted the comprehensive patient navigation system was designed to ensure patients remained in the narrow network to receive care. CONCLUSIONS: ACO and HMO contracts with selective narrow networks supported by comprehensive patient navigation can reduce expenditures and improve specialty access and patient satisfaction compared to broad-network plans that lack these features. Payers should consider implementing narrow networks with comprehensive support systems.

The article discusses the potential benefits of using electronic patient-reported outcomes (ePROs) in quality measurement. ePROs allow patients to directly report their health status and experience of care, and can be collected electronically either at the point of care or remotely. The authors argue that integrating ePROs into routine care can improve the patient-clinician encounter and drive organizational-level learning health system efforts. They also suggest that payers can use quality measures to incentivize the adoption of ePROs by healthcare organizations. However, there are challenges related to measure design, implementation, and technological integration that need to be addressed for successful implementation. [Extracted from the article]

OBJECTIVE: To evaluate the impact of hospitals participation in the Medicare Shared Savings Program (MSSP) on their financial performance. DATA SOURCES: Centers for Medicare & Medicaid Services Hospital Cost Reports and MSSP Accountable Care Organizations (ACO) Provider-Level Research Identifiable File from 2011 to 2018. STUDY DESIGN: We used an event-study design to estimate the temporal effects of MSSP participation on hospital financial outcomes and compared within-hospital changes over time between MSSP and non-MSSP hospitals while controlling for hospital and year fixed effects and organizational and service-area characteristics. The following financial outcomes were evaluated: outpatient revenue, inpatient revenue, net patient revenue, Medicare revenue, operating margin, inpatient revenue share, Medicare revenue share, and allowance and discount rate. DATA COLLECTION/EXTRACTION METHODS: Secondary data linked at the hospital level. PRINCIPAL FINDINGS: Controlling for trends in non-MSSP hospitals, MSSP participation was associated with differential increases in net patient revenue by $3.28 million (p

Accountable care organizations (ACOs) are responsible for the quality and cost of care of specified patient populations, including the cost of referrals. Motivated by this environment, we study care coordination for healthcare referrals. We consider an ACO that refers an uncertain number of patients from its attributed population to a preferred external provider for specialized health services. ACOs are typically paid under the Medicare Shared Savings Program (MSSP). Under the MSSP, the payer sets a spending benchmark for the beneficiary population during a fixed time period and shares any gains (losses) relative to it with the ACO. During the billing period, all services delivered to the attributed population by the ACO and external providers continue to be reimbursed under fee-for-service. Gains (losses) are determined at the end of the period by comparing the actual spending, which includes all care expenses (regular visits, referrals, and failed treatments) incurred by the payer in the period to the predefined benchmark. In this environment, the ACO and external providers—the latter not compensated under the MSSP—lack incentives to invest enough in care coordination initiatives. We study financial incentive mechanisms between the ACO and its preferred external provider to achieve integrated care coordination in referral markets under the MSSP. We show that traditional fee-for-service and capitation agreements do not provide sufficient incentives for care coordination in referral markets. However, a risk- and cost-sharing mechanism can induce integrated care coordination efforts while satisfying the ACO and provider's participation constraints. We characterize a family of such mechanisms and numerically study the variability of the ACO and the external provider's profit. We demonstrate that this type of agreement can be used not only to induce integrated care coordination but can also result in a Pareto improvement in profit variability. We also illustrate the impact of the different MSSP risk tracks parameters on the performance of this care coordination mechanism, including their effect on the quality of care and the payer's mean spending.

