Accelerating the Shift to Downside Risk in Medicare Accountable Care Organizations: Effects on Clinical Quality and Costs among Older Patients

医疗保险责任医疗组织加速转向下行风险：对老年患者临床质量和成本的影响

• 批准号: 10432116
• 负责人: BRENT K. HOLLENBECK
• 金额: $ 33.99万
• 依托单位: UNIVERSITY OF MICHIGAN AT ANN ARBOR
• 依托单位国家: 美国
• 财政年份: 2020
• 资助国家: 美国
• 起止时间: 2020-09-30 至 2025-04-30
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10432116
• 关键词: Accountability; Address; Administrator; Affect; American; Benchmarking; Caring; Clinical; Contracts; Cost Control; Data; Drops; End stage renal failure; Evaluation; Fee-for-Service Plans; Health; Health Care Costs; Healthcare; Hospitals; Incentives; Information Systems; Interview; Location; Measures; Medicare; Medicare claim; Modeling; Motivation; Organizational Models; Outcome; Pathway interactions; Patient Selection; Patients; Performance; Physicians; Population; Preventive service; Price; Process; Provider; Quality of Care; Rewards; Risk; Sampling; Savings; Standardization; Structure; Telephone; United States Centers for Medicare and Medicaid Services; Work; base; beneficiary; care coordination; care costs; care delivery; cost; cost shifting; falls; financial incentive; health care quality; health management; high risk; improved; innovation; insight; mindfulness; next generation; older patient; optimism; payment; population health; programs; success

PROJECT SUMMARY Older patients receive fragmented healthcare that is of variable quality and cost. To address this problem, the Centers for Medicare & Medicaid Services (CMS) developed accountable care organizations (ACOs). ACOs create incentives for providers to work together, while being mindful of their spending. Evaluations of the Medicare Shared Savings Program (MSSP)—CMS’s largest ACO initiative—show that participating organizations have improved care quality for older patients. Nonetheless, their costs remain high because they do not have enough “skin in the game.” The majority of ACOs have contracts in which they share a small percentage of the savings with Medicare when they reduce their annual costs below a benchmark but are not penalized if they fall short (i.e., they have no downside risk). Without the financial threat of downside risk, ACOs have less reason to innovate and increase efficiency. Thus, CMS announced “Pathways to Success” in December 2018, requiring current MSSP ACOs to shift to downside risk in as little as one year. However, shifting so quickly may be detrimental. The MSSP is voluntary, and many ACOs that have engaged in meaningful care redesign may not be ready to take on the possibility of having to repay CMS millions and leave the program instead. Indeed, 40% of ACOs facing contract renewal this July dropped out. Without the potential for shared savings, exiting ACOs may divest their data systems and coordination capabilities needed for population health management, which are costly to maintain. In turn, the ACOs’ patients may suffer lower care quality and higher costs. The decision to stay in the MSSP may have unintended consequences, too. ACOs may pursue cost-containment strategies like favorable patient selection. They may also limit their focus to CMS-required metrics (at the expense of other clinically important ones). These moves would hurt older patients who stand to gain the most from ACOs. In this context, we propose a combined qualitative and quantitative study with three Specific Aims. 1) To examine decisions around MSSP participation and the impact that these decisions have on an organization’s approach to care delivery after launch of Pathways to Success. Using administrative data, we will purposefully sample 12 ACOs without downside risk that faced contract renewal in 2019—six that renewed and six that did not. We will conduct semi-structured phone interviews with key stakeholders to better understand what factors influenced their participation decision and how their decision is affecting their efforts to improve care coordination and population health. 2) To assess the effects of MSSP exit on clinical quality and costs among older patients. We will analyze national Medicare claims (2008 to 2022) and identify MSSP-aligned fee-for-service beneficiaries. Among these beneficiaries, we will then measure their healthcare quality and costs (based on CMS-required outcome and process metrics and total price-standardized Medicare spending) before and after launch of Pathways to Success. 3) To evaluate for unintended consequences on older patients from continued participation. For ACOs identified in Aim 2 that remain in the MSSP, we will evaluate whether they take part in favorable patient selection. We will also measure their organizational performance against CMS-required and non- required outcome and process metrics before and after launch of Pathways to Success. Impact. Findings from our study will provide policymakers with actionable insights as they incorporate downside risk into advanced payment models and serve to inform ACO stakeholders who are considering organizational next steps.

项目摘要 老年患者获得质量可变和成本的零散的医疗保健。为了解决这个问题， Medicare＆Medicaid服务中心（CMS）开发了负责任的护理组织（ACO）。 ACOS 为提供者提供激励措施，同时注意他们的支出。评估 Medicare共享储蓄计划（MSSP） - CMS最大的ACO倡议 - 显示参加 组织改善了老年患者的护理质量。尽管如此，他们的成本仍然很高，因为他们 没有足够的“游戏中的皮肤”。大多数ACO都有合同，他们共享一个小的合同 当医疗保险将年度成本降低到基准低于基准时，用医疗保险节省的百分比 如果他们跌倒不足（即，没有下行风险）会受到惩罚。没有下行风险的财务威胁， ACO的创新和提高效率的理由较少。这是CMS宣布的“成功途径” 2018年12月，要求当前的MSSP ACO在短短一年内转变为下行风险。然而， 可以这么快地确定转移。 MSSP是自愿的，许多参与的ACO 有意义的护理重新设计可能不愿意承担必须偿还CMS的可能性，并且 而是离开程序。确实，今年7月面临合同续约的ACO中有40％退出了。没有 共享节省的潜力，退出ACO可能会剥离其数据系统和所需的协调能力 对于人口健康管理，维护成本很高。反过来，ACO的患者可能遭受较低的痛苦 护理质量和更高的成本。留在MSSP的决定也可能带来意外的后果。 ACO可能会购买成本控制策略，例如有利的患者选择。他们也可能限制他们的注意力 到CMS需要的指标（以其他临床上重要的指标为代价）。这些举动会伤害年龄 从ACO中获得最大收益的患者。在这种情况下，我们提出了一个合并的定性和 定量研究具有三个特定目标。 1）检查有关MSSP参与和 这些决定对组织发起后的护理交付方法的影响 成功的途径。使用管理数据，我们将有目的地品尝12个ACO，而无需下行风险 该公司在2019年面临合同续约，续签了六个，而六个则没有。我们将进行半结构化 与主要利益相关者的电话访谈，以更好地了解哪些因素影响了他们的参与决定 以及他们的决定如何影响他们改善护理协调和人口健康的努力。 2）到 评估MSSP出口对老年患者临床质量和成本的影响。我们将分析 国家医疗保险索赔（2008年至2022年），并确定由MSSP对准的服务受益人。其中 受益人，我们将衡量他们的医疗保健质量和成本（基于CMS的结果和 过程指标和总价格标准化的医疗保险支出）在启动通往途径之前和之后 成功。 3）评估继续参与的老年患者的意外后果。 对于保留在MSSP中的AIM 2中确定的ACO，我们将评估它们是否参与有利 患者选择。我们还将衡量他们针对CMS所需和非 - 的组织绩效 在启动成功途径之前和之后，所需的结果和过程指标。影响。来自 我们的研究将为决策者提供可行的见解，因为它们将下行风险纳入高级风险 付款模型并有助于通知正在考虑组织下一步的ACO利益相关者。