Achieving financial success on the total cost of care takes time, but the benefits of accountable care organizations are not limited to shared savings, according to a report published in the American Journal of Managed Care.
Authors Farzad Mostashari, MD, and Travis Broome based their findings on running their own physician-led ACO organization.
Aledade, formed in 2014, has ACOs in New York, Delaware, Maryland, Arkansas, West Virginia, Tennessee, Mississippi, Florida, Louisiana, Virginia, and Kansas.
Aledade ACOs have successfully increased primary care utilization and revenue, decreased lab and imaging costs, and decreased emergency department and hospital utilization and readmission, according to the authors.
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However, Medicare Shared Savings ACOs present a challenge to providers, particularly those in independent practices, they said.
Much of the challenge is in the implementation of health information technology.
Also, many ACOs have seen millions of dollars of savings evaporate due to the downward risk adjustment feature of MSSP, in which risk adjustment can decrease the benchmark, but never increase it.
Physician-led ACOs also need to pay particular attention to specialist costs. In particular, specialist practices that have been reclassified as hospital outpatient settings can double the cost to Medicare for visits and procedures.
"Aledade has the resources to understand and accommodate to these factors, but many ACOs do not," the authors said. "Overall, we have learned that given the right support and incentives, independent primary care practices can deliver better outcomes to patients, boost quality across the healthcare system, and lower costs."
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Based on CMS data for 2015, two Aledade-initiated ACOs with practices in Maryland, New York, and Arkansas, were in the 98th percentile of quality scores across all 327 ACOs that began in 2012 to 2014. The ACOs essentially broke even, with zero percent savings and zero cost increase.
The Delaware ACO quality scores were in the 88th percentile, with a calculated cost increase of 2.5 percent.
In the MSSP Track 1 program, Aledade worked with practices to increase their availability and access to patients and to actively reach out to patients who had not been seen recently for annual wellness visits.
Total primary care services received by their patients increased slightly, by 5 percent, in the Delaware ACO, compared with national fee-for-service trends.
The ACOs were able to increase the number of patients attributed to the groups. They minimized the rate of patient "churn," in which accountability for a patient's care shifts between primary care practices. The increase in Delaware was 15 percent, versus 2 percent for the average MSSP ACO.
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Additionally, retention was high, with 87 and 88 percent, respectively, of patients who were preliminarily attributed to the ACO being continuously enrolled by the end of 2015.
Rates increased for aspirin use for patients with ischemic vascular disease, screening and follow up for elevated blood pressure, and tobacco use screening and cessation.
The independent primary care practices decreased emergency department visits by being more available and accessible to their patients and educating them about appropriate ED use, the authors said.
They increased contact with their patients after discharge, sometimes with the active help of hospitals and sometimes despite its absence, they said, and substantially reduced readmissions and acute hospital utilization.
Overall, CMS programs have shown some mixed results, from the lack of savings in the Comprehensive Primary Care demonstration, to the dropouts from the Pioneer ACO program and underwhelming results from the first year of the Bundled Payment for Care Improvement Initiative, the authors said.
However, an increasing number of ACOs have generated savings above their minimum savings rate each year, and success appears to increase with the number of years in the program, increasing from 21 percent of first year ACOs, to 42 percent of ACOs that were in their fourth year, according to the AJMC report.
Medicare Shared Savings Program ACOs reported saving more than $400 million in 2015. The Centers for Medicare and Medicaid Services started the program in 2010 to link payments to quality improvement and reduced costs.
The shift from volume to value continues with the implementation of the Medicare Access and CHIP Reauthorization Act, or MACRA, on Jan. 1, 2017. CMS recently released four options to make it easier for providers and physicians to comply with MACRA's quality payment program.
"The movement 'from volume to value' in payments must co-evolve with the delivery system's ability to transform itself to deliver better care at lower cost," the authors said.
Twitter: @SusanJMorse