Capsule Commentary on Navathe, et al., Do Changes in Post-acute Care Use at Hospitals Participating in an Accountable Care Organization Spillover to all Medicare Beneficiaries? 1,2,3 Michael L. Barnett, MD, MS 1 2 Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA; Department of Medicine, Harvard Medical School, Boston, MA, USA. J Gen Intern Med 33(6):943 This important evidence from Navathe and colleagues sup- DOI: 10.1007/s11606-018-4431-9 ports the concept that the financial incentives in the ACO © Society of General Internal Medicine 2018 program are too weak to generate program-wide changes in care delivery. Together with evidence of modest savings 2–4 among ACO-attributed patients in the MSSP, these results imply that hospitals are narrowly responding to ACO incen- tives to largely target patients they are financially responsible his careful analysis by Navathe and colleagues examines for. It is probably unrealistic to expect system-wide delivery a crucial question in health care policy: how does post- reform from payment changes that only affect small slices of acute care (PAC) use respond to new payment incentives? The 5 hospitals’ or individual providers’ patients. Though the ACO investigators explored this question in Medicare’saccountable model has promise, this study reinforces that their current care organization (ACO) payment model, as implemented in implementation lacks the teeth necessary to create true reform. the Medicare Shared Savings Program (MSSP) from 2012– 2013. Early research has shown that the modest savings achieved so far in the MSSP have been concentrated in re- Corresponding Author: Michael Barnett, MD, MS; Department of 2,3 duced PAC spending. However, a key methodological issue Health Policy and Management Harvard T.H. Chan School of Public Health, Boston, MA, USA (e-mail: firstname.lastname@example.org). is that these analyses have focused exclusively on ACO- attributed patients. In general, only a minority of admitted Medicare patients Compliance with ethical standards: will generally be attributed to a hospital’s ACO. Therefore, it Conflict of interest: The author declares that he does not have a is an open question how hospitals would respond to ACO conflict of interest. incentives affecting some patients but not others. Optimisti- cally, ACO incentives could spur development of hospital- wide programs to improve the value of care delivery. On the REFERENCES other hand, hospitals could instead narrowly focus cost sav- 1. Navathe AS, Bain AM, Werner RM. Do changes in post-acute care use at ings measures on their ACO patients, ignoring others. hospitals participating in an accountable care organization spillover to all Medicare beneficiaries? J Gen Intern Med 2018 https://doi.org/10.1007/ Using a robust observational study design to control for s11606-018-4368-z selection bias among patients and hospitals treated in ACOs, 2. McWilliams JM, Hatfield LA, Chernew ME, Landon BE, Schwartz AL. Early Performance of Accountable Care Organizations in Medicare. N Engl Navathe and colleagues found no evidence that ACO partici- J Med 2016;374(24):2357–66. pation changed the likelihood of patients’ discharge to PAC 3. McWilliams JM, Gilstrap LG, Stevenson DG, Chernew ME, Huskamp vs. control hospitals. There was also little impact in length of HA, Grabowski DC. Changes in Postacute Care in the Medicare Shared Savings Program. JAMA Intern Med 2017 stay for patients discharged to PAC. There were differential 4. McWilliams JM. Changes in Medicare Shared Savings Program Savings reductions in PAC payments to skilled nursing facilities and From 2013 to 2014. JAMA 2016;316(16):1711–3. 5. Landon BE. Tipping the Scale — The Norms Hypothesis and Primary Care inpatient rehabilitation facilities, but these estimates did not Physician Behavior. N Engl J Med 2017;376(9):810–1. reach statistical significance. Published online April 9, 2018
Journal of General Internal Medicine – Springer Journals
Published: Apr 9, 2018
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