I read with great interest an article published in the May issue of Health Affairs, based on a study of results coming out of Pioneer ACO Program accountable care organizations. The article, written by a large team of researchers—John Hsu, Mary Price, Christine Vogeli, Richard Brand, Michael E. Chernew, Sreekanth K. Chaguturu, Eric Weil, and Timothy G. Ferris—was entitled “Bending The Spending Curve By Altering Care Delivery Patterns: The Role Of Care Management Within A Pioneer ACO.”
In it, Hsu and his fellow researchers described how they examined care management practices implemented at Massachusetts General Hospital in Boston, and what they found. As they wrote in their abstract, “Accountable care organizations (ACOs) appear to lower medical spending, but there is little information on how they do so. We examined the impact of patient participation in a Pioneer ACO and its care management program on rates of emergency department (ED) visits and hospitalizations and on Medicare spending,” the authors wrote. “We used data for the period 2009–14, exploiting naturally staggered program entry to create concurrent controls to help isolate the program effects. The care management program (the ACO’s primary intervention) targeted beneficiaries with elevated but modifiable risks for future spending. ACO participation had a modest effect on spending, in line with previous estimates. Participation in the care management program was associated with substantial reductions in rates for hospitalizations and both all and nonemergency ED visits, as well as Medicare spending, when compared to preparticipation levels and to rates and spending for a concurrent sample of beneficiaries who were eligible for but had not yet started the program. Rates of ED visits and hospitalizations were reduced by 6 percent and 8 percent, respectively, and Medicare spending was reduced by 6 percent. Targeting beneficiaries with modifiable high risks and shifting care away from the ED represent viable mechanisms for altering spending within ACOs.”
By way of background, Hsu and his coauthors wrote, “Before the start of the Pioneer ACO program, one of the main hospitals within the Partners HealthCare System, Massachusetts General Hospital, had participated in the Medicare Care Management for High Cost Beneficiaries Demonstration and had developed an intensive care management program. The study ACO extended this program throughout the Partners HealthCare System with no changes to the basic structure of the program, except for centralizing operations. The care management program represented the ACO’s primary strategy for achieving its contractual cost and quality goals under the Pioneer ACO program,” the coauthors noted. “The ACO employed no other contemporaneous, systematic programs. Specifically, the care management program identified beneficiaries who first appeared likely to be at high risk for future spending and then selected the subset of this group whose costs appeared to be modifiable, using information from each beneficiary’s primary care physician. These beneficiaries with elevated but potentially modifiable risks for future spending were eligible for the care management program.”
The study’s authors hypothesized that the rates of ED visits and inpatient admissions would decline over time with greater exposure to the care management program, and also that spending would increase initially as unmet needs were addressed but then decline in response to the program’s effects.
Importantly, the researchers found the following:
> Overall participation in the ACO was associated with lower ED visit rates, both for all ED visits (91 percent of the rates of nonparticipants) and for nonemergency visits (86 percent). As beneficiaries’ length of participation in the ACO increased, the rate of ED visits—both overall and nonemergency visits—declined in stepwise fashion.
> Participants’ rates for hospitalizations were 92 percent of the rates for nonparticipants. Hospitalization rates increased initially after program entry and then declined in a stepwise fashion with increasing length of exposure. The increase was not significant, but the subsequent declines were.
> Overall participation in the ACO was associated with a reduction in Medicare spending of $14 per participant per month (Exhibit 4), a decline of 2 percent. This association was not significantly different from no change, but the magnitude of the decline was comparable to estimates in previous studies. The associations between length of ACO participation and reduced Medicare spending were significant.
> Overall participation in the care management program was associated with a reduction in Medicare spending of $101 per participant per month, a decline of 6 percent. The spending reductions increased with longer program exposure, in a stepwise fashion. All associations were significant except that between spending and program participation in the first six months.