OBJECTIVE: To evaluate whether primary care physicians participation in the Medicare Shared Savings Program (MSSP) is associated with changes in their preventive services delivery. DATA SOURCES: Medicare Provider Utilization and Payment Physician and Other Supplier Public Use File and MSSP Accountable Care Organizations (ACO) Provider-Level Research Identifiable File from 2012 to 2018. STUDY DESIGN: The design was a two-way fixed effects model estimating within-provider changes in preventive services delivery over time controlling for provider time-invariant characteristics, national time trends, and characteristics of served patients. The following preventive services were evaluated: influenza vaccination, pneumococcal vaccination, clinical depression screening, colorectal cancer screening, breast cancer screening, Body Mass Index (BMI) screening and follow-up, tobacco use assessment, and annual wellness visits. Both the likelihood of providing services and the volume of services delivered were evaluated. DATA COLLECTION/EXTRACTION METHODS: Secondary data linked at the provider level. PRINCIPAL FINDINGS: MSSP participation was associated with an increase in the likelihood of providing influenza vaccination (0.7 percentage-points), pneumococcal vaccination (2.0 percentage-points), clinical depression screening (2.1 percentage-points), tobacco use assessment (0.3 percentage-points), and annual wellness visits (4.1 percentage-points). A similar increase was found for the volume of services delivered per 100 patients for several preventive services: influenza vaccination (0.18), pneumococcal vaccination (0.56), clinical depression screening (0.46), and annual wellness visits (1.52). MSSP participation was associated with a decrease in the likelihood (-0.4 percentage-points) and the volume of colorectal cancer screening (-0.03). CONCLUSIONS: Primary care physicians participation in MSSP was associated with an increase in the likelihood and the volume of several preventive services.

Background: Food insecurity is common in the United States, especially in Rhode Island, where it affects up to 33% of residents. Food insecurity is associated with adverse health outcomes and disproportionally affects people from minoritized backgrounds. Produce prescription programs, in which healthcare providers write "prescriptions" for free or reduced cost vegetables, have been used to address food insecurity and diet-related chronic disease. Although there is growing evidence for the effectiveness of produce prescription programs in improving food security and diet quality, there have been few efforts to use implementation science methods to improve the adoption of these programs. Methods: This two-phase pilot study will examine determinants and preliminary implementation and effectiveness outcomes for an existing produce prescription program. The existing program is funded by an Accountable Care Organization in Rhode Island and delivered in primary care practices. For the first phase, we conducted a formative evaluation, guided by the Consolidated Framework for Implementation Research 2.0, to assess barriers, facilitators, and existing implementation strategies for the produce prescription program. Responses from the formative evaluation were analyzed using a rapid qualitative analytic approach to yield a summary of existing barriers and facilitators. In the second phase, we presented our formative evaluation findings to a community advisory board consisting of primary care staff, Accountable Care Organization staff, and staff who source and deliver the vegetables. The community advisory board used this information to identify and refine a set of implementation strategies to support the adoption of the program via an implementation blueprint. Guided by the implementation blueprint, we will conduct a single-arm pilot study to assess implementation antecedents (i.e., feasibility, acceptability, appropriateness, implementation climate, implementation readiness), implementation outcomes (i.e., adoption), and preliminary program effectiveness (i.e., food and nutrition security). The first phase is complete, and the second phase is ongoing. Discussion: This study will advance the existing literature on produce prescription programs by formally assessing implementation determinants and developing a tailored set of implementation strategies to address identified barriers. Results from this study will inform a future fully powered hybrid type 3 study that will use the tailored implementation strategies and assess implementation and effectiveness outcomes for a produce prescription program. Trial registration: Clinical trials: NCT05941403, Registered June 9, 2023. [ABSTRACT FROM AUTHOR]

