OBJECTIVES:To examine whether the growth of Medicare Shared Savings Program (MSSP) accountable care organizations (ACOs) and Medicare Advantage (MA) penetration was associated with changes in health care use among commercially insured populations. STUDY DESIGN:Observational study using claims data. METHODS:Using Health Care Cost Institute claims data (2015-2019), we conducted a repeated cross-sectional study of 13,041,197 enrollees aged 55 to 64 years in 50 states and the District of Columbia in employer-sponsored insurance plans of 4 national payers. Linear models estimated relationships between enrollees' health care use and county-level MSSP ACO and MA penetration, controlling for enrollee and market characteristics and county and year fixed effects. Outcomes of interest were enrollees' probability of receiving preventive care services (influenza immunization, breast cancer screening, colorectal cancer screening), having any outpatient emergency department visits, and having any inpatient hospitalization in a year. RESULTS:A majority of counties (72.1%) experienced increases in penetration of MSSP ACOs and MA from 2015 to 2019. Median (IQR) MSSP ACO penetration increased from 5.9% (1.6%-16.9%) to 18.9% (9.3%-31.5%), and median (IQR) MA penetration increased from 19.5% (11.2%-29.3%) to 26.8% (15.9%-36.6%). MSSP ACO and MA penetration was not substantively associated with changes in commercial enrollees' use of preventive care, emergency department, and hospital services. CONCLUSIONS:The expansion of MSSP ACOs and MA was not associated with substantive changes in health care use among commercial enrollees. The lack of spillovers from Medicare to commercial enrollees may stem from misaligned incentives from different payers, indicating the potential importance of multipayer alignment in ongoing payment reforms.

Artificial intelligence (AI) has the potential to transform care delivery by improving health outcomes, patient safety, and the affordability and accessibility of high-quality care. AI will be critical to building an infrastructure capable of caring for an increasingly aging population, utilizing an ever-increasing knowledge of disease and options for precision treatments, and combatting workforce shortages and burnout of medical professionals. However, we are not currently on track to create this future. This is in part because the health data needed to train, test, use, and surveil these tools are generally neither standardized nor accessible. There is also universal concern about the ability to monitor health AI tools for changes in performance as they are implemented in new places, used with diverse populations, and over time as health data may change. The Future of Health (FOH), an international community of senior health care leaders, collaborated with the Duke-Margolis Institute for Health Policy to conduct a literature review, expert convening, and consensus-building exercise around this topic. This commentary summarizes the four priority action areas and recommendations for health care organizations and policymakers across the globe that FOH members identified as important for fully realizing AI’s potential in health care: improving data quality to power AI, building infrastructure to encourage efficient and trustworthy development and evaluations, sharing data for better AI, and providing incentives to accelerate the progress and impact of AI.

Disparities in access to health care are persistent and contribute to poor health outcomes for many populations around the world. Barriers to access are often similar across countries, despite differences in how health systems are structured. Health care leaders can work to address these barriers through bold, evidence-based actions. The Future of Health (FOH), an international community of senior health leaders, collaborated with the Duke-Margolis Institute for Health Policy to identify priority organizational and policy actions needed to improve equitable access to health care through a consensus-building exercise, a targeted literature review, and an expert discussion group. This paper describes four key action areas for health care leaders that FOH members identified as critical to enabling the future of equitable access to health care: ensuring prioritization of and accountability for equitable access to care; establishing comprehensive, organization-wide strategies to address barriers to access; clearly defining and incentivizing improvement on key measures related to reducing disparities in access; and establishing cross-sector partnerships to improve equitable access.

North Carolina Medicaid's Healthy Opportunities Pilots program is the country's first comprehensive program to evaluate the impact of paying community-based organizations to provide eligible Medicaid enrollees with an array of evidence-based services to address four domains of health-related social needs, one of which is housing. Using a mixed-methods approach, we mapped the distribution of severe housing problems and then examined the design and implementation of Healthy Opportunities Pilots housing services in the three program regions. Four cross-cutting implementation and policy themes emerged: accounting for variation in housing resources and needs to address housing insecurity, defining and pricing housing services in Medicaid, engaging diverse stakeholders across sectors to facilitate successful implementation, and developing sustainable financial models for delivery. The lessons learned and actionable insights can help inform the efforts of stakeholders elsewhere, particularly other state Medicaid programs, to design and implement cross-sectoral programs that address housing-related social needs by leveraging multiple policy-based resources. These lessons can also be useful for federal policy makers developing guidance on addressing housing-related needs in Medicaid.

ImportanceFederally qualified health centers (FQHCs) have increasingly participated in the Medicare Shared Savings Program (MSSP) accountable care organizations (ACOs), one of the most widespread value-based programs. Although FQHCs may strengthen ACOs’ ability to provide affordable care to diverse Medicare beneficiaries, evidence on ACOs’ performance by FQHC participation is limited.ObjectivesTo compare beneficiary characteristics, utilization, expenditure, and quality between ACOs with and without FQHC participation and assess changes in ACO performance after including first FQHCs.Design, Setting, and ParticipantsUsing MSSP public use files, this cross-sectional study compared performance of ACOs that always had FQHC participation with ACOs that never had FQHC participation from January 1, 2016, to December 31, 2022, supplemented with staggered difference-in-differences analyses of ACOs’ first-time inclusion of FQHCs on performance measures. Data analysis was performed from December 1, 2023, to February 29, 2024.ExposureParticipation of FQHCs in the MSSP.Main Outcomes and MeasuresMeasures of ACO-assigned beneficiaries, utilization, expenditure, and quality per ACO-year.ResultsAmong 752 ACOs in the descriptive analysis, 140 ACOs always had at least 1 FQHC participant, whereas 612 ACOs never had FQHC participants. Compared with ACOs that never had FQHC participation, those that always had FQHC participation provided care to more socioeconomically disadvantaged beneficiaries (mean [SD] with dