Medicare Value-Based Approaches and Care Use Among Commercially Insured Adults

ABSTRACT

Objectives: To examine whether the growth of Medicare Shared Savings Program (MSSP) accountable care organizations (ACOs) and Medicare Advantage (MA) penetration was associated with changes in health care use among commercially insured populations.

Study Design: Observational study using claims data.

Methods: Using Health Care Cost Institute claims data (2015-2019), we conducted a repeated cross-sectional study of 13,041,197 enrollees aged 55 to 64 years in 50 states and the District of Columbia in employer-sponsored insurance plans of 4 national payers. Linear models estimated relationships between enrollees’ health care use and county-level MSSP ACO and MA penetration, controlling for enrollee and market characteristics and county and year fixed effects. Outcomes of interest were enrollees’ probability of receiving preventive care services (influenza immunization, breast cancer screening, colorectal cancer screening), having any outpatient emergency department visits, and having any inpatient hospitalization in a year.

Results: A majority of counties (72.1%) experienced increases in penetration of MSSP ACOs and MA from 2015 to 2019. Median (IQR) MSSP ACO penetration increased from 5.9% (1.6%-16.9%) to 18.9% (9.3%-31.5%), and median (IQR) MA penetration increased from 19.5% (11.2%-29.3%) to 26.8% (15.9%-36.6%). MSSP ACO and MA penetration was not substantively associated with changes in commercial enrollees’ use of preventive care, emergency department, and hospital services.

Conclusions: The expansion of MSSP ACOs and MA was not associated with substantive changes in health care use among commercial enrollees. The lack of spillovers from Medicare to commercial enrollees may stem from misaligned incentives from different payers, indicating the potential importance of multipayer alignment in ongoing payment reforms.

Am J Manag Care. 2026;32(2):e43-e49. https://doi.org/10.37765/ajmc.2026.89887

Takeaway Points

• A majority of counties experienced growth in penetration of Medicare value-based approaches: Medicare Shared Savings Program (MSSP) accountable care organizations (ACOs) and Medicare Advantage (MA).
• The expansion of MSSP ACOs and MA was not strongly associated with changes in commercial enrollees’ use of preventive care, emergency department, and hospital services; the associations were small in magnitude and not economically significant.
• We find little evidence of substantive spillovers from MSSP ACOs and MA to commercial enrollees, consistent with a lack of multipayer alignments in terms of implementing value-based payments.

Medicare beneficiaries are increasingly receiving care through non–fee-for-service arrangements. In 2023, 10.9 million Medicare beneficiaries received care from a provider participating in 1 of the 456 accountable care organizations (ACOs) under the Medicare Shared Savings Program (MSSP), the largest alternative payment model.¹ Providers in ACOs can share savings with CMS if they achieve spending reductions and meet certain quality standards. Meanwhile, Medicare Advantage (MA) has also seen substantial growth since its inception in 2003, with 51% of all Medicare beneficiaries (30.8 million individuals) enrolled as of 2023.² Approximately 58% of payments from MA plans to health providers have been made through advanced value-based payment programs such as episode-based payments or capitation.³ Prior study findings have shown that MSSP ACOs and MA were associated with modest reductions in spending and less inpatient utilization.^4-6 MSSP ACOs were also associated with clinicians’ increased delivery of certain preventive care services, such as influenza vaccination and clinical depression screening.^4-6

Increasing attention has been paid to whether payment innovations implemented by one payer could induce benefit for patients of other payers.⁷ One such mechanism is through the multipayer alignment, where multiple payers and stakeholders agree to launch similar payment innovations. Another mechanism is through spillover effects. Positive spillovers may exist if providers change behavior and extend efforts to reduce spending or improve patient outcomes beyond patients covered by the payment innovations. Especially when economies of scale exist, applying similar practice patterns to all patients regardless of insurance status could yield cost savings for organizations. However, negative spillovers could also exist. Payment innovations often affect providers’ revenue stream, which could be either positive or negative in models with2-sided risks. To offset the changes in revenue from one payer, providers could alter practice pattern or service volume in an opposite direction for patients covered by other payers.⁸

