Two recently published studies demonstrate that although gains achieved by accountable care organizations (ACOs) may be slight, they increase over time, and one of the studies showed that ACOs can benefit substantially by including at-home care.

In the first study, a research team used Medicare fee-for-service claims to assess changes in spending for post-acute care and changes in the use of post-acute care associated with participation in the Medicare Shared Savings Program (MSSP). The analysis included a random 20 percent sample of beneficiaries, which covered more than 8.3 million hospitalizations and more than 1.5 million stays in skilled nursing facilities (SNFs). Beneficiaries in ACOs were compared with those served by non-ACO providers (the control group), before and after entry into the MSSP. 

For the cohort of ACOs that entered the MSSP in 2012 (n=114), spending on post-acute SNF care was a statistically significant 9 percent lower by 2014, or $106 less per beneficiary, compared with the control group. The reductions in spending were achieved through lower use of inpatient care, lower rates of discharge to SNFs and shorter SNF stays (i.e., greater use of at-home care). 

The analysis showed that reductions in spending increased with longer ACO participation. In addition, independent physician groups performed as well as, and in some cases better than, hospital-based ACOs in terms of lowering costs.

“Post-acute care spending reductions were more consistent with efforts by clinicians working within hospitals and SNFs to influence care for ACO patients than with hospital-wide initiatives by ACOs or use of preferred SNFs,” the study authors noted.

In the other study, researchers compared early results from Colorado’s Medicaid ACO model with those from Oregon’s Medicaid ACO model.

When the Colorado ACO model was formed in 2011, seven regional care collaborative organizations were established. They received funding on a per-member, per-month basis for coordinating care with providers and connecting enrollees with community services. Participating providers had no financial risk. 

In the Oregon ACO model, which was initiated in 2012 with $1.9 billion in federal funding, the 16 coordinated care organizations that were created were responsible for managing all patient care within a global budget. These organizations took on full financial risk for their patient populations.

After two years, Oregon’s Medicaid ACO exhibited relative performance improvements in some aspects of care when compared with Colorado’s Medicaid ACO, but the two models demonstrated similar performance on standardized expenditures for selected services. 

In an accompanying commentary, Carrie Colla and Elliott Fisher of the Dartmouth Institute for Health Policy and Clinical Practice recommended that, based on the findings of the first study, regulators should consider approaches that improve the viability of independent physician groups, “including the equalization of payment rates across sites of care or direct financial support for independent practices as used in the advanced payment model.” Colla and Fisher said the study of the state Medicaid ACOs “suggests that strong incentives may not be necessary” to achieve behavior change.

The studies and commentary were published online Feb. 13 by JAMA Internal Medicine

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