Collective Reform Program Participation Did Not Improve Health Outcomes

Collective participation in delivery system and payment reform programs, including accountable care organizations (ACOs), was not generally associated with improved health services outcomes in primary care settings, according to a study published in JAMA Health Forum.

Policymakers have implemented several reform programs to improve primary care delivery in healthcare systems. The CMS Meaningful Use (MU) incentive program focuses on practice infrastructure and requires providers to include patient health data in the EHR, including allergies, smoking status, and other health issues.

The National Committee for Quality Assurance Patient-Centered Medical Home (PCMH) program prioritizes and recognizes medical practices that promote care coordination. Other programs focus on reimbursement and providing value-based care to patients, such as accountable care organizations like the Medicare Shared Savings Program (MSSP).

Policymakers said they hoped these reform approaches would generate collaboration, as they each focus on a different aspect of care delivery. However, the organizers implemented and operated the programs separately; therefore, the program requirements and goals may not be sufficiently aligned.

To understand if provider participation in one or multiple reform programs helped improve primary care outcomes, researchers analyzed data from the Medicare Provider Analysis and Review (MEDPAR), Medicare outpatient files, and carrier claims files. They focused on Medicare fee-for-service (FFS) beneficiaries assigned to a primary care organization in 2009, 2010, and from 2015 to 2017.

The study included data from 47,8000 primary care organizations and around 5.6 million Medicare beneficiaries.

Reform program participation was not exceptionally high among the primary care organizations, but meaningful use had the highest participation out of the three. Around 23 percent of practices participated in MU for one to two years, with an additional 36.9 percent participating for three to six years.

Seven percent of organizations participated in MSSP for one to two years, and 14.7 percent participated for three to six years. Patient-centered medical home models had the lowest participation rates, with 1.2 percent of primary care organizations involved for one to two years and 1.4 percent for three to six years.

Participation in all three programs was only associated with better performance for diabetes guideline adherence, the study found. Primary care organizations that participated in MU, PCMH, and MSSP saw a corresponding 0.05 increase in the number of measures met.

Organizations that participated in only MU and PCMH saw slightly higher diabetes guideline adherence, while stand-alone participation in the two programs was also associated with increased adherence. However, MSSP participation was not associated with higher diabetes guidelines adherence.

Program participation was not associated with any change in all-cause hospital utilization, according to the study. However, organizations that participated in MSSP alone and MU and MSSP saw a lower probability of ambulatory care sensitive (ACS) admissions per beneficiary per year.

Finally, researchers looked at whether reform participation was associated with reduced annual Medicare spending.

Organizations that participated in MU and MSSP saw $33.89 lower spending per beneficiary per year, indicating a savings of 0.51 percent in one year. Stand-alone MSSP participation was associated with $37.04 lower spending per beneficiary per year or a savings of 0.55 percent.

Joint MU and MSSP participation and stand-alone MSSP participation were both associated with lower skilled nursing facility spending as well.

Additionally, a combination of program participation led to lower acute care spending. Organizations that participated in all three programs saw a $58.94 reduction in spending per beneficiary per year. Participants in MU alone, MU and MSSP, and PCMH and MSSP also saw reduced acute care spending.

Although participation in all three reform programs improved certain outcomes, single program participation was more heavily associated with better performance, researchers said.

“Collectively, these findings suggest that there is no systematic program synergy, at least not with the outcomes examined,” the study stated. “We suspect that this is because of their complex requirements and experimental nature, particularly MU and MSSP, which were novel in their designs and foci.”

In order to improve primary care health service outcomes, policymakers should adjust the reform programs so that their goals and requirements align with one another, the researchers suggested. This way, participation in all the reform programs will lead to better performance and improved primary care engagement.