Understanding the potential implications of MSSP and MA penetration across commercial payers is important for examining the net impact of both programs. Several studies have documented potential cost-reducing and quality-enhancing effects of MA on traditional Medicare (TM).^9,10 Recent research has found limited spending implications of MSSP ACOs on non–ACO-attributed TM beneficiaries, but investigators observed a shift in the site of care from outpatient facilities to physician offices when non–ACO-attributed beneficiaries moved to areas with more beneficiaries in ACOs.¹¹ However, evidence on the spillovers of ACOs and MA onto commercially insured populations is limited. One study found that increased market-level MA penetration yields declines in hospital spending for both TM beneficiaries and commercially insured younger populations.¹² Another study found that physicians’ participation in MSSP ACOs did not reduce spending after a clinical episode among their commercially insured patients in Michigan.¹³ However, this evidence focused on the effect of only MSSP or MA using data before 2016. Given the growing proportion of Medicare beneficiaries attributed to ACOs and enrolling in MA, examining the 2 programs simultaneously in the current context is needed.

This study provides new evidence on potential implications of Medicare value-based approaches on commercially insured populations. We first describe the relationship between the growth of MSSP ACO and MA programs. Then we examine the association of market-level ACO and MA penetration with a variety of utilization measures among commercially insured adults.

METHODS

Data and Study Population

This study was approved by the Duke University institutional review board. We analyzed the Health Care Cost Institute (HCCI) 2.0 Commercial Claims Research Dataset.¹⁴ This database includes information on individuals’ health insurance enrollment and claims from 4 national health insurance companies, covering one-third of the employer-sponsored insurance population in the US. The HCCI data contain enrollees’ 5-digit zip code of residency, allowing us to link to other data sources.

We studied commercially insured enrollees aged 55 to 64 years from 2015 to 2019 in 50 states and the District of Columbia. Later years were not included due to the implications of the COVID-19 pandemic on health utilization. The spillovers of Medicare programs are most likely to be observed among commercial enrollees closest in age to Medicare beneficiaries due to similarity in the types of conditions and care processes for the 2 groups. We limited the sample to enrollees with 12-month enrollment in a calendar year to observe their complete health care use. For the analysis of breast cancer screening, we limited the analysis to female enrollees, for whom breast cancer screening is recommended.¹⁵ We further excluded enrollees in counties for which Medicare-eligible populations were below the first percentile (563 individuals) to rule out the potential instability of our exposure variables. Detailed inclusion and exclusion criteria are shown in eAppendix Table 1 (eAppendix available at ajmc.com).

Exposure Variables

We constructed ACO penetration and MA penetration at the county level. We defined ACO penetration as the proportion of MSSP ACO–assigned beneficiaries among all Medicare-eligible populations in a county in a given year using the CMS Number of Accountable Care Organization Assigned Beneficiaries by County files.¹⁶ The annual counts of beneficiaries assigned to an ACO in a county were suppressed if they were less than 10. We imputed these suppressed counts using differences between the national total number of ACO-assigned beneficiaries published in the CMS Shared Savings Program Fast Facts¹ and the number derived from the county files with suppression, divided by the number of ACO-counties with suppression in each year. We defined MA penetration as the proportion of MA beneficiaries among all Medicare-eligible populations in a county using the CMS MA State/County Penetration data.¹⁷ We used the January files of each year.

Outcomes

We examined a set of dichotomous indicators that an enrollee received certain preventive care services (influenza immunization, breast cancer screening, colorectal cancer screening) in outpatient settings in a year because the delivery of these services is included in the quality metrics of MSSP ACOs. We also examined dichotomous indicators of having any outpatient emergency department (ED) visits and any inpatient hospitalization. See eAppendix Table 2 for algorithms we used to identify the utilization of these services.

Enrollee and Market Characteristics

We obtained enrollee sex and insurance product type (health maintenance organization, point-of-service, preferred provider organization, and other) from the HCCI data. For market characteristics, we obtained population profiles at the level of Zip Code Tabulation Areas (ZCTAs) from the American Community Survey, including the percentage of adults insured by Medicare, percentage of adults insured by private insurers, and median household income. To account for variations in ACO performance, we used CMS MSSP program data to calculate county-level mean ACO savings per beneficiary and expenditure per beneficiary, weighted by each ACO’s share of beneficiary in a county. To account for the supply of health providers, we obtained the county-level number of primary care physicians from the Area Health Resources Files and the number of Medicare-certified general acute care hospitals from the CMS Hospital Cost Report, both per 1,000,000 population in a county.

