April 12, 2018 – For Medicare accountable care organizations (ACOs), primary care management of common chronic diseases is an important strategy for providing cost-effective care. But early data suggest that the proportion of visits for chronic conditions delivered by primary care providers (PCPs) varied between ACOs, reports a study in the May issue of Medical Care, published by Wolters Kluwer.
At least in the first year of the largest Medicare ACO program, patients received a large proportion of visits for the management of chronic conditions from specialists, rather than PCPs, according to the new research by Evan Cole, PhD, and colleagues of University of Pittsburgh Graduate School of Public Health. They write, "Many ACOs may underutilize PCPs, and thus could actively shift care to less expensive primary care for potential savings to payers."
ACOs Vary in Care for Chronic Conditions
The researchers analyzed 2013 data on about 3.7 million visits to ACO providers by 1.1 million patients with at least one of eight chronic conditions. Medicare ACOs were initiated in 2012 as part of the Affordable Care Act, most under the Medicare Shared Savings Program (MSSP). In these arrangements, ACO providers have financial incentives to provide care for enrolled patients in the most cost-effective manner.
Access to care provided by PCPs—such as family medicine or internal medicine physicians—is seen as a central component of the Medicare ACO model. The researchers looked at the proportion of PCP versus specialist visits for patients with chronic health problems in 219 ACOs. The study focused on eight common chronic conditions that can be managed "routinely and effectively" by comprehensive primary care: asthma, chronic kidney disease, chronic obstructive pulmonary disease, depression, diabetes, hyperlipidemia (high cholesterol), hypertension (high blood pressure), and rheumatoid arthritis/osteoarthritis.
Among the 219 ACOs, an average 61 percent of chronic condition visits were to PCPs. However, this figure varied across ACOs: from a minimum of 34 to a maximum of 81 percent. There was also substantial variation by condition, as PCPs accounted for most visits for hyperlipidemia, hypertension, and diabetes, but only 17.5 percent of visits for depression.
In adjusted analyses, select demographic and health factors of the ACO's patient population were associated with the proportion of PCP visits. Local health system components also appeared to influence PCP utilization. For example, ACOs in regions with a larger supply of specialists had lower proportions of visits for chronic conditions delivered by PCPs.
The authors also looked at how ACO structural characteristics were associated with the use of PCPs. At the "average" ACO, about half of providers contracted to provide care were PCPs in 2013. However, this figure varied widely, from 13 to 100 percent. The share of visits for chronic conditions made to PCPs were higher at ACOs that had contracted with a higher proportion of PCPs. This relationship was consistent for seven of the eight conditions studied, the exception being depression. Overall, patterns of chronic condition visits were similar for ACO-attributed patients compared to similar non-ACO Medicare beneficiaries.
The new study provides an "early look" at how ACOs used primary care in the early years of the Medicare ACO program. The results show that "some ACOs utilize PCPs to manage chronic conditions to a greater extent than others," Dr. Cole and coauthors write.
The low percentage of PCPs in some Medicare ACOs is likely related to both patient population and organizational factors, the researchers add. Barriers that ACOs may face in shifting visits to PCPs "could include low numbers of PCPs contracted in the ACO, and existing referral patterns and patient relationships with specialists."
Further studies using more recent data will be needed to determine how patterns of care may have shifted since the early years of ACO implementation. Dr. Cole comments, "Related to that line of research, our study shows that ACOs are starting from different places specific to chronic condition visits."
About Medical Care
Rated as one of the top ten journals in health care administration, Medical Care is devoted to all aspects of the administration and delivery of health care. This scholarly journal publishes original, peer-reviewed papers documenting the most current developments in the rapidly changing field of health care. Medical Care provides timely reports on the findings of original investigations into issues related to the research, planning, organization, financing, provision, and evaluation of health services. In addition, numerous special supplementary issues that focus on specialized topics are produced with each volume. Medical Care is the official journal of the Medical Care Section of the American Public Health Association.
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