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Association Between Specialist Office Visits and Health Expenditures in Accountable Care Organizations.
JAMA Netw Open 2019; 2(7):e196796JN

Abstract

Importance

Accountable care organizations (ACOs) aim to control health expenditures while improving quality of care. Primary care has been emphasized as a means to reduce spending, but little is known about the implications of using specialists for achieving this ACO objective.

Objective

To examine the association between ACO-beneficiary office visits conducted by specialists and the cost and utilization outcomes of those visits.

Design, Setting, and Participants

This cross-sectional study obtained data on 620 distinct ACOs from the Centers for Medicare & Medicaid Services Shared Savings Program Accountable Care Organizations Public-Use Files from April 1, 2012, to September 30, 2017. Generalized estimating equation models were used for analysis of ACOs, adjusting for ACO-beneficiary health status, Medicare enrollment groups, ACO size, and proportion of participating specialists.

Exposures

Specialist encounter proportion, the percentage of office visits provided by a specialist, was categorized into 7 discrete groups: less than 35%, 35% to less than 40%, 40% to less than 45% (reference group), 45% to less than 50%, 50% to less than 55%, 55% to less than 60%, and 60% or greater.

Main Outcomes and Measures

The primary outcome was total expenditures (given in US dollars) per assigned beneficiary person-year. The secondary outcomes were total numbers of emergency department visits, hospital discharges, skilled nursing facility discharges, and magnetic resonance imaging orders.

Results

In total, the data set included 1836 ACO-year (number of participation years per ACO) observations for 620 distinct ACOs. Those ACOs with a specialist encounter proportion of 40% to less than 45% had $1129 (95% CI, $445-$1814) lower per-beneficiary person-year spending than did ACOs in the lowest specialist encounter proportion group and had $752 (95% CI, $115-$1389) lower per-beneficiary person-year spending compared with ACOs in the highest specialist encounter proportion group. Monotonic decreases in emergency department visits, hospital discharges, and skilled nursing facility discharges were observed with increasing specialist encounter proportion. Conversely, monotonic increases in magnetic resonance imaging volume discharges were observed with increasing specialist encounter proportion.

Conclusions and Relevance

These findings suggest that an ACO's ability to reduce spending may require sufficient involvement in care processes from specialists, who seem to complement the intrinsic primary care approach in ACOs.

Authors+Show Affiliations

Department of Health Policy and Promotion, University of Massachusetts Amherst, Amherst.Department of Health Policy and Promotion, University of Massachusetts Amherst, Amherst.Department of Health Policy and Promotion, University of Massachusetts Amherst, Amherst.Department of Health Policy and Promotion, University of Massachusetts Amherst, Amherst.

Pub Type(s)

Journal Article

Language

eng

PubMed ID

31290989

Citation

Shetty, Vishal Anand, et al. "Association Between Specialist Office Visits and Health Expenditures in Accountable Care Organizations." JAMA Network Open, vol. 2, no. 7, 2019, pp. e196796.
Shetty VA, Balzer LB, Geissler KH, et al. Association Between Specialist Office Visits and Health Expenditures in Accountable Care Organizations. JAMA Netw Open. 2019;2(7):e196796.
Shetty, V. A., Balzer, L. B., Geissler, K. H., & Chin, D. L. (2019). Association Between Specialist Office Visits and Health Expenditures in Accountable Care Organizations. JAMA Network Open, 2(7), pp. e196796. doi:10.1001/jamanetworkopen.2019.6796.
Shetty VA, et al. Association Between Specialist Office Visits and Health Expenditures in Accountable Care Organizations. JAMA Netw Open. 2019 Jul 3;2(7):e196796. PubMed PMID: 31290989.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Association Between Specialist Office Visits and Health Expenditures in Accountable Care Organizations. AU - Shetty,Vishal Anand, AU - Balzer,Laura B, AU - Geissler,Kimberley H, AU - Chin,David L, Y1 - 2019/07/03/ PY - 2019/7/11/entrez PY - 2019/7/11/pubmed PY - 2019/7/11/medline SP - e196796 EP - e196796 JF - JAMA network open JO - JAMA Netw Open VL - 2 IS - 7 N2 - Importance: Accountable care organizations (ACOs) aim to control health expenditures while improving quality of care. Primary care has been emphasized as a means to reduce spending, but little is known about the implications of using specialists for achieving this ACO objective. Objective: To examine the association between ACO-beneficiary office visits conducted by specialists and the cost and utilization outcomes of those visits. Design, Setting, and Participants: This cross-sectional study obtained data on 620 distinct ACOs from the Centers for Medicare & Medicaid Services Shared Savings Program Accountable Care Organizations Public-Use Files from April 1, 2012, to September 30, 2017. Generalized estimating equation models were used for analysis of ACOs, adjusting for ACO-beneficiary health status, Medicare enrollment groups, ACO size, and proportion of participating specialists. Exposures: Specialist encounter proportion, the percentage of office visits provided by a specialist, was categorized into 7 discrete groups: less than 35%, 35% to less than 40%, 40% to less than 45% (reference group), 45% to less than 50%, 50% to less than 55%, 55% to less than 60%, and 60% or greater. Main Outcomes and Measures: The primary outcome was total expenditures (given in US dollars) per assigned beneficiary person-year. The secondary outcomes were total numbers of emergency department visits, hospital discharges, skilled nursing facility discharges, and magnetic resonance imaging orders. Results: In total, the data set included 1836 ACO-year (number of participation years per ACO) observations for 620 distinct ACOs. Those ACOs with a specialist encounter proportion of 40% to less than 45% had $1129 (95% CI, $445-$1814) lower per-beneficiary person-year spending than did ACOs in the lowest specialist encounter proportion group and had $752 (95% CI, $115-$1389) lower per-beneficiary person-year spending compared with ACOs in the highest specialist encounter proportion group. Monotonic decreases in emergency department visits, hospital discharges, and skilled nursing facility discharges were observed with increasing specialist encounter proportion. Conversely, monotonic increases in magnetic resonance imaging volume discharges were observed with increasing specialist encounter proportion. Conclusions and Relevance: These findings suggest that an ACO's ability to reduce spending may require sufficient involvement in care processes from specialists, who seem to complement the intrinsic primary care approach in ACOs. SN - 2574-3805 UR - https://www.unboundmedicine.com/medline/citation/31290989/Association_Between_Specialist_Office_Visits_and_Health_Expenditures_in_Accountable_Care_Organizations L2 - https://jamanetwork.com/journals/jamanetworkopen/fullarticle/10.1001/jamanetworkopen.2019.6796 DB - PRIME DP - Unbound Medicine ER -