The Centers for Medicare and Medicaid Services (CMS) released 2015 performance results for the Pioneer ACO Model and the Medicare Shared Savings Program, which together included more than 400 accountable care organizations.

Total savings for 2015 exceeded $466 million. In all, 125 ACOs (31 percent) met their savings threshold and quality performance standards, thereby qualifying for shared savings. 

RESULTS: PIONEER
Twelve ACOs participated in the Pioneer model in 2015—the model’s fourth performance year. Of those, eight generated savings that exceeded a total of $37 million, and four generated losses. Six of the eight that generated savings qualified for shared savings. Only one of the four that generated losses owed shared losses. 

The 2015 mean quality score for the Pioneer ACOs was 92.26 percent, compared with 87.2 percent in 2014. Nine ACOs had overall quality scores above 90 percent in 2015. 

RESULTS: MSSP
Of the 392 ACOs participating in the MSSP in 2015, 119 earned shared savings and another 83 held their health care costs below their benchmark but did not meet the minimum savings threshold (and thus did not qualify for shared savings).

In 2014, 92 of 333 MSSP ACOs earned shared savings and another 89 held their costs below their benchmark but did not qualify for shared savings. No Track 2 ACOs owed shared losses.

MSSP ACOs that reported quality in both 2014 and 2015 improved on 84 percent of the quality measures reported in both years.

A greater percentage of MSSP ACOs that participated in a prepaid savings model (Advance Payment or AIM) generated savings above their minimum savings rate as compared with ACOs that did not participate in a prepaid savings model (45 percent vs. 29 percent). 

QUALITY METRICS
CMS made several changes to the quality measures that ACOs are required to report. There are now 38 metrics tracked, compared to 33 in previous years.

  • CMS dropped the medication reconciliation requirement (ACO-12) and added ACO-39 documentation of medications in the medical record (ACO-39).

  • CMS dropped the individual reporting requirement for five diabetes-related measures (ACO-22 through ACO-26), and instead replaced them with the DM composite score from those five metrics. It kept the measure that tracks the percentage of diabetics whose HbA1c is poorly controlled (ACO-27) and added a measure to track the percentage of diabetic patients who received an eye exam within the last 12 months (ACO-41).

  • The agency added a 30-day readmission metric for skilled nursing facilities (ACO-35).

  • CMS also added all-cause unplanned admissions for patients with diabetes (ACO-36), heart failure (ACO-37) and patients with multiple chronic conditions (ACO-38). 

  • CMS added a measure to track depression remission at 12 months (ACO-40).

  • The coronary artery disease composite score has been dropped.

Our Take: Let’s dive a little deeper into the numbers.

In Performance Year 1, 32 Pioneer ACOs spent about $7.5 billion caring for 668,002 Medicare beneficiaries, or about $11,222 per person. Fast forward to Performance Year 4: 12 Pioneers spent nearly $4.3 billion on 461,442 Medicare beneficiaries, approximately $9,298 per person. That’s a 21 percent reduction in per-beneficiary spending over a four-year period.

But what about quality? In Performance Year 1, self-reported patient experience measures averaged 78.8 out of 100 possible points; in Year 4, the same measures averaged 80.1 out of 100—a modest but noticeable increase. The Diabetes Composite Score climbed 74 percent from Year 1 to Year 4, from 25.5 to 44.3. Average all-cause, risk-adjusted readmission rates stayed about the same, at around 15.4 percent.

In Performance Year 1, 220 MSSP ACOs spent $42.3 billion on 3,675,263 beneficiaries, or about $11,500 per person. In 2015, 392 MSSP ACOs spent $72.9 billion on 7,270,233 beneficiaries, or about $10,022 per person. Over a three-year period, MSSPs were able to shrink per-beneficiary spending by nearly 15 percent.

As to the quality issue, MSSP patient experience scores were unchanged from the first year to 2015. Readmission rates also remained unchanged, at 14.9 percent. But the Diabetes Composite Score increased 65 percent from Year 1 to Year 3, from 21.5 to 35.4.

All this is very good news for Medicare (and the rest of us). ACOs have a stranglehold on costs while improving population health and the overall experience of health care. Score one for The Triple Aim.

Where the data are more troubling lies within each individual ACO. For example, Atrius Health and Allina Health each were able to save about 2.5 percent of their 2015 budget target. Atrius’ gross savings was about $6.8 million and Allina’s was $3.6 million. Yet while Allina earned $2.3 million in shared savings—65 percent of total savings—Atrius netted only $448,722. Their CMS overall quality score was virtually identical. Did CMS forget to add another zero to their earned savings? Weird. 

Banner Health, the darling of the Pioneer ACOs, netted nearly $25 million on $35 million in shared savings. The Phoenix-based ACO spent $10,231 per beneficiary in 2015, about a 3 percent decline from 2012.

Peoria, Ill.-based OSF Healthcare was the only Pioneer to owe CMS at the end of Performance Year 4, to the tune of $1.6 million. Yet it spent $9,200 per beneficiary—about 5 percent more than in 2012, but still less than the average spent per beneficiary in 2015 among all Pioneers, which was about $9,300.

No wonder they left the program.

To be fair, OSF and Banner are in two very different markets. Banner covers a diverse population in an urban and suburban setting. OSF cares for primarily small-town and rural patients throughout central and southern Illinois. Considering the differences in the patient populations, it makes it difficult to compare the two.

But from OSF’s perspective, it held costs down over time without sacrificing quality, yet after four years of operations it’s writing a check to the government. 

OSF didn’t abandon the ACO concept. In fact, it’s part of the Next Generation program. Maybe this time its baseline will be more favorable, allowing OSF to recoup some of those losses.

Whatever is going on behind the scenes at CMS, one thing is clear. Financially speaking, the ACO program has been a phenomenal success.

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2015 ACO PERFORMANCE TABLES (DOWNLOAD)

Contents include:

Top Performing MSSP ACOs, by Earned Savings
Top Performing MSSP ACOs, by Total Savings as a Percentage of Benchmark
Top Performing MSSP ACOs, by Total Savings Per Beneficiary
Top Performing MSSP ACOs, by CMS Quality Score
Poorly Performing MSSP ACOs, by Earned Savings
Poorly Performing MSSP ACOs, by Total Savings as a Percentage of Benchmark
Poorly Performing MSSP ACOs, by Total Savings Per Beneficiary
Poorly Performing MSSP ACOs, by CMS Quality Score
2015 Pioneer ACO Performance Summary

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