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The American Journal of Managed Care May 2018
Impact of Emergency Physician–Provided Patient Education About Alternative Care Venues
Pankaj B. Patel, MD; David R. Vinson, MD; Marla N. Gardner, BA; David A. Wulf, BS; Patricia Kipnis, PhD; Vincent Liu, MD, MS; and Gabriel J. Escobar, MD
Monitoring the Hepatitis C Care Cascade Using Administrative Claims Data
Cheryl Isenhour, DVM, MPH; Susan Hariri, PhD; and Claudia Vellozzi, MD, MPH
Delivery of Acute Unscheduled Healthcare: Who Should Judge Whether a Visit Is Appropriate (or Not)?
Adam Sharp, MD, MSc, and A. Mark Fendrick, MD
Impact of Formulary Restrictions on Medication Intensification in Diabetes Treatment
Bruce C. Stuart, PhD; Julia F. Slejko, PhD; Juan-David Rueda, MD; Catherine E. Cooke, PharmD; Xian Shen, PhD; Pamela Roberto, PhD; Michael Ciarametaro, MBA; and Robert Dubois, MD
Characteristics and Medication Use of Veterans in Medicare Advantage Plans
Talar W. Markossian, PhD, MPH; Katie J. Suda, PharmD, MS; Lauren Abderhalden, MS; Zhiping Huo, MS; Bridget M. Smith, PhD; and Kevin T. Stroupe, PhD
Rural Hospital Transitional Care Program Reduces Medicare Spending
Keith Kranker, PhD; Linda M. Barterian, MPP; Rumin Sarwar, MS; G. Greg Peterson, PhD; Boyd Gilman, PhD; Laura Blue, PhD; Kate Allison Stewart, PhD; Sheila D. Hoag, MA; Timothy J. Day, MSHP; and Lorenzo Moreno, PhD
Understanding Factors Associated With Readmission Disparities Among Delta Region, Delta State, and Other Hospitals
Hsueh-Fen Chen, PhD; Adrienne Nevola, MPH; Tommy M. Bird, PhD; Saleema A. Karim, PhD; Michael E. Morris, PhD; Fei Wan, PhD; and J. Mick Tilford, PhD
Currently Reading
Changes in Specialty Care Use and Leakage in Medicare Accountable Care Organizations
Michael L. Barnett, MD, MS, and J. Michael McWilliams, MD, PhD
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Olena Mazurenko, MD, PhD; Jay Shen, PhD; Guogen Shan, PhD; and Joseph Greenway, MPH
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Changes in Specialty Care Use and Leakage in Medicare Accountable Care Organizations

Michael L. Barnett, MD, MS, and J. Michael McWilliams, MD, PhD
Reducing specialty leakage is promoted as crucial for accountable care organizations (ACOs). This study finds that Medicare ACOs had modest reductions in specialty use and minimal changes in leakage.

Objectives: Reducing leakage to outside specialists has been promoted as a key strategy for accountable care organizations (ACOs). We sought to examine changes in specialty care leakage and use associated with the Medicare Shared Savings Program (MSSP).

Study Design: Analyses of trends in ACOs from 2010 to 2014 and quasi-experimental difference-in-differences analyses comparing changes for ACOs versus local non-ACO providers from before until after the start of ACO contracts, stratified by ACO specialty composition and year of MSSP entry.

Methods: We used Medicare claims for a 20% sample of beneficiaries attributed to ACOs or non-ACO providers. The main beneficiary-level outcome was the annual count of new specialist visits. ACO-level outcomes included the proportion of visits for ACO-attributed patients outside of the ACO (leakage) and proportion of ACO Medicare outpatient revenue devoted to ACO-attributed patients (contract penetration).

Results: Leakage of specialist visits decreased minimally from 2010 to 2014 among ACOs. Contract penetration also changed minimally but differed substantially by specialty composition (85% for the most primary care–oriented quartile vs 47% for the most specialty-oriented quartile). For the most primary care–oriented quartile of ACOs in 2 of 3 entry cohorts, MSSP participation was associated with differential reductions in new specialist visits (–0.04 visits/beneficiary in 2014 for the 2012 cohort; –5.4%; P <.001). For more specialty-oriented ACOs, differential changes in specialist visits were not statistically significant.

Conclusions: Leakage of specialty care changed minimally in the MSSP, suggesting ineffective efforts to reduce leakage. MSSP participation was associated with decreases in new specialty visits among primary care–oriented ACOs.

Am J Manag Care. 2018;24(5):e141-e149

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