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The American Journal of Managed Care September 2019
VA Geriatric Scholars Program’s Impact on Prescribing Potentially Inappropriate Medications
Zachary Burningham, PhD; Wei Chen, PhD; Brian C. Sauer, PhD; Regina Richter Lagha, PhD; Jared Hansen, MStat; Tina Huynh, MPH, MHA; Shardool Patel, PharmD; Jianwei Leng, MStat; Ahmad Halwani, MD; and B. Josea Kramer, PhD
The Sociobehavioral Phenotype: Applying a Precision Medicine Framework to Social Determinants of Health
Ravi B. Parikh, MD, MPP; Sachin H. Jain, MD, MBA; and Amol S. Navathe, MD, PhD
From the Editorial Board: Jan E. Berger, MD, MJ
Jan E. Berger, MD, MJ
Medicaid Managed Care: Issues for Enrollees With Serious Mental Illness
Jean P. Hall, PhD; Tracey A. LaPierre, PhD; and Noelle K. Kurth, MS
Multi-Payer Advanced Primary Care Practice Demonstration on Quality of Care
Musetta Leung, PhD; Christopher Beadles, MD, PhD; Melissa Romaire, PhD; and Monika Gulledge, MPH; for the MAPCP Evaluation Team
Physician-Initiated Payment Reform: A New Path Toward Value
Suhas Gondi, BA; Timothy G. Ferris, MD, MPH; Kavita K. Patel, MD, MSHS; and Zirui Song, MD, PhD
Managed Care for Long-Stay Nursing Home Residents: An Evaluation of Institutional Special Needs Plans
Brian E. McGarry, PT, PhD; and David C. Grabowski, PhD
Changes in Ambulatory Utilization After Switching From Medicaid Fee-for-Service to Managed Care
Lisa M. Kern, MD, MPH; Mangala Rajan, MBA; Harold Alan Pincus, MD; Lawrence P. Casalino, MD, PhD; and Susan S. Stuard, MBA
Did Medicare Advantage Payment Cuts Affect Beneficiary Access and Affordability?
Laura Skopec, MS; Joshua Aarons, BA; and Stephen Zuckerman, PhD
Currently Reading
Medicare Shared Savings Program ACO Network Comprehensiveness and Patient Panel Stability
Cassandra Leighton, MPH; Evan Cole, PhD; A. Everette James, JD, MBA; and Julia Driessen, PhD
Call Center Performance Affects Patient Perceptions of Access and Satisfaction
Kevin N. Griffith, MPA; Donglin Li, MPH; Michael L. Davies, MD; Steven D. Pizer, PhD; and Julia C. Prentice, PhD

Medicare Shared Savings Program ACO Network Comprehensiveness and Patient Panel Stability

Cassandra Leighton, MPH; Evan Cole, PhD; A. Everette James, JD, MBA; and Julia Driessen, PhD
Medicare Shared Savings Program accountable care organization (ACO) network comprehensiveness is associated with stable patient assignment year to year. Panel stability was significantly associated with improved diabetes and hypertension control in the short term.

Objectives: The current Medicare Shared Savings Program (MSSP) accountable care organization (ACO) attribution methodology creates unpredictability for ACOs that are developing and deploying strategic initiatives aimed at improving value. The goal of this study is to determine if ACO network comprehensiveness is associated with the stability of assigned Medicare beneficiaries from 2013 to 2014.

Study Design: We utilized a beneficiary-level logistic regression model to determine association of network comprehensiveness with stable attribution to an MSSP ACO.

Methods: Using 2013 and 2014 Medicare fee-for-service beneficiary and provider files, we developed a measure of network comprehensiveness based on 2013 provider contracts, determined beneficiary attribution, and generated market-level measures. Additional population and quality measures were obtained from the US Census and the ACO Public Use File.

Results: Of the 1,317,858 observed beneficiaries, 84.38% were attributed to the same ACO in 2013 and 2014, and mean (SD) ACO network comprehensiveness was 0.30 (0.20). We found that a 0.10 increase in network comprehensiveness score significantly increased the odds of remaining attributed to the same ACO by 4.5% (P = .001). Patient panel stability was significantly associated with improved diabetes (P = .01) and hypertension (P = .02) control, timely access to care (P = .001), and delivery of health education (P = .03) over the 2-year period.

