Changes in Postacute Care in the Medicare Shared Savings Program

Abstract

Importance: Postacute care is thought to be a major source of wasteful spending. The extent to which accountable care organizations (ACOs) can limit postacute care spending has implications for the importance and design of other payment models that include postacute care.

Objective: To assess changes in postacute care spending and use of postacute care associated with provider participation as ACOs in the Medicare Shared Savings Program (MSSP) and the pathways by which they occurred.

Design, setting, and participants: With the use of fee-for-service Medicare claims from a random 20% sample of beneficiaries with 25 544 650 patient-years, 8 395 426 hospital admissions, and 1 595 352 stays in skilled nursing facilities (SNFs) from January 1, 2009, to December 31, 2014, difference-in-difference comparisons of beneficiaries served by ACOs with beneficiaries served by local non-ACO health care professionals (control group) were performed before vs after entry into the MSSP. Differential changes were estimated separately for cohorts of ACOs entering the MSSP in 2012, 2013, and 2014.

Exposures: Patient attribution to an ACO in the MSSP.

Main outcomes and measures: Postacute spending, discharge to a facility, length of SNF stays, readmissions, use of highly rated SNFs, and mortality, adjusted for patient characteristics.

Results: For the 2012 cohort of 114 ACOs, participation in the MSSP was associated with an overall reduction in postacute spending (differential change in 2014 for ACOs vs control group, -$106 per beneficiary [95% CI, -$176 to -$35], or -9.0% of the precontract unadjusted mean of $1172; P = .003) that was driven by differential reductions in acute inpatient care, discharges to facilities rather than home (-0.6 percentage points [95% CI, -1.1 to 0.0], or -2.7% of the unadjusted precontract mean of 22.6%; P = .03), and length of SNF stays (-0.60 days per stay [95% CI, -0.99 to -0.22], or -2.2% of the precontract unadjusted mean of 27.07 days; P = .002). Reductions in use of SNFs and length of stay were largely due to within-hospital or within-SNF changes in care specifically for ACO patients. Participation in the MSSP was associated with smaller significant reductions in SNF spending in 2014 for the 2013 ACO cohort (-$27 per beneficiary [95% CI, -$49 to -$6], or -3.3% of the precontract unadjusted mean of $813; P = .01) but not in the 2013 or 2014 cohort's first year of participation (-$13 per beneficiary [95% CI, -$33 to $6]; P = .19; and $4 per beneficiary [95% CI, -$15 to $24]; P = .66). Estimates were similar for ACOs with and without financial ties to hospitals. Participation in the MSSP was not associated with significant changes in 30-day readmissions, use of highly rated SNFs, or mortality.

Conclusions and relevance: Participation in the MSSP has been associated with significant reductions in postacute spending without ostensible deterioration in quality of care. Spending reductions were more consistent with clinicians working within hospitals and SNFs to influence care for ACO patients than with hospital-wide initiatives by ACOs or use of preferred SNFs.

Figure. Differential Changes in SNF Spending in Post-contract Period by ACO Subgroup and Cohort, Admission-level Analysis

Differential changes in SNF spending in the post-acute period are displayed by ACO subgroup, with more negative estimates indicating greater spending reductions. Displayed subgroup estimates are for the pooled 2013–2014 post-contract period and are provided separately for the 2012 (blue) and 2013 (red) entry cohorts of MSSP ACOs, with the number of ACOs in each subgroup, overall and by cohort, provided in parentheses. Error bars indicate 95% confidence intervals. Overall, differential reductions in SNF spending for independent physician groups (differential change pooled across cohorts and 2013 and 2014: −$114; P=0.02) and organizations financially integrated with hospitals (−$67; P=0.003) were similar (P=0.38 for subgroup difference in estimates).