[PPT] - THE IMPACT OF ACO PARTICIPATION ON POST-ACUTE CARE UTILIZATION AMONG PowerPoint Presentation

SLIDE 1

THE IMPACT OF ACO PARTICIPATION ON POST-ACUTE CARE UTILIZATION AMONG MEDICARE BENEFICIARIES

Department of Health Care Management The Leonard Davis Institute of Health Economics University of Pennsylvania School of Medicine

Amol Navathe, MD, PhD Academy Health Annual Research Meeting June 26, 2017

Amol Navathe MD, PhD – not for reproduction without permission

SLIDE 2

2

Medicare Post Acute Care (PAC) spending is

BIG ($60B in 2015)

PAC is the largest driver of spending variation

in Medicare

Medicare has introduced alternate payment

models such as bundled payment and ACOs, in part, to reduce unwarranted variation in PAC

Background

SLIDE 3

3

Early evidence suggests ACOs achieved

small decreases in institutional PAC use and spending for beneficiaries attributed to ACOs

However, only 15% of beneficiaries are

attributed to ACOs

Study Motivation

Do the effects of ACOs spill over to all beneficiaries?

SLIDE 4

4

To evaluate whether hospitals participating

in the Medicare Shared Savings Program (MSSP) experienced hospital-wide changes in PAC use and Medicare spending

Objective

SLIDE 5

5

Design: Difference-in-differences study

comparing changes in PAC use and Medicare spending among patients admitted to ACO hospitals versus changes at non-ACO hospitals

Setting: National sample of hospitals and

Medicare-certified PAC providers between 2010-2013

Methods

15,276 SNFs
1,216 IRFs
9,651 HHAs
233 MSSP ACO hospitals

initiating in 3 waves

3,103 non-ACO

hospitals

SLIDE 6

6

Study Population: 11,683,573 Medicare

beneficiaries experiencing 26,503,086 hospital admissions

Outcomes: Proportion of discharges and

Medicare payments to SNFs, IRFs, and HHAs

Sub-groups: 6 of the most frequent conditions

for PAC use and highest-severity

Methods

SLIDE 7

7

Sample Characteristics

ACO Non-ACO

Unique Beneficiaries 1,290,648 10,392,925 Total Number of admissions 2,933,534 23,569,552 Age 79.2 79.0 Male 42% 42% Black 8% 10% Elixhauser comorbidity score 9.0 8.8 Primary Diagnosis Lower extremity joint replacement 5.0% 5.1% Heart Failure 5.0% 5.2% Pneumonia 3.7% 4.1% 30-day Readmission Rate 16.3% 16.2% 30-day Mortality Rate 4.7% 4.9%

SLIDE 8

8

Hospital and Market Characteristics

Hospital Number of beds Teaching status Ownership PAC in same hospital ACO HHA SNF IRF Market Number of ACOs ACO hospital admission share Number of PACs SNF IRF HHA Herfindahl-Hirschman index (HHI)

SLIDE 9

9

0% 10% 20% 30% 40% 50% 60% 70%

Percent of Discharges Quarter

Non-ACO Hospitals ACO Wave 1 Hospitals ACO Wave 2 Hospitals ACO Wave 3 Hospitals

Unadjusted Trends in Institutional PAC (SNF/IRF) Use

SLIDE 10

10

5%
4%
3%
2%
1%

0% 1% 2% 3% 4% 5%

Change in Probability

Risk-adjusted Change in Probability of Discharge to Institutional PAC from ACO vs. Non-ACO Hospital

All High- Risk Hip Fx Joints CABG CHF COPD AMI

Patient Population

SLIDE 11

11

5%
4%
3%
2%
1%

0% 1% 2% 3% 4% 5%

Change in Probability IRF HHA SNF

Risk-adjusted Change in Probability of Discharge to Any PAC from ACOs with Co-Participating SNF, IRF, HHA

SLIDE 12

12

$400
$300
$200
$100

$0 $100 $200 $300 $400

Change in PAC Payments IRF HHA SNF

Risk-adjusted Change in Medicare Payments by PAC type from ACOs vs. non-ACOs

SLIDE 13

13

Hospital participation in an ACO did not

result in changes in PAC utilization or payments – statistical zeros

This was true even when considering high

PAC-use conditions like joint replacement and heart failure

Inclusion of hospitals and PAC providers in

the same ACO did not alter the effect

Conclusions

SLIDE 14

14

ACO hospitals may differ from non-ACO

hospitals in unobservable ways because the program is voluntary

We focus on a sub-set of ACOs that include a

hospital

Use of administrative data may limit risk-

adjustment

Limitations

SLIDE 15

15

ACO hospitals are not redesigning PAC referral

patterns hospital-wide, but selecting for attributed beneficiaries

Integration of hospitals and PAC providers

within ACOs may not be enough

This suggests a certain degree of caution on

the expectations for ACO programs to curb high PAC use and variation nationwide

Implications

SLIDE 16

16

Co-investigators:
Rachel Werner, MD, PhD, University of

Pennsylvania

Alex Bain, BS, University of Pennsylvania
Funders:
AHRQ and NIA

Acknowledgements

SLIDE 17

17

amol@wharton.upenn.edu

Questions?

SLIDE 18

18

APPENDIX

SLIDE 19

19

Hospital and Market Characteristics

Hospital (n = 3,336) ACO Hospitals (N=233) Non-ACO Hospitals (N=3103)

No. certified beds, mean (SD)

356 (279) 222 (220) RB ratio (Teaching status) (%) Non-teaching (RB ratio = 0) 65.67 81.31 Minor teaching (RB ratio < 0.25) 21.89 13.66 Major teaching (RB ratio ≥ 0.25) 12.45 4.99 Ownership (%) Government 10.30 18.34 Not for profit 82.40 58.06 For profit 7.30 23.60 PAC in same hospital ACO (%) HHA 25.32 NA SNF 13.73 NA IRF 51.93 NA Market (n = 307)b With ACO (N=95) Without ACO (N=212)

No. ACOs in market

1.38 (0.74) N/A ACO hospital admission in market (%) 32.38 (22.10) N/A

No. PACs in market (%)

SNF 73.43 (63.86) 39.15 (35.81) IRF 5.91 (6.01) 3.09 (3.36) HHA 51.69 (78.74) 22.36 (27.04) HHI, mean (SD)c\ Hospital 2171.96 (1844.53) 3185.14 (2022.89) Aggregate PAC 392.31 (275.00) 622.50 (423.50)

SLIDE 20

20

0% 10% 20% 30% 40% 50% 60% 70%

Percent of Discharges Quarter

Non-ACO Hospitals ACO Wave 1 Hospitals ACO Wave 2 Hospitals ACO Wave 3 Hospitals

Unadjusted Trends in Home Health Agency Use

SLIDE 21

21

5%
4%
3%
2%
1%

0% 1% 2% 3% 4% 5%

Change in Probability

Risk-adjusted Change in Probability of Discharge to Any PAC from ACO vs. Non-ACO Hospital

All High-Risk Hip Fx Joints CABG CHF COPD AMI

Patient Population

SLIDE 22

22

Change in Probability of Discharge to Post Acute Care from ACO Hospital, by Location

Unconditional Restricted to DRG groupb Unrestricted (n=25,528,375) High Risk, (n=5,173,403) Joint Replacement (n=1,275,791) Hip and Femur Fracture (n=408,487) Coronary Artery Bypass (n=165,139) Heart Failure (n=1,319,929) Chronic Lung Disease (n=1,101,764) Acute Myocardial Infarction (n=996,440) Discharge to PAC (95% CI) 0.000 (-0.003, 0.003)

0.003 (-0.007,

0.002)

0.009 (-0.018,

0.001)

0.005 (-0.011,

0.002) 0.006 (-0.018, 0.030)

0.002 (-0.011,

0.006)

0.005 (-0.014,

0.003)

0.001 (-0.001,

0.007) p-value 0.89 0.23 0.08 0.15 0.61 0.58 0.22 0.83 Discharge to SNF (95% CI) 0.000 (-0.003, 0.002)

0.004 (-0.008,

0.000)

0.006 (-0.019,

0.006)

0.004 (-0.010,

0.011) 0.002 (-0.019, 0.022)

0.002 (-0.009,

0.005)

0.005 (-0.012,

0.001)

0.003 (-0.008,

0.003) p-value 0.73 0.06 0.33 0.58 0.87 0.59 0.11 0.39 Discharge to IRF (95% CI) 0.000 (-0.002, 0.002) 0.000 (-0.002, 0.002) 0.001 (-0.007, 0.010) 0.0006 (-0.011, 0.012) 0.009 (-0.006, 0.023) 0.001 (-0.001, 0.003) 0.000 (-0.002, 0.001) 0.002 (0.000, 0.003) p-value 0.96 0.69 0.80 0.92 0.25 0.19 0.73 0.08 Discharge to HHA (95% CI) 0.001 (-0.002, 0.003) 0.001 (-0.002, 0.004)

0.004 (-0.017,

0.009)

0.001 (-0.006,

0.003)

0.004 (-0.010,

0.031)