Statistical Analysis

We examined the trends in MSSP ACO penetration and MA penetration as well as the correlation between the 2 penetration measures and their changes. Unadjusted means and proportions for outcomes, exposure variables, and covariates were also reported. We used linear probability models to estimate the relationship between outcomes and exposure variables, controlling for aforementioned enrollee and market characteristics. All models included county fixed effects and year fixed effects, which allowed us to identify how changes in our outcomes were associated with the within-county growth of ACO and MA penetration while the magnitude of growth varied across counties.

We report all coefficient estimates of interest as associations of outcomes with a 10–percentage point (PP) increase in the exposure variable. SEs were clustered at the county level to account for potential correlation across observations.¹⁸ Statistical analyses were performed with Stata/SE 18 (StataCorp LLC). A 2-sided P value less than .05 was considered statistically significant.

Because ACOs and MA can provide either aligned or contradictory incentives to clinicians, we examined whether the associations of our outcomes with ACO penetration varied by the level of MA penetration by adding to the model an interaction term of the 2 penetration measures. Additionally, because rural areas could have less ACO activity, we tested whether our results were sensitive to the exclusion of enrollees living in rural areas (defined as zip codes without a core-based statistical area code). We also included a model that interacts the ACO and MA penetration with a set of indicators of the tertiles of ZCTA-level percentage of privately insured populations. Markets with more privately insured populations may generate more revenue when extending practices for Medicare patients to commercial patients and have better resources to maintain quality levels, potentially resulting in larger spillovers.

RESULTS

From 2015 to 2019, median (IQR) MSSP ACO penetration increased from 5.9% (1.6%-16.9%) to 18.9% (9.3%-31.5%) and median (IQR) MA penetration increased from 19.5% (11.2%-29.3%) to 26.8% (15.9%-36.6%) (Figure 1, panels A and B). At the county-year level, ACO penetration and MA penetration were negatively correlated (correlation = –0.12 in 2019) (Figure 1, panel C). Most counties (72.1%) experienced increases in both ACO and MA penetration during the study period (Figure 1, panel D).

The analytic sample included 13,041,197 unique enrollees (29,643,808 enrollee-years) from 2961 counties, with a mean (SD) county-level ACO penetration of 17.9% (12.0%) and mean (SD) county-level MA penetration of 33.0% (14.0%) (Table). On average, the ACOs in our sample generated net Medicare program savings of $155.2 in a county annually (SD = $297.4).

Figure 2 shows estimates of spillovers from ACO and MA to commercial enrollees regarding use of preventive services. A 10-PP increase in ACO penetration was associated with a 0.13-PP increase in the probability of receiving influenza immunization (95% CI, 0.02-0.24; 0.49% increase relative to the sample mean) and a 0.29-PP increase in the probability of receiving breast cancer screening among female enrollees (95% CI, 0.08-0.49; 0.59% increase relative to the sample mean). No significant associations were observed for receiving colorectal cancer screening. A 10-PP increase in MA penetration was associated with a 0.44-PP decrease in colorectal cancer screening (95% CI, –0.72 to –0.16; 2.68% decrease relative to the sample mean). Higher MA penetration was negatively associated with the probability of receiving all modalities of colorectal cancer screening (eAppendix Table 3).

Regarding hospital and ED visits, we found that a 10-PP increase in ACO penetration was associated with a 0.05-PP increase in the probability of having ED visits in a year (95% CI, 0.001-0.11; 0.43% increase relative to the sample mean) but was not associated with having hospital admissions (Figure 3). A 10-PP increase in MA penetration was associated with a 0.20-PP increase in the probability of having ED visits (95% CI, 0.03-0.37; 1.72% increase relative to the sample mean) and a 0.08-PP increase in the probability of hospitalizations (95% CI, 0.01-0.15; 1.60% increase relative to the sample mean).

