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: 10026743
• 负责人: John Malcolm Hollingsworth
• 金额: $ 44.3万
• 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/10026743
• 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.

项目概要 老年患者接受的医疗保健分散，质量和成本参差不齐。为了解决这个问题， 医疗保险和医疗补助服务中心 (CMS) 建立了责任医疗组织 (ACO)。 ACO 为供应商合作创造激励，同时注意他们的支出。的评价 医疗保险共享储蓄计划 (MSSP)——CMS 最大的 ACO 计划——表明参与 组织提高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 没有足够的“利益参与”。大多数 ACO 都签订了共享一小部分的合同 当他们将年度成本降低到基准以下但未达到基准时，医疗保险节省的百分比 如果他们达不到要求（即他们没有下行风险），就会受到惩罚。如果没有下行风险的财务威胁， ACO 没有太多理由进行创新和提高效率。因此，CMS 宣布了“成功之路” 2018 年 12 月，要求当前的 MSSP ACO 在短短一年内转向下行风险。然而， 如此迅速的转变可能是有害的。 MSSP 是自愿的，许多 ACO 都参与了 有意义的护理重新设计可能还没有准备好承担必须偿还 CMS 数百万美元的可能性，并且 而是离开该程序。事实上，今年 7 月面临续签合同的 ACO 中有 40% 退出了。如果没有 共享节省的潜力，现有的 ACO 可能会剥离其所需的数据系统和协调能力 用于人口健康管理，维护成本高昂。反过来，ACO 的患者可能会遭受更少的痛苦 护理质量和更高的成本。留在 MSSP 的决定也可能会产生意想不到的后果。 ACO 可能会采取成本控制策略，例如有利的患者选择。他们也可能会限制自己的注意力 CMS 所需的指标（以牺牲其他临床重要指标为代价）。这些举动会伤害老年人 从 ACO 中获益最多的患者。在此背景下，我们提出了一个综合的定性和 具有三个具体目标的定量研究。 1) 检查有关 MSSP 参与的决策以及 这些决策对组织启动后提供护理服务的方法产生的影响 成功之路。使用管理数据，我们将有目的地对 12 个 ACO 进行抽样，而不会产生下行风险 2019 年，有 6 家面临续签合同，6 家没有续签。我们将进行半结构化 与主要利益相关者进行电话访谈，以更好地了解哪些因素影响了他们的参与决策 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) 至 评估 MSSP 退出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）并确定与 MSSP 一致的按服务收费受益人。其中 然后，我们将衡量他们的医疗保健质量和成本（基于 CMS 要求的结果和 流程指标和总价格标准化医疗保险支出）在推出 Pathways 之前和之后 成功。 3) 评估持续参与对老年患者的意外后果。 对于目标 2 中确定的仍保留在 MSSP 中的 ACO，我们将评估它们是否参与有利的 患者选择。我们还将根据 CMS 要求和非 CMS 来衡量他们的组织绩效 成功之路启动前后所需的结果和流程指标。影响。调查结果来自 我们的研究将为政策制定者提供可行的见解，帮助他们将下行风险纳入先进的研究中。 支付模型，并用于告知正在考虑组织后续步骤的 ACO 利益相关者。