Changes in Postacute Care in the Medicare Shared Savings Program

Abstract

IMPORTANCEPostacute care is thought to be a major source of wasteful spending. The extent to which accountable care organizations (ACOs) can limit postacute care spending has implications for the importance and design of other payment models that include postacute care. OBJECTIVE To assess changes in postacute care spending and use of postacute care associated with provider participation as ACOs in the Medicare Shared Savings Program (MSSP) and the pathways by which they occurred. DESIGN, SETTING, AND PARTICIPANTS With the use of fee-for-service Medicare claims from a random 20% sample of beneficiaries with 25 544 650 patient-years, 8 395 426 hospital admissions, and 1 595 352 stays in skilled nursing facilities (SNFs) from January 1, 2009, to December 31, 2014, difference-in-difference comparisons of beneficiaries served by ACOs with beneficiaries served by local non-ACO health care professionals (control group) were performed before vs after entry into the MSSP. Differential changes were estimated separately for cohorts of ACOs entering the MSSP in 2012, 2013, and 2014. EXPOSURES Patient attribution to an ACO in the MSSP. MAIN OUTCOMES AND MEASURES Postacute spending, discharge to a facility, length of SNF stays, readmissions, use of highly rated SNFs, and mortality, adjusted for patient characteristics. RESULTS For the 2012 cohort of 114 ACOs, participation in the MSSP was associated with an overall reduction in postacute spending (differential change in 2014 for ACOs vs control

Medicare ACO Program Savings Not Tied To Preventable Hospitalizations Or Concentrated Among High-Risk Patients

“…Together, our study and prior studies demonstrate that by 2014 the MSSP was associated with a reduction in hospitalizations that was modest (1.6%) and observed only in the 2012 entry cohort, a modest reduction in inpatient spending only in the 2012 entry cohort that explained only 25.8% of the total spending reduction achieved by that cohort, 11 no significant reductions in readmissions, 11 minimal increases in medication use and adherence among patients with cardiovascular disease or diabetes, 18 largely unchanged if not higher rates of hospitalization for common chronic conditions that are the focus of MSSP quality measures, and total spending reductions that were not clearly and consistently concentrated among high-risk patients. This pattern of findings is not one that would be expected if MSSP savings were driven primarily by care coordination and management efforts that target specific conditions and/or high-risk groups and that aim to keep patients out of the hospital.…”

“…In concert with other evidence, 11,15 these findings suggest that early savings in the MSSP have not accrued in the areas that would be expected if they were driven by care management for high-risk patients and prevention of hospitalizations for ACSCs or hospitalizations in general. Among ACOs entering in 2012, reductions in per-beneficiary spending were greater among high-risk patients, but also significant and similar in relative terms among the much larger group of lower-risk patients.…”

“…Much of the savings have been due to lower use of overused services such as skilled nursing facility (SNF) care, high-priced hospital outpatient departments, and home health care. 5,11 Reductions in inpatient spending for ACO patients have been proportionally smaller, 11 and several studies through 2013 found minimal or no reductions in hospitalizations for ambulatory care-sensitive conditions (ACSCs). 3–5 For high-risk patients with multiple conditions, one study found greater absolute reductions in hospitalizations in 2013 than for lower-risk patients but similar relative reductions.…”

Organizational Attributes Associated With Medicare ACO Quality Performance

“…Although these associations may be confounded by unobserved ACO attributes that simultaneously affect ACOs’ patient base, the practice of postacute care, and quality measures, our results suggest that postacute care, especially follow‐up visits with primary care providers, may be a feasible strategy to enhance quality outcomes. This is consistent with early evidence that shows by discharging appropriate patients to home rather than facility, follow‐up care may help ACOs reduce postacute spending without deterioration in care quality …”

Can accountable care organisations really improve the English NHS? Lessons from the United States

“…Other aspects of care integration remain weak, including between physical and mental health 25. Medicare ACOs are targeting reductions in use of skilled nursing facilities and high cost outpatient procedures—services often thought to be overused in the US1426…”