We observed larger associations between ACO penetration and outcomes in areas with a higher percentage of privately insured individuals for influenza immunization and breast cancer screening and smaller associations for ED visits and hospitalization. Associations between MA penetration and outcomes were similar across areas with different percentages of privately insured individuals (eAppendix Table 4). Consistent with the main findings, the magnitude of all associations was similarly small.

When examining whether the association between ACO penetration and outcomes varied by the level of MA penetration, we found only that the association between ACO penetration and probability of receiving influenza immunization was stronger in counties with low MA penetration (eAppendix Table 5). Our findings are robust to the exclusion of enrollees living in rural areas (eAppendix Table 6).

DISCUSSION

In this study, we examined whether the growth of Medicare beneficiaries in MSSP ACOs and MA—2 major value-based arrangements in Medicare—was associated with the types of health care use that are commonly tracked in value-based arrangements among commercially insured adults. In general, we found that the spillover effects of ACOs and MA were minimal. Although we observed associations for several outcomes regarding preventive services use and hospitalizations, the magnitudes were not significant from a practical perspective.

Our findings are generally consistent with previous research on Medicare-to-commercial spillovers. Post et al compared spending among commercially insured patients seeking care from physicians who participated in Medicare ACOs with those who did not. They found no significant difference in 90-day or 91- to-365-day spending after a significant clinical episode among commercially insured patients in Michigan.¹³ Baicker and colleagues found lower hospital costs and shorter length of stay per hospitalization for commercially insured populations in areas with greater MA penetration but did not observe association between MA penetration and the number of hospitalizations.¹² Our study extends prior work by examining the use of preventive services and ED care in addition to hospital inpatient use.

One explanation for the lack of spillovers is that providers could strategically alter service volume for commercially insured patients in response to the direct utilization effect of Medicare value-based programs. Because MSSP ACOs and MA have been shown to reduce hospital utilization for targeted patients,^4-6 hospitals in markets with high ACO and MA penetration could face potential decline in Medicare revenue and excess capacity. To maintain profitability, these hospitals would have fewer incentives to further reduce hospitalizations for commercial patients. Another explanation is that the optimization of practice for one population cannot be easily extended to another population. Interventions designed for Medicare patients may not be applicable to commercial patients who are generally younger and have lower risks and medical needs. However, the preventive services included in our study have been recommended for our study population by clinical guidelines.^15,19,20 During our study period, commercial insurers were required to cover these guideline-recommended preventive services for eligible populations without patient cost sharing. Hence, the lack of incentives to improve enrollees’ receipt of these services needs further research.

More likely, the lack of spillover effects of ACOs and MA on commercially insured populations suggests that misaligned incentives and value-based model design elements (eg, quality measures, financial penalties and bonuses) across payers may inhibit the snowballing and spillover of positive benefits. Said differently, even if value-based contracts and enrollees covered by these contracts have been growing across all payers,^3,21 different payers and providers could develop different value-based contracts. As such, providers face trade-offs and may not be able to scale interventions and quality improvements across patients regardless of payers. Moreover, such fragmentation in payments could increase providers’ administrative burdens and deter efforts to improve care for most patients.²²

The ongoing effort to advance multipayer alignment by health care purchasers (eg, CMS, states, employers) would benefit from improving and reiterating existing frameworks.^23,24 For example, to advance quality measure alignment, the Universal Foundation, a streamlined set of adult and child quality measures, has been developed with the expectation of fully digital measure collection and reporting.²⁵ Additionally, to facilitate the exchange of health information among health systems, payers, and patients, CMS mandated electronic clinical quality measure reporting for ACOs at the start of 2025.²⁶

More complete data will be needed to more accurately assess a broad array of value-based arrangements on different populations. CMS has proposed MA policy changes in response to stakeholder feedback urging increased MA data transparency and public accessibility, including expanded Part C data collection requirements intended to assess MA uptake of alternative payment models.²⁷ Meanwhile, the National Committee for Quality Assurance has also adopted digital quality measurement into its strategy, aligned with CMS’ goals. Specifically, several of the Healthcare Effectiveness Data and Information Set measures have been selected for mandatory reporting through electronic clinical data systems reporting, allowing for a variety of data sources to be used in real time.²⁸ Future work can utilize large-scale data to evaluate how clinician- and practice-level characteristics and policy environments could mediate the benefit of value-based arrangements for both targeted and nontargeted populations.

Limitations

Our study has several limitations. First, we only examined the ACO and MA penetration at the county level due to a lack of information on clinicians’ participation in ACO and MA contracts. Future studies can explore whether commercial enrollees’ health care utilization varies by their providers’ involvement in ACOs and MA in this data set. Second, although our regression models controlled for numerous enrollee and market characteristics and used county fixed effects to account for time-invariant geographic heterogeneity, there could have been unobserved enrollee characteristics (eg, race and ethnicity) and time-varying market characteristics omitted from our analyses (eg, penetration of value-based payment contracts of commercial plans) due to limitations of claims data. To alleviate the concern, we controlled for enrollees’ insurance product type to capture potential payment innovations launched by private insurers. Third, we did not differentiate potentially avoidable ED visits from other ED visits and did not differentiate hospitalizations due to ambulatory care–sensitive conditions from other types of hospitalizations. Fourth, our study is limited by using data from 2015 to 2019 to avoid disruptions in health care utilization patterns during the COVID-19 pandemic. Future studies could use more recent data, as ACO and MA penetration continued to grow after our study period, potentially creating stronger incentives for providers to maintain similar cost and quality standards for all patients. Fifth, to fully capture potential receipt of preventive services, our breast cancer screening and colorectal cancer screening measures included services that may be used for diagnostic purposes, potentially overestimating the rates. Sixth, our study sample was not nationally representative, although the data sets covered approximately one-third of enrollees in employer-sponsored insurance plans from 4 nationwide insurers. Finally, due to limited data availability, the calculation of ACO penetration was based on only MSSP ACOs. However, the MSSP accounts for a majority of Medicare beneficiaries attributed to ACOs during our study period, ranging from 88% to 91%.²⁹ Given the relatively small enrollment of other Medicare ACO programs in this period, the implication of excluding beneficiaries attributed to non-MSSP ACOs is expected be minimal.

CONCLUSIONS

In this repeated cross-sectional study, we observed that most counties in the US experienced increases in market-level penetration of Medicare ACOs and MA from 2015 to 2019. However, the expansion of the 2 programs was not strongly associated with changes in commercial enrollees’ use of preventive care, ED, and hospital services. The lack of spillover effects from Medicare to commercial enrollees may suggest misaligned incentives across payers.

Acknowledgments

This research was supported by a collaborative initiative between the Duke-Margolis Institute for Health Policy and West Health to advance and accelerate value-based payment reform in the US health care system. The funding source had no involvement in study design; collection, analysis, and interpretation of data; the writing of the report; or the decision to submit the article for publication.

The authors acknowledge the assistance of the Health Care Cost Institute and its data contributors in providing the claims data analyzed in this study.

Author Affiliations: Duke-Margolis Institute for Health Policy, Duke University (KL, SD, FM, MKB, RSS), Washington, DC, and Durham, NC; Sanford School of Public Policy, Duke University (MKB), Durham, NC.

Source of Funding: This research was supported by West Health.

Author Disclosures: Dr Li reports being employed by Amazon, but the work related to this study was done during her appointment at Duke University and before her employment with Amazon. Mr McStay has received lecture fees for speaking at the invitation of a commercial sponsor.Dr Saunders is a cochair of the Health Evolution Roundtable on Value-Based Care for Specialized Populations.The remaining authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (KL, FM, MKB, RSS); acquisition of data (FM); analysis and interpretation of data (KL, MKB, RSS); drafting of the manuscript (SD); critical revision of the manuscript for important intellectual content (KL, SD, FM, MKB, RSS); statistical analysis (KL, MKB); obtaining funding (FM, RSS); administrative, technical, or logistic support (SD, FM); and supervision (FM, RSS).

Address Correspondence to: Kun Li, PhD, Amazon, 410 Terry Ave N, Seattle, WA 98109. Email: kunli.hp@gmail.com.

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