Medicare ACO Healthcare Spending Recovered to Pre-Pandemic Levels

Between 2019 and 2021, healthcare spending by accountable care organizations (ACOs) in the Medicare Shared Savings Program (MSSP) recovered to pre-pandemic levels but shifted from inpatient to outpatient spending and quality performance declined, a study published in JAMA Network Open found.

Following reduced spending and utilization for non-COVID-19 care in 2020, MSSP generated $1.9 billion in net savings for Medicare in 2020. Net savings decreased slightly to $1.7 billion in 2021, but 81 percent of the 475 ACOs achieved savings.

The study used MSSP public use files from 2019 to 2021 to assess whether spending and utilization recovered to pre-pandemic levels in 2021. Researchers analyzed MSSP’s per capita spending overall and across inpatient, post-acute, and outpatient care, excluding COVID-19-related spending. They also looked at changes in utilization, quality performance, and patient experience measures.

Mean total non-COVID-19 spending recovered to pre-pandemic levels, falling by just 0.9 percent between 2019 and 2021. In contrast, spending declined by 8.5 percent in 2020. However, there was a shift in where the spending was concentrated.

In 2021, mean acute inpatient spending was 12.4 percent lower than pre-pandemic levels, outpatient spending increased to 3.8 percent higher than in 2019, and post-acute spending remained flat.

Mean utilization was lower than pre-pandemic levels for inpatient discharges (-12.6 percent), post-acute discharges (-9.6 percent), and emergency department visits (-8.9 percent). Meanwhile, primary care use returned to baseline figures, declining by only 0.6 percent from 2019 to 2021.

The overall quality performance score in MSSP decreased by an adjusted 5.1 points, falling from 94.7 in 2019 to 90.0 in 2021.

However, screening rates for depression (4.1 percent), falls (1.9 percent), and tobacco use (3.1 percent) increased in 2021. Influenza vaccination rates also grew by 5.6 percent. This suggests that financial accountability may successfully boost preventive care uptake.

Mean blood pressure control was worse in 2021, with rates of controlled high blood pressure declining by 1.9 percent. Poorly controlled diabetes recovered to pre-pandemic levels after increasing by 10.2 percent in 2020.

Patient experience scores decreased across all measures between 2019 and 2021, except for the health promotion and education measure. Stewardship of patient resources (-5.7 percent), access to specialists (-3.5 percent), and health and functional status (-2.9 percent) saw the steepest declines in scores.

Timely care and share decision-making scores also fell, which may reflect system challenges with managing the rebound in outpatient utilization amid workforce shortages and burned-out clinicians, researchers said.

Despite the mean quality performance score dropping, 99 percent of ACOs met the quality threshold for shared savings eligibility.

“Moving forward, the exclusion of COVID-19-related care from financial accountability should be revisited as endemicity takes hold, utilization patterns shift, and high-value COVID-19 care becomes a reasonable objective,” the study concluded.