The answer is unclear and depends on the degree to which ACOs—formed by various combinations of hospitals, health systems and medical groups—improve healthcare's inconsistent quality and lower its painfully high costs. The results are mixed. The Pioneer ACOs lowered Medicare spending by $817 million during the first two years—although some saw costs go up instead of down—and quality scores vary widely.
Accountable care offers providers incentives to meet quality and financial targets. The incentives structures differ between the two Medicare ACO programs, the Pioneer model and the Shared Savings Program. Pioneers agreed to stronger incentives with potential for financial penalties as well as bonuses. The chance of losing money prompted several Pioneers to drop out.
Nine exited after the first year and of those, eight had negative financial performance, as did three of the four that dropped out after the second year. Financial performance is measured by whether ACOs' patient care costs is lower or higher than Medicare's target. Bonuses go to those with savings. ACOs with costs above target face penalties.
“There's mixed news on the savings,” Kocot said. Among those that finished the first two years, 14 of the 20 ACOs with final numbers slowed spending and aggregate scores for quality improved in the second year. “We're encouraged that quality seems to be increasing,” he said. Quality improved significantly for treatment of chronically ill patients, increasing 10%, a Brookings analysis shows. Pioneers were scored against benchmarks for quality performance starting in the second year. The first year, Pioneers were simply required to supply the CMS with their results.
“They seem to be managing the conditions of their populations,” Kocot said. “That's kind of what we were hoping they would rise to the occasion to do.”
Indeed, a dozen Pioneers ranked in the nation's top decile for performance on a composite of five diabetes-care quality measures in the second year. Notably, Pioneers with poor financial performance were far more likely to rank among the nation's top performers on diabetes management, including Beacon Health, which saw spending accelerate 5.6% above target for penalty of $2.89 million.
The Pioneer with the biggest bonus, the Montefiore ACO in New York, ranked in the top decile for smoking intervention and use of beta blocker therapy, but scored in the 40th percentile nationally for its diabetes management scores. Diabetes management is a new target for improvement, said Dr. Andrew Racine, senior vice president and chief medical officer for Montefiore.
Montefiore will dedicate entire clinic days to diabetic care with primary care, specialists and diabetic educators available to see patients in one location at one time, he said. Racine said that will enable immediate treatment or intervention when providers identify a need, instead of referring patients for future appointments.
Racine said past improvement efforts have shown results. Efforts to increase access to behavioral healthcare increased depression screening rates from 28.4% to 40% in one year. At 40%, Montefiore outperforms eight out of 10 U.S. providers.
The Pioneers' performance on quality scores for avoidable hospital admissions was spotty. Pioneer scores were more likely to rank below the 30th percentile —the minimum threshold required for Pioneers' performance to count toward a financial award—than in the top decile on a measure of avoidable admissions for asthma and chronic obstructive pulmonary disease. Nine ACOs ranked below the 30th percentile nationally. Three scored in the top decile. For a measure of avoidable heart failure admissions, scores for nine Pioneers ranked in the bottom third nationally and none placed in the top decile.
Meanwhile, patients scored Pioneers favorably for access and rated their doctors even more highly. Pioneers performed well when patients were asked whether they could make an appointment when needed and gain access to specialists. Doctors earned high marks for listening to patients and explaining things clearly. Patients asked to rate their doctor overall did so glowingly. Nearly all Pioneers earned top scores for asking patients whether they smoke and offering them help to quit.
The Pioneer participants say the availability of performance data for their peers is crucial. When the numbers were posted, Dr. Dave Krueger, executive director and medical director for Bellin-ThedaCare Healthcare Partners in Wisconsin, immediately contacted Pioneers with strong scores in areas where Bellin-ThedaCare was weaker. It is the first time he has had access to such data. “At least now we can look around and say, 'How do we do this?' ” Krueger said.
Follow Melanie Evans on Twitter: @MHmevans