Background: Risk stratification and population management strategies are critical for providing effective and equitable care for the growing population of older adults in the USA. Both frailty and neighborhood disadvantage are constructs that independently identify populations with higher healthcare utilization and risk of adverse outcomes. Objective: To examine the joint association of these factors on acute healthcare utilization using two pragmatic measures based on structured data available in the electronic health record (EHR). Design: In this retrospective observational study, we used EHR data to identify patients aged ≥ 65 years at Atrium Health Wake Forest Baptist on January 1, 2019, who were attributed to affiliated Accountable Care Organizations. Frailty was categorized through an EHR-derived electronic Frailty Index (eFI), while neighborhood disadvantage was quantified through linkage to the area deprivation index (ADI). We used a recurrent time-to-event model within a Cox proportional hazards framework to examine the joint association of eFI and ADI categories with healthcare utilization comprising emergency visits, observation stays, and inpatient hospitalizations over one year of follow-up. Key Results: We identified a cohort of 47,566 older adults (median age = 73, 60% female, 12% Black). There was an interaction between frailty and area disadvantage (P = 0.023). Each factor was associated with utilization across categories of the other. The magnitude of frailty's association was larger than living in a disadvantaged area. The highest-risk group comprised frail adults living in areas of high disadvantage (HR 3.23, 95% CI 2.99–3.49; P < 0.001). We observed additive effects between frailty and living in areas of mid- (RERI 0.29; 95% CI 0.13–0.45; P < 0.001) and high (RERI 0.62, 95% CI 0.41–0.83; P < 0.001) neighborhood disadvantage. Conclusions: Considering both frailty and neighborhood disadvantage may assist healthcare organizations in effectively risk-stratifying vulnerable older adults and informing population management strategies. These constructs can be readily assessed at-scale using routinely collected structured EHR data. [ABSTRACT FROM AUTHOR]

The journey to value relies heavily on a strong foundation in population health and on supporting systems of care. However, as the Centers for Medicare & Medicaid Services and commercial insurers rethink reimbursements to achieve cost savings, both patients and payments to health care organizations are at risk. The case for value-based care is ever stronger yet health systems will have to mature their culture, population health infrastructure, technologies and analytics capabilities, and leadership and management systems. In this article, the authors describe the functional organizational structure of the clinical transformation team responsible for population health in the University Hospitals Accountable Care Organizations (ACO). Based on their experiences building and evolving population health for the University Hospitals ACO, the authors layout the 3 pillars supporting their structure, including operations, clinical design, and data and analytics, and key areas of focus for each pillar. [ABSTRACT FROM AUTHOR]

Patient-reported outcome (PRO)-based performance measures (PRO-PMs) offer opportunities to aggregate survey data into a reliable and valid assessment of performance at the entity-level (eg, clinician, hospital, and accountable care organization). Our objective was to address the existing literature gap regarding the implementation barriers, current use, and principles for PRO-PMs to succeed. As quality measurement experts, we first highlighted key principles of PRO-PMs and how alternative payment models (APMs) may be integral in promoting more widespread use. In May 2023, we reviewed the Centers for Medicare and Medicaid Services (CMS) Measures Inventory Tool for active PRO-PM usage within CMS programs. We finally present principles to prioritize as part PRO-PMs succeeding within APMs. We identified 5 implementation barriers to PRO-PM use: original development of instrument, response rate sufficiency, provider burden, hesitancy regarding fairness, and attribution of desired outcomes. There existed 54 instances of active PRO-PM usage across CMS programs, including 46 unique PRO-PMs within 14 CMS programs. Five principles to prioritize as part of greater PRO-PM development and incorporation within APMs include the following: (1) clinical salience, (2) adequate sample size, (3) meaningful range of performance among measured entities and the ability to detect performance change in a reasonable time frame, (4) equity focus, and (5) appropriate risk adjustment. Identified barriers and principles to prioritize should be considered during PRO-PM development and implementation phases to link available and novel measures to payment programs while ensuring provider and stakeholder engagement. • Patient-reported outcome-based performance measures (PRO-PMs) offer a way to collect patient-centered information and aggregate the collected data into a reliable and valid measure of performance at the entity level (eg, clinician, hospital, and accountable care organization); yet they have been potentially underused within the promising avenue of alternative payment models. • We identified 54 instances of active PRO-PM usage across Centers for Medicare and Medicaid Services programs as well as 5 principles to prioritize as part of greater PRO-PM development and incorporation within alternative payment models: (1) clinical salience, (2) adequate sample size, (3) meaningful range of performance among measured entities and the ability to detect performance change in a reasonable timeframe, (4) equity focus, and (5) appropriate risk adjustment. • A phased and iterative PRO-PM implementation strategy that overcomes identified barriers should be considered to ensure provider and stakeholder engagement and ultimately inform and improve healthcare-related decision making by allowing reliable outcome comparisons across entities. [ABSTRACT FROM AUTHOR]