Conclusions: The comprehensiveness of an MSSP ACO’s contracted provider network is associated with stable patient assignment year to year. Patient panel stability may aid in the longitudinal management of some conditions.

Am J Manag Care. 2019;25(9):e267-e273
Takeaway Points

This study provides initial insights into accountable care organization (ACO) structural impact on attribution over time.
  • With all new payment models, it is critical to know how providers respond so that iterative improvements can be made to achieve cost and quality objectives.
  • Patient panel stability was associated with improved diabetes and hypertension control, validating the ACO model’s ability to affect patient outcomes.
  • By constructing a provider network that mitigates the effect of the attribution process, the ACO can position itself for better performance on select quality measures.
The Medicare Shared Savings Program (MSSP) is an alternative payment model (APM) to traditional Medicare fee-for-service (FFS) and incentivizes the provision of efficient and effective healthcare through various levels of risk sharing.1 To participate in the MSSP, healthcare providers and organizations voluntarily collaborate and enter into a contract to create an accountable care organization (ACO). The ACO’s providers become collectively responsible for the overall quality and cost of care for assigned Medicare FFS beneficiaries.

Beneficiaries are assigned to an ACO based on primary care utilization of contracted providers.2,3 CMS specifies only 1 ACO eligibility requirement related to the composition of the contracted provider network. The ACO simply needs to include a sufficient number of primary care physicians to be assigned 5000 beneficiaries.1 This design latitude has led to the proliferation of uniquely organized and structured ACOs.4

Researchers have determined that ACO structural differences are influenced by external market forces.4,5 These differences have been categorized into measures of size of provider network, scope of services, breadth of provider type participation, proportion of primary care in network, leadership type, integrated delivery system membership, performance management strategies, and prior payment reform experience.4,6,7 Researchers have used structural and organizational measures to evaluate the cost and quality outcomes of ACOs, but these evaluations have yielded mixed results.7-9 Although other studies have used proxies for breadth and size of contracts, comprehensiveness of ACO provider networks has not been examined. Comprehensiveness is the inclusion of a minimum number of primary care and specialty providers necessary to serve a population. A more comprehensive network could increase access, improve provider communication, and reduce external utilization. It potentially offers ACOs greater control of the attribution process.

The attribution process mediates the relationship between organizational structure and outcome performance. CMS uses a prospective attribution method with retrospective reconciliation to assign beneficiaries to ACOs in the Track 1 and Track 2 MSSP models.2 A beneficiary must receive a plurality of primary care services from one of the contracted providers to be assigned to an ACO. This directly links the ACO’s network to the attribution process. ACO leadership receive preliminary panels during the performance year based on historic utilization. These panels are adjusted at the year’s end to reflect actual performance year utilization.10,11 The ACO’s cost and quality performance is calculated using this final list.

Organizations rely on complete and perfect information to make operational decisions that minimize risk.12-15 The retrospective reconciliation process introduces large uncertainty about the beneficiaries for whom an ACO is responsible. ACOs want to optimize the investment of organizational resources to improve population health and achieve MSSP goals.16 However, it is difficult to maximize performance without knowing the target that one needs to reach. The uncertainty produced by MSSP attribution can potentially affect an ACO’s proactive development and deployment of strategic interventions and initiatives aimed at improving value.10,11

Furthermore, the implementation of strategic and targeted population health initiatives often does not result in immediate and lasting changes. It can take years to modify utilization patterns, curve costs, and improve condition management—tenets central to the MSSP. This adds another important dimension to the MSSP attribution process: patient panel stability over time. When an attributed population remains stable year to year, the ACO has greater opportunity to enact interventions and witness returns on investment.17,18 Research has shown that ACO patient panel stability is moderately associated with better ACO performance.18,19

It is critical to evaluate supply-side response and perceptions to understand program impacts and to identify effective strategies and best practices. In this study, we expand on prior ACO organizational literature by exploring the mediating relationship of the attribution process. Specifically, we analyze if ACO patient panel stability from 2013 to 2014 is a result of provider network comprehensiveness in 2013. We then determine if patient panel stability is associated with changes in patient and caregiver experience performance and select quality metrics.

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