Out-of-network primary care may be associated with higher per-beneficiary spending in Medicare accountable care organizations (ACOs), reported a recent study published in Health Affairs.
Out-of-network primary care may be associated with higher per beneficiary spending in Medicare accountable care organizations (ACOs), reported a recent study published in Health Affairs.
The effect of ACOs on actual spending has been debated, but it is a point of increasing concern, since Medicare spending is projected to hit $1.7 trillion a year in about 10 years.
The researchers investigated out-of-network care and per beneficiary spending using national Medicare data on 1.6 million patients from 2012 to 2015. The study determined which beneficiaries were attributed to a Medicare Shared Savings Program (MSSP) accountable care organization (ACO) during a given year and included those who had continuous Parts A and B coverage in that year. Then, the researchers used a 2-step process to calculate the proportion of outpatient primary care and specialty care visits delivered out of network.
“Despite great fanfare, MSSP evaluations have demonstrated only modest spending reductions, with significant variation across ACOs in performance. One reason for such variation may be differences in the level of out-of-network care that ACO beneficiaries receive,” the study noted. “Unlike beneficiaries in health maintenance organizations, which are allowed to implement explicit mechanisms to incentivize patients to stay in network (for example, requiring referrals and charging higher fees for out-of-network care), beneficiaries assigned to an ACO are free to seek care from whomever they want.”
The results revealed that there was no association between out-of-network specialty care and ACO spending. However, each percentage point increase in receipt of out-of-network primary care was associated with an increase of $10.79 in quarterly total ACO spending per patient, or about $43 annually. Furthermore, after breaking down total spending by place of service, the researchers found that out-of-network primary care was associated with higher spending in outpatient, skilled nursing facility, and emergency department settings, but not inpatient settings.
“These findings highlight the critical role of primary care physicians and suggest that ACOs that are not able to keep primary care services in network are less likely to succeed under current ACO policies. Relatedly, we also found that ACOs with higher levels of out-of-network primary care were also more likely to serve disadvantaged patients, which suggests that current Medicare ACO design may inadvertently exacerbate existing health care disparities,” concluded the authors.
According to the study, the results emphasize the need for policy makers to develop explicit incentives for beneficiaries to seek more of their primary care within network.
Reference
Lin S, Yan P, et al. Out-of-network primary care is associated with higher per beneficiary spending in Medicare ACOs. Health Aff (Millwood). 2020;39(2):310-318. doi: 10.1377/hlthaff.2019.00181.
Looking Back on ISPOR 2024: Hot Policy Topics, Welcome Focus on Employers, and More
May 10th 2024Kimberly Westrich, MA, chief strategy officer of the National Pharmaceutical Council, reflects on the most valuable learnings from the 2024 meeting of ISPOR—The Professional Society for Health Economics and Outcomes Research, including lively discussions of the Inflation Reduction Act and workshops on value assessment.
Read More
CMS Medicare Final Rule: Advancing Benefits, Competition, and Consumer Protection
May 7th 2024On this episode of Managed Care Cast, we're talking with Karen Iapoce, senior director of government products and programs at ZeOmega, about the recent CMS final rule on Medicare Part D and Medicare Advantage.
Listen
Navigating Health Policy in an Election Year: Insights From Dr Dennis Scanlon
April 2nd 2024On this episode of Managed Care Cast, we're talking with Dennis Scanlon, PhD, the editor in chief of The American Journal of Accountable Care®, about prior authorization, price transparency, the impact of health policy on the upcoming election, and more.
Listen
The Senate Finance Committee has introduced bipartisan legislation that proposes using Medicaid and Medicare programs to help prevent and reduce generic drug shortages; US indicators for COVID-19, flu, and respiratory syncytial virus (RSV) declined further last week; findings from a recent study reveal growing disparities in child death rates across racial and ethnic groups.
Read More
Health Equity and Access Weekly Roundup: May 4, 2024
May 4th 2024This week, the Center on Health Equity and Access highlights a variety of gaps that exist in health care, spanning women's health, the rising rate of metabolic disease, and policy for LGBTQ+ and immigrant populations. The consensus among featured experts points to comprehensive care models.
Read More