Objectives: To describe the impact of Accountable Communities of Health (ACHs) on organizational and community partnerships and explore how ACHs contribute to systems change. Data Sources and Study Setting: The California Accountable Communities of Health Initiative (CACHI) was a 5‐year, $17 M investment in community health transformation in 13 ACH sites. Data sources include two surveys, key informant interviews, small group conversations, and ACH meeting observations and document review. Study Design: This was a mixed‐methods, observational study. Surveys conducted in 2021 and 2022 focused on ACH progress in building organizational and community partnerships and ACH impact on partners and systems, respectively. Interviews and small group conversations were conducted toward the end of the CACHI grant period and designed to complement the surveys. Data Collection: Survey respondents included ACH backbone agency staff and partner organization representatives (n = 141 in 2021 and 88 in 2022). Semistructured individual interviews and group conversations were conducted with 40 ACH backbone staff and partners. Documents were collected via grant reporting and directly from ACH staff. Data were analyzed descriptively and thematically. Principal Findings: ACHs appear to have supported organizational partnerships and collaboration. Seventy‐six percent of survey respondents reported that their ACH had strengthened organizations' ability to work together and 65% reported developing new or deepened connections. While ACH participants reported a better understanding of community needs and priorities, progress on community relationships, and greater attention to equity and racial justice, many saw room for improvement on meaningful community engagement. Systems changes and precursors of systems change observed across ACH sites included strengthened partnerships, enhanced knowledge, increased capacity, more collaborative ways of working, and new funding streams. Conclusions: The ACH model is effective at strengthening organizational partnerships and catalyzing other systems changes and precursors including enhanced knowledge, increased capacity, more collaborative ways of working, and new funding. [ABSTRACT FROM AUTHOR]

Background: Medication nonadherence is the leading cause of poor health outcomes and increased risk of hospitalizations. Previous studies have shown that pharmacist interventions can help improve medication adherence and CMS quality measures. Objective: The purpose of this study was to examine the impact of clinical pharmacists' interventions on medication adherence and PDC scores for ACEi/ARBs, statins, and noninsulin antidiabetic medications in the primary care setting. Methods: This observational study was conducted at four primary care clinics to evaluate PDC scores pre- and post-pharmacist interventions from April 2020 to December 2020. Eligible patients were Humana Part D beneficiaries with a baseline PDC score <85%. The primary outcome of this study was to evaluate the average change in final PDC scores, and 1-month change in PDC scores following a pharmacist intervention. Secondary outcomes were number and types of adherence barriers identified, interventions provided by the pharmacist, and barriers and interventions category (pharmacy, patient or physician-related). Results: A total of 89 barriers were identified and 208 interventions were completed. A statistically significant difference in the average change of final PDC score from baseline was seen among those on ACEi/ARBs (72.5 to 78.0, p = 0.004) and statins (73.3 to 76.6, p < 0.001). Similarly, a statistically significant change was observed from baseline to 1-month PDC among those on ACEi/ARBS (72.5 to 75.4, p = 0.001) and statins (73.3 to 74.9, p < 0.001). Conclusion: Pharmacists located in a primary care setting improved medication adherence and PDC score for patients on ACEIs/ARBs and statins. [ABSTRACT FROM AUTHOR]

This report aimed to assess how accountable care organizations (ACOs) addressed ongoing opioid use disorder treatment needs over time. Responses from the 2018 (N=308 organizations) and 2022 (N=276) National Survey of Accountable Care Organizations (response rate=55% in both years) were used to examine changes in availability of medication for opioid use disorder (MOUD) among ACOs with Medicare and Medicaid contracts. The percentage of respondents offering at least one MOUD grew from 39% in 2018 to 52% in 2022 (p<0.01). MOUDs were more likely to be available in 2022 among ACOs with (vs. without) in-network substance use treatment facilities (80% vs. 33%, p<0.001). The percentage of 2022 respondents who reported offering MOUD was similar in states with high versus low opioid overdose mortality rates. Despite growing availability of MOUD among ACOs, nearly half reported not offering any MOUD in 2022, and the availability of MOUD did not increase with treatment need. [ABSTRACT FROM AUTHOR]

