By focusing on beneficiaries with high risks of future spending and steering care away from emergency departments, one participant in the Pioneer ACO model offered a scalable program which can achieve sustainable decreases in care costs, according to a study in the May 2017 issue of Health Affairs.
Led by John Hsu, MD, MBA, director of the clinical economics and policy analysis program at Massachusetts General Hospital’s Morgan Institute, the study used Medicare claims data from the accountable care organization (ACO) within Partners Healthcare participating in the Pioneer model. The study group included all beneficiaries who were initially aligned with the ACO in 2012 and 2013, along with the population in the care management program, which focused on “chronically ill patients with multiple health issues, such as diabetes, heart failure and depression.”
“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,” Hsu and coauthors wrote. “These beneficiaries with elevated but potentially modifiable risks for future spending were eligible for the care management program.”
Patients were assigned a nurse care manager as a central point of contact. Custom treatment plans involved a larger care team, including a primary care physician, social workers and specialists working with the patient in various settings.
An April study led by Hsu dealing with the same Pioneer ACO found its effectiveness was limited by physician and patient turnover. In this case, however, the care management strategy appeared to have a positive impact.
For example, while the general ACO population had lower rates of ED visits (91 percent of the rates on nonparticipants), the higher risk beneficiaries in the care management program also had lower ED rates, at 94 percent of nonparticipants.
For hospitalizations, care management participants had 92 percent of the rates for nonparticipants. Those rates increased initially, as Hsu and his coauthors expected, and then “declined in a stepwise fashion with increasing length of exposure.”
The program also bent the spending curve. While the overall ACO population saw only a small decline in Medicare spending compared to the general population—2 percent, or $14 less per month—care management participants again outperformed the rest of the ACO, with a reduction of of $101 per participant per month, a decline of 6 percent.
“Two components of the ACO were specifically designed to decrease visits to the ED: giving beneficiaries alternative ways to talk with providers when needed and encouraging beneficiaries to use lower-intensity sites of care, such as urgent care centers, when appropriate,” Hsu and his coauthors wrote. “The subsequent changes were not one-time cost shifts but changes in the site of care and reductions in use rates, which increased the likelihood that these changes will be sustainable over time.”
To Partners, a key finding was how greater reductions were seen the longer a patient stayed in the program.
“Although the effects of payment system changes are still ongoing, this study reinforces the observation that altering care delivery takes time, but is worth the investment,” said Gregg Meyer, MD, MSc, chief clinical officer at Partners.