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The American Journal of Accountable Care March 2018
Medicare Accountable Care Spending Patterns: Shifting Expenditures Associated With Savings
David B. Muhlestein, PhD, JD; Spencer Q. Morrison, BA; Robert S. Saunders, PhD; William K. Bleser, PhD, MSPH; Mark B. McClellan, MD, PhD; and Lia D. Winfield, PhD
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ACO Quality Over Time: The MSSP Experience and Opportunities for System-Wide Improvement
William K. Bleser, PhD, MSPH; Robert S. Saunders, PhD; David B. Muhlestein, PhD, JD; Spencer Q. Morrison, BA; Hoangmai H. Pham, MD, MPH; and Mark B. McClellan, MD, PhD
A Managed Care Organization's Call Center–Based Social Support Role
Zachary Pruitt, PhD; Pamme Lyons Taylor, MBA, MHCA; and Kristopher M. Bryant, BS
The Skills of the Ambulatory Intensivist: A Review
Craig Tanio, MD, MBA, FACP; and Arnold R. Eiser, MD, MACP
Thirty-Day Readmissions: Relationship to Physician Attending Type and Social Connectedness
Carey C. Thomson, MD, MPH; Nathalie Bloch, MD, MPA; Tafadzwa Muguwe, MD, MS; Kendell Clement, PhD; Shani Legore, BA; Orissa Viza, MSW, MPH; Joanne Kerwin, PhD; and Valerie E. Stone, MD, MPH
Outpatient Referral Rates in Family Medicine
Maribeth Porter, MD, MS; John Malaty, MD; Charlie Michaudet, MD; Paulette Blanc, MPH; Jonathan J. Shuster, PhD; and Peter J. Carek, MD, MS
Predictive Factors of Discharge Navigation Lag Time
Charles Walker, MD; Sayeh Bozorghadad, BS; Leah Scholtis, PA-C; Chung-Yin Sherman, CRNP; James Dove, BA; Marie Hunsinger, RN, BSHS; Jeffrey Wild, MD; Joseph Blansfield, MD; and Mohsen Shabahang, MD, PhD

ACO Quality Over Time: The MSSP Experience and Opportunities for System-Wide Improvement

William K. Bleser, PhD, MSPH; Robert S. Saunders, PhD; David B. Muhlestein, PhD, JD; Spencer Q. Morrison, BA; Hoangmai H. Pham, MD, MPH; and Mark B. McClellan, MD, PhD
From 2013 to 2016, Medicare Shared Savings Program accountable care organizations (ACOs) improved quality. Continued infrastructure development funding, better relationships with postacute care facilities, and shared learnings among diverse ACOs would maximize quality improvement.
ABSTRACT

Objectives: To investigate accountable care organization (ACO) quality improvement over the first 4 Medicare Shared Savings Program (MSSP) years.

Study Design: Fixed-effects analysis examined associations of within-ACO MSSP quality metric changes with key time-variant ACO traits: changes in postacute care (PAC) expenditure and size (attributed beneficiaries). Fixed-effects subgroup analyses and linear regression were used for key time-invariant traits: ACO taxonomy (physician-led, hospital-led, or co-led), risk-bearing maturity, commercial contract presence, and rurality.

Methods: The sources of data were secondary MSSP public use files linked to the Leavitt Partners ACO Database (ACO panel: n = 528; 2013-2016).

Results: Confirming early federal findings, MSSP ACOs, on average, improved most quality measures. Larger ACOs had higher quality, but ACOs grew rapidly for the first 3 years, bringing “growing pains” in quality measures related to clinical care for at-risk populations, before plateauing in size in the fourth year. By comparison, PAC expenditures increased in the first year but then decreased in all remaining years, and PAC spending changes were inversely associated with quality, especially in quality measures related to care coordination and patient safety. Successes and challenges varied most notably by ACO taxonomy, risk-bearing maturity, and rurality.

Conclusions: MSSP ACOs improved quality despite their sicker, older population, suggesting that the model might work in other settings and populations and could shift to more advanced risk and payment models (eg, population-based prospective payment). Continued ACO infrastructure development funding, better relationships with PAC facilities, and opportunities for diverse ACOs to share their learnings would maximize quality improvement.

The American Journal of Accountable Care. 2018;6(1):e1-e15

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