Accountable Care Organizations (ACOs) are healthcare collaboration networks comprised of hospitals and other healthcare providers. The motivation behind the formation of ACOs is to improve the quality of care while reducing healthcare costs. Despite these commendable goals, hospitals' participation in ACOs remains low; the most significant barrier being the risk associated with joining. Our research tackles this timely and potentially impactful topic by exploring factors that facilitate hospitals' ACO entry decisions. We apply resource dependence theory to explain that competition network characteristics, organizational network characteristics, and internal organizational characteristics mitigate hospitals' financial risk and are therefore critical to ACO participation. Using survival analysis, we test our research hypotheses using longitudinal data from 3114 hospitals. Our findings suggest that hospitals with a high level of competition network centrality are more likely to join an ACO, while hospitals with a high level of competition network tie diversity are less likely to join. In addition, hospitals with experience in joining other healthcare networks, such as Regional Healthcare Information Organizations, or belonging to a large parent group, are inclined to enter an ACO. Lastly, hospitals with a high level of unabsorbed slack are prone to ACO participation. Given that knowledge of hospitals' participation in ACOs is lacking, this research is relevant for practitioners in the US healthcare industry. Specifically, it provides insights for hospital administrators on the critical resources that need to be strengthened before joining an ACO. Our findings also provide practical guidance for healthcare policy makers on how to profile, target, and efficiently promote ACO participation among hospitals. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: Post-hospitalization remote patient monitoring (RPM) has potential to improve health outcomes for high-risk patients with chronic medical conditions. The purpose of this study is to determine the extent to which RPM for patients with congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD) is associated with reductions in post-hospitalization mortality, hospital readmission, and ED visits within an Accountable Care Organization (ACO). Methods: Nonrandomized prospective study of patients in an ACO offered enrollment in RPM upon hospital discharge between February 2021 and December 2021. RPM comprised of vital sign monitoring equipment (blood pressure monitor, scale, pulse oximeter), tablet device with symptom tracking software and educational material, and nurse-provided oversight and triage. Expected enrollment was for at least 30-days of monitoring, and outcomes were followed for 6 months following enrollment. The co-primary outcomes were (a) the composite of death, hospital admission, or emergency care visit within 180 days of eligibility, and (b) time to occurrence of this composite. Secondary outcomes were each component individually, the composite of death or hospital admission, and outpatient office visits. Adjusted analyses involved doubly robust estimation to address confounding by indication. Results: Of 361 patients offered remote monitoring (251 with CHF and 110 with COPD), 140 elected to enroll (106 with CHF and 34 with COPD). The median duration of RPM-enrollment was 54 days (IQR 34–85). Neither the 6-month frequency of the co-primary composite outcome (59% vs 66%, FDR p-value = 0.47) nor the time to this composite (median 29 vs 38 days, FDR p-value = 0.60) differed between the groups, but 6-month mortality was lower in the RPM group (6.4% vs 17%, FDR p-value = 0.02). After adjustment for confounders, RPM enrollment was associated with nonsignificantly decreased odds for the composite outcome (adjusted OR [aOR] 0.68, 99% CI 0.25–1.34, FDR p-value 0.30) and lower 6-month mortality (aOR 0.41, 99% CI 0.00–0.86, FDR p-value 0.20). Conclusions: RPM enrollment may be associated with improved health outcomes, including 6-month mortality, for selected patient populations. [ABSTRACT FROM AUTHOR]