0.002 (-0.008,

0.005) 0.000 (-0.006, 0.007) 0.000 (-0.006, 0.006) p-value 0.57 0.68 0.58 0.53 0.72 0.60 0.94 0.99 Conditional on Discharge to PAC Restricted to DRG group Unrestricted (n=10,218,784) High Risk (n=2,429,937) Joint Replacement (n=1,008,231) Hip and Femur Fracture (n=370,299) Coronary Artery Bypass (n=101,759) Heart Failure (n=513,743) Chronic Lung Disease (n=313,249) Acute Myocardial Infarction (n=220,427) Discharge to SNF (95% CI) 0.000 (-0.005, 0.005)

0.003 (-0.009,

0.003)

0.002 (-0.016,

0.013) 0.000 (-0.014, 0.014) 0.006 (-0.019, 0.032) 0.000 (-0.012, 0.012) 0.000 (-0.015, 0.015)

0.004 (-0.021,

0.013) p-value 0.98 0.32 0.80 0.99 0.63 0.99 1.00 0.64 Discharge to IRF (95% CI) 0.000 (-0.034, 0.004) 0.001 (-0.003, 0.005) 0.002 (-0.009, 0.013) 0.001 (-0.012, 0.014) 0.009 (-0.013, 0.030) 0.003 (-0.002, 0.007)

0.001 (-0.005,

0.004) 0.008 (-0.001, 0.014) p-value 0.92 0.50 0.66 0.87 0.43 0.20 0.82 0.03 Discharge to HHA (95% CI) 0.000 (-0.005, 0.004) 0.002 (-0.004, 0.007)

0.001 (-0.015,

0.013)

0.001 (-0.006,

0.004)

0.015 (-0.040,

0.010)

0.003 (-0.015,

0.009) 0.001 (-0.015, 0.016)

0.004 (-0.020,

0.013) p-value 0.96 0.54 0.94 0.66 0.24 0.63 0.94 0.67

SLIDE 23

23

Risk-adjusted Change in Probability of Discharge from ACOs with Co-Participating SNF, IRF, HHA

SLIDE 24

24

10 20 30 40 50 60 70 Discharge Percent (%) Quarter

Percent Discharge to Home

Non-ACO Hospitals ACO Wave 1 Hospitals ACO Wave 2 Hospitals ACO Wave 3 Hospitals

SLIDE 25

25

10 20 30 40 50 60 70 Discharge Percent (%) Quarter

Percent Discharge to SNF

Non-ACO Hospitals ACO Wave 1 Hospitals ACO Wave 2 Hospitals ACO Wave 3 Hospitals

SLIDE 26

26

10 20 30 40 50 60 70 Discharge Percent (%) Quarter

Percent Discharge to IRF

Non-ACO Hospitals ACO Wave 1 Hospitals ACO Wave 2 Hospitals ACO Wave 3 Hospitals

SLIDE 27

27

10 20 30 40 50 60 70 Discharge Percent (%) Quarter

Percent Discharge to SNF Conditional on PAC Discharge

Non-ACO Hospitals ACO Wave 1 Hospitals ACO Wave 2 Hospitals ACO Wave 3 Hospitals

SLIDE 28

28

10 20 30 40 50 60 70 Discharge Percent (%) Quarter

Percent Discharge to IRF Conditional on PAC Discharge

Non-ACO Hospitals ACO Wave 1 Hospitals ACO Wave 2 Hospitals ACO Wave 3 Hospitals

SLIDE 29

29

10 20 30 40 50 60 70 Discharge Percent (%) Quarter

Percent Discharge to HHA Conditional on PAC Discharge

Non-ACO Hospitals ACO Wave 1 Hospitals ACO Wave 2 Hospitals ACO Wave 3 Hospitals

SLIDE 30

30

5%
4%
3%
2%
1%

0% 1% 2% 3% 4% 5%

Change in Probability

Change in Probability of Discharge to SNF from ACO Hospital Conditional on PAC Discharge

Patient Population

SLIDE 31

31

Change in Medicare PAC Payments and Length of Stay, by PAC Type

Payment by PAC Type ($) PAC Length of Stay (days) SNF (95% CI)

108.33 (-228.23, 11.56)

0.027 (-0.508, 0.561) p-value 0.08 0.92 IRF (95% CI)

119.46 (-304.87, 65.96)
0.071

p-value 0.21 0.34 HHA (95% CI) 1.65 (-24.22, 27.53) 0.018 (-0.214, 0.073) p-value 0.90 0.86 Any PAC (95% CI)

130.41 (-24.22, 27.53)
0.008 (-0.395, 0.379)

p-value 0.03 0.97