ACO Gains in First Years Are 'Promising, Not Overwhelming'

Marcia Frellick

October 30, 2014

Two studies on the cost, care quality, and patient experience associated with accountable care organizations (ACOs) published in the October 30 issue of the New England Journal of Medicine point to moderate cost savings and gains in quality and access in the payment model's first years.

An accompanying editorial by Lawrence Casalino, MD, PhD, summarized ACOs' progress, according to these studies, as "promising but not overwhelming." Dr Casalino works in the Department of Healthcare Policy and Research, Weill Cornell Medical College, New York City.

In the cost study, Zirui Song, MD, PhD, from the Department of Medicine, Massachusetts General Hospital, Boston, and colleagues evaluated spending and quality measures in the first 4 years of the Blue Cross Blue Shield of Massachusetts Alternative Quality Contract (AQC) compared with in a control group from other states. The AQC is a risk contract, meaning it distributes shared savings if spending is under budget, and shared risk if spending exceeds the budget.

From 2009 to 2012, spending on medical claims grew less per enrollee per quarter in the AQC cohorts than it did in the control state cohorts. The savings were 6.8% ($62.21) in 2009 and then 8.8%, 9.1%, and 5.8%, respectively, in the next 3 years. Most of the savings came in outpatient facilities, and specifically from reduced cost for and less use of imaging and tests.

ACOs Have Higher Care Quality Scores

The AQC groups also improved more in chronic disease management quality. AQC groups increased from 79.6% of the population meeting standards in 2007 to 2008 to 84.5% from 2009 through 2012 compared with 79.8% and 80.8%, respectively, in the respective periods for the Healthcare Effectiveness Data and Information Set national average.

Quality measures included five outcomes: control of the glycated hemoglobin level (≤9%), control of the low-density lipoprotein cholesterol level (<100 mg/dL), and blood pressure control (<140/80 mm Hg) in patients with diabetes; the same level of control of low-density lipoprotein cholesterol in patients with coronary artery disease' and a blood pressure control level of 140/90 mm Hg in patients with hypertension.

Access, Coordination of Care Improve

A second study on patient experience, by J. Michael McWilliams, MD, PhD, from the Department of Health Care Policy, Harvard Medical School, Boston, and colleagues, found that Medicare ACO contracts were associated with improvements in some measures of patient experience, but with no difference in others.

The researchers used Consumer Assessment of Healthcare Providers and Systems survey data to compare experiences for 32,334 fee-for-service beneficiaries attributed to ACOs, with a control group of 251,593 beneficiaries attributed to other providers 3 years before and 1 year after the start of Medicare ACO contracts in 2012.

As compared with the control group, patients in ACOs reported improvements in areas affected by decisions by organizations, such as access to care and coordination of care. However, in the areas in which physicians' interpersonal skills are needed to make a change, such as physician ratings and interactions with physicians, no significant improvements were reported.

"These findings have important implications for patients and policy," the authors write. "Enhanced experiences by patients may encourage their loyalty to ACOs, potentially addressing some of the care fragmentation and instability in beneficiary assignment that diminish incentives and rewards for ACOs. Moreover, should preliminary evidence of savings generated by ACOs be confirmed, our findings would indicate that ACOs may be able to achieve savings in ways that do not adversely affect patients' experiences."

Consistent With CMS Findings

In his editorial, Dr Casalino said the two studies' results are consistent with findings from the Centers for Medicare & Medicaid.

"ACOs in the CMS programs have on average achieved modest reductions in costs for Medicare beneficiaries, thereby generating 'shared savings' revenue for themselves and net savings for CMS, and have improved their performance on nearly all quality and patient-experience measures included in the program," he notes.

Two authors of the cost study report receiving personal fees from Blue Cross Blue Shield of Massachusetts outside the submitted work. The other authors and editorialist have disclosed no relevant financial relationships.

N Engl J Med. 2014;371:1704-1724, 1750-1751. Song abstract, McWilliams extract, Editorial extract

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