Background:The coronavirus disease (COVID-19) pandemic highlighted the need for effective communication and information sharing among health care organizations and public health systems (PHSs). Health information exchange (HIE) plays a vital role in improving quality control and efficiency in hospital settings, particularly in underserved areas. Objective:This study aimed to investigate the variation of HIE availability among hospitals based on their collaboration with the PHS and affiliation with Accountable Care Organizations (ACOs) in 2020, as well as variation by community social determinants of health. Methods:The primary data set used for this study comprised the linked data set of the 2020 American Hospital Association (AHA) Annual Survey and the AHA Information Technology Supplement. The measures used included the hospital's participation in HIE networks, availability of data exchange, and HIE measures during the COVID-19 pandemic, including whether hospitals effectively received electronically transmitted information from outside providers for COVID-19 treatment. Results:The sample size of hospitals ranged from 1,316 to 1,436, depending on different outcomes related to HIE questions. Of the hospitals surveyed, ∼67% reported public health collaboration and ACO affiliation, while 7% reported neither. Hospitals without public health collaboration or ACO affiliation were more likely to be located in underserved areas. Compared with hospitals without public health collaboration or ACO affiliation, hospitals with both were 9% more likely to report the availability of electronically transmitted clinical information from outside providers and to participate in local and national HIE networks. Furthermore, these hospitals were 30% (marginal effect [ME] = 0.30, p < 0.001) more likely to report effective receipt of information from outside providers for COVID-19 treatment and 12% (ME = 0.12, p = 0.02) more likely to always/often receive clinical information for COVID-19 treatment electronically. Conclusions:Hospital collaboration with the PHS and ACO affiliation are associated with greater availability of electronic health data, particularly during the COVID-19 pandemic. [ABSTRACT FROM AUTHOR]

Goals: Of 513 accountable care organizations (ACOs) participating in the Medicare Shared Savings Program (MSSP) in 2020, 67% generated a positive shared savings of approximately $2.3 billion. This research aimed to examine their financial performance trends and drivers over time. Methods: The unit of analysis was the ACO in each year of the study period from 2016 to 2020. The dependent variable was the ACOs' total shared savings earned annually per beneficiary. The independent variables included ACO age, risk model, clinician staffing type, and provider type (hybrid, hospital-led, or physician-led). Covariates were the average risk score among beneficiaries, payer type, and calendar year. The Centers for Medicare & Medicaid Services (CMS) public use files (PUFs) and a commercial healthcare data aggregator were the data sources. Results: ACOs' earned shared savings grew annually by 35%, while the proportions of ACOs with positive shared savings grew by 21%. For 1-year increase in ACO age, an additional $0.57 of shared savings per beneficiary was observed. ACOs with two-sided risk contracting were associated with an average marginal increase of $109 in shared savings per beneficiary compared to ACOs with one-sided risk contracting. Primary care physicians were associated with the greatest increase in earned shared savings per beneficiary. In contrast, nurse practitioners/physician assistants/clinical nurse specialists were associated with a reduction in earned shared savings. Under a one-sided risk model, hospital-led ACOs were associated with $18 higher average shared savings earning per beneficiary compared to hybrid ACOs, while physician-led ACOs were associated with lower average saved shared earnings per beneficiary at --$2 compared to hybrid ACOs. Provider-type results were not statistically significant at the 5% nominal level. No statistically significant differences were observed between provider types under a two-sided risk model. Practical Applications: For all ACO provider types, building broader primary care provider networks was correlated with positive financial results. Future research should examine whether ACOs are conducting specific preventive screenings for cancer or monitoring conditions such as diabetes, hypertension, heart disease, obesity, mental disorders, and joint disorders. Such studies may answer health policy and strategy questions about the effects of incentives for improved ACO performance in serving a healthier population. [ABSTRACT FROM AUTHOR]

Value‐based primary care has reduced health care costs, improved the quality of rendered care, and enhanced the patient experience. Value‐based care emphasizes prevention, outreach, follow‐up, patient engagement, and comprehensive, whole‐person health. Primary care Accountable Care Organizations have leveraged technology‐enabled workflows, practice transformation, and cutting‐edge data and analytics to achieve success. These efforts are increasingly aided by predictive modeling used in the context of patient identification and prioritization algorithms. Value‐based kidney care programs can glean salient takeaways from successful value‐based primary care methods and models. The kidney care community is experiencing unprecedented transformation as novel payer programs and financial models burgeon. The authors contend these efforts can be accelerated by the adoption of techniques honed in value‐based primary care. To optimize value‐based kidney care, though, nephrology thought leaders must transcend the archetype of value‐based primary care. To do so, the nephrology community must: (1) impel behavioral change among fee‐for‐service adherents; (2) harness emerging policy, guidelines, and quality measures; (3) adopt innovative tools, technologies, and therapies. In aggregating lessons from value‐based primary care—and leveraging novel methodologies and approaches—the kidney care community will be better equipped to achieve the quadruple aim for kidney care. [ABSTRACT FROM AUTHOR]

Abstract Objective: To examine the effect of urologist participation in value-based payment models on the initial management of men with newly diagnosed prostate cancer. Methods: Medicare beneficiaries with prostate cancer diagnosed between 2017 and 2019, with 1 year of follow-up, were assigned to their primary urologist, each of whom was then aligned to a value-based payment model (the merit-based incentive payment system [MIPS], accountable care organization [ACO] without financial risk, and ACO with risk). Multivariable mixed-effects logistic regression was used to measure the association between payment model participation and treatment of prostate cancer. Additional models estimated the effects of payment model participation on use of treatment in men with very high risk (i.e., >75%) of non-cancer mortality within 10 years of diagnosis (i.e., a group of men for whom treatment is generally not recommended) and price-standardized prostate cancer spending in the 12months after diagnosis. Results: Treatment did not vary by payment model, both overall (MIPS—67% [95% CI 66%–68%], ACOs without risk—66% [95% CI 66%–68%], ACOs with risk—66% [95% CI 64%–68%]). Similarly, treatment did not vary among men with very high risk of non-cancer mortality by payment model (MIPS—52% [95% CI 50%–55%], ACOs without risk—52% [95% CI 50%–55%], ACOs with risk—51% [95% CI 45%–56%]). Adjusted spending was similar across payment models (MIPS—$16,501 [95% CI $16,222–$16,780], ACOs without risk—$16,140 [95% CI $15,852–$16,429], ACOs with risk—$16,117 [95% CI $15,585–$16,649]). Conclusions: How urologists participate in value-based payment models is not associated with treatment, potential overtreatment, and prostate cancer spending in men with newly diagnosed disease. [ABSTRACT FROM AUTHOR]

Bradley Beauvais, Michael Mileski, Zo Ramamonjiarivelo, Kimberly Ann Lee, Clemens Scott Kruse, Jose Betancourt, Rohit Pradhan, Ramalingam Shanmugam School of Health Administration, Texas State University, San Marcos, TX, USACorrespondence: Bradley Beauvais, School of Health Administration, Texas State University, San Marcos, TX, USA, Tel +1 (210)627-1078, Email bmb230@txstate.eduBackground: Although hospitals have been the traditional setting for interventional and rehabilitative care, skilled nursing facilities (SNFs) can offer a high-quality and less costly alternative than hospitals. Unfortunately, the financial health of SNFs is often a matter of concern. To partially address these issues, SNF leaders have increased engagement in a number of affiliations to assist in improving quality and reducing operational costs, including Accountable Care Organizations (ACOs), Health Information Exchanges (HIEs), and participation in Bundled Payment for Care Improvement (BPCI) programs. What is not well understood is what impact these affiliations have on the financial viability of the host organizations. Given these factors, this study aims to identify what association, if any, exists between SNF affiliations and revenue generation.Methods: Data from calendar year 2022 for n=13,447 SNFs in the US were assessed using multivariate regression analysis. We evaluated two separate dependent measures of revenue generation capacity: net patient revenue per bed and net patient revenue per discharge and considered three unique facility affiliations including (1) ACOs, (2) HIEs, and (3) BPCI participants.Results: Six multivariable linear regressions revealed that ACO affiliation is negatively associated with revenue generation on both dependent measures, while HIE affiliation and BPCI participation reflected mixed results.Conclusion: A better understanding of the financial impact of SNFs’ affiliations may prove insightful. By carefully considering the value of each affiliation, and how each is applicable to any given market, policymakers, funding agencies, and facility leaders may be able to better position SNFs for more sustainable financial performance in a challenging economic environment.Keywords: skilled nursing facilities, accountable care organizations, health information exchanges, bundled payment for care improvement, revenue, discharges

On March 1, 2018, the Massachusetts Medicaid and Children's Health Insurance Program (MassHealth) launched an ambitious accountable care organization (ACO) program that sought to integrate care across the physical, behavioral, functional, and social services continuum while holding ACOs accountable for cost and quality. The study objective was to describe changes in health care utilization among MassHealth members during the pre-ACO baseline (2015–2017) and post-implementation periods (2018 and 2019). Using MassHealth administrative data, the authors conducted a repeated cross-sectional study of MassHealth members enrolled in ACOs during 2015–2019. Rates of primary care visits, all-cause and primary-care sensitive emergency department (ED) visits, ED boarding, hospitalizations, acute unplanned admissions, and readmissions were reported during the baseline period (2015–2017) and year 1 (2018) and year 2 (2019). Primary care visit rates increased for adult members throughout the study period from a baseline mean of 7.2–9.2 per member per year (observed-to-expected [O:E]: 1.16) in 2019. Observed all-cause hospitalization rates fell below expected values with O:E ratios of 0.96 among adults and 0.79 among children in 2018, and 0.96 and 0.92 among adults and children, respectively, in 2019. All-cause ED visit rates increased slightly, and rates of pediatric asthma-related admissions, unplanned admissions for adults with ambulatory care sensitive conditions, and unplanned admissions and ED boarding for adults with substance use disorder and serious mental illness all declined for the study period. These findings are suggestive of utilization shifts to higher-value, lower-cost care under Massachusetts's innovative and comprehensive ACO model. [ABSTRACT FROM AUTHOR]

Congenital heart disease (CHD) is the most common birth anomaly in the US. Research shows lost-to-follow-up trends and racial disparities in healthcare use. This study examines racial differences in healthcare use among Medicaid-covered children with CHD. Using 2010–2019 claims data from a pediatric Medicaid Accountable Care Organization, 960 Black and White children with complex CHD and ≥ 3 years of continuous Medicaid coverage were identified. Three cohorts were constructed (starting age: < 1-year-olds, 1–5-year-olds, 6–15-year-olds) and followed for 3 years. Multivariate analysis assessed annual healthcare use (cardiology, primary care, emergency department) by race, adjusting for patient and provider covariates. Overall, 51% of patients had an annual cardiology visit, and 54% had an annual primary care visit. Among the 1–5-year-old cohort, Black children were predicted to be 13% less likely to have an annual cardiology visit compared to their White counterparts (p = 0.001). Older Black children were predicted to be more likely to have a primary care visit compared to their White counterparts. Nearly half of Medicaid-enrolled children with complex CHD did not receive recommended cardiology care. Young Black children were less likely to receive an annual cardiac visit, while older Black children were more likely to receive primary care. While the percentage with an annual cardiac visit was low, the majority had seen a cardiologist within the 3-year window, suggesting these children are still receiving cardiology care, if less frequently than recommended. Opportunities exist for cardiology and primary care to collaborate to ensure patients receive timely recommended care. [ABSTRACT FROM AUTHOR]

Objectives: Currently, the Medicare Shared Savings Program (MSSP) requires beneficiaries to have 1 or more visits with a qualifying physician to be attributed to an accountable care organization (ACO). Allowing primary care nurse practitioners (NPs) to serve as qualifying providers for the sake of attribution could be an effective way to expand access to the program but could potentially draw in sicker beneficiaries and increase an ACO's benchmarks. Study Design: This observational study assesses the potential impact of changing the MSSP attribution rules to include NPs and other advanced practice clinicians. Methods: For this analysis, we ran MSSP attribution for the entire United States with and without including NPs as attribution-eligible providers. We then compared the change in attributed population with the change in CMS hierarchical condition category (HCC) risk scores. Results: For the majority of ACOs, allowing NPs to serve as an attribution-eligible provider had little impact on the number of attributed beneficiaries or the mean HCC score. For a small number of ACOs (n = 18), the change increased attribution by more than 10%. The mean change in HCC score was 0. Conclusions: Allowing NPs to serve as attribution-eligible clinicians would result in more attribution to MSSP ACOs without increasing the level of patient complexity, a positive impact for those interested in growing ACOs. [ABSTRACT FROM AUTHOR]