“To our knowledge,” the authors wrote, “this is the first detailed empirical examination of how a Pioneer ACO altered utilization and spending for its aligned Medicare beneficiaries. There were modest overall ACO spending reductions, with magnitudes comparable to those of all ACOs as described in other published reports and generally consistent with the assessment of the Partners ACO by CMS. For example, J. Michael McWilliams and coauthors found a 1.2 percent reduction in spending associated with joining an ACO, David Nyweide and colleagues found a 3.8 percent reduction,3 and the Government Accountability Office21 and we found a 2 percent reduction. L&M Policy Research (as part of its contract with CMS) found a $20 reduction in spending per month,22 compared to $14 in our study.” In brief, they wrote, “Our major overall finding is that participating in an ACO and a care management program lowered utilization and spending. The dose-response pattern further supports the validity of this finding: ED visits decreased relatively quickly, particularly for conditions amenable to outpatient care, while hospitalization rates increased initially before decreasing.”
So, what does all this mean? The results that these researchers found at Mass General were significant. While not earth-shattering, they were consistent over time, and showed a strong link between length of time in the program and results/outcomes. They also, as noted in the paragraph above, were consonant with the results of similar other studies. What’s more, I found it interesting how inpatient hospitalization rates initially rose for ACO participants, then consistently fell after that. Reflecting on some of the process elements involved in care management programs in ACO organizations, it is likely that the initial rise in hospitalizations reflects the fact that care managers and clinicians probably uncovered some previously undiagnosed clinical situations or unmet patient care needs, which were then taken care of—which, of course, is one of the things that care management should do.
What’s more, it should be noted that these researchers did their meta-analysis using data from 2009 through 2014; indeed, the data analyzed was from Mass General’s participation in the Medicare Care Management for High Cost Beneficiaries Demonstration. One could be virtually certain that care management strategies have advanced since 2014 at that hospital organization.
Further, one of the great things that ACO-based care management work can do almost immediately is to better site care. As the authors wrote, “There were sizable reductions in overall ED visits soon after program entry, particularly for conditions amenable to outpatient care.” In other words, working on appropriately reducing ED visits turned out at Mass General to be, as it has turned out to be in so many other patient care organizations, proverbial “low-hanging fruit.”
Interestingly, the authors noted, “The reductions in hospitalization rates were associated with being in the program for a longer period of time but not with brief exposures to the program, as we originally hypothesized. Overall, this study’s findings on the effects of care management were consistent with those of the Medicare Care Management for High Cost Beneficiaries Demonstration, which was the forerunner of the program we analyzed.”
As the authors noted in the conclusion to their article, “The United States is in the midst of a large national experiment in which changes in payment policy are intended to alter the health care system and thereby reduce medical spending growth. Early findings (here and in the literature) suggest that ACOs can generate modest spending reductions, relative to what would have been spent without ACOs. This study provides some evidence of how one large and successful Pioneer ACO appears to have achieved its stated savings—through an integrated care management program with narrowly targeted beneficiaries. Overall, our findings provide evidence of the effects of payment system changes that are still ongoing, while also demonstrating the importance of giving the changes time to take hold and show results over the long term.”
From my perspective, this study validated so much that is being learned about what ACO-based care management can do. Going forward, I would love for researchers to study the care management processes of the leading ACOs nationwide, based on the most advanced strategies and techniques, particularly those that involve continuous clinical performance improvement work that incorporates a continuous feedback loop involving data collection, data analysis, the sharing of data with clinician leaders and frontline clinicians in order to make changes in clinical decision support, clinician documentation, care delivery, care management, and patient and family engagement—and for researchers to look at how the leveraging of data and data analytics for those purposes might be and should be improving both care delivery and management processes, and outcomes.
I also believe that the modest amount of savings seen in the demonstration project—6 percent—was and is just the beginning for organizations like Mass General/Partners. The kinds of changes involved in that organization’s initial work are no doubt being improved on even now.
So, as the leaders of patient care organizations push forward into care management within ACO frameworks, we can expect to see improvements across the board in both clinical and financial outcomes. And more studies like this one in Health Affairs should provide encouragement to all those in the trenches making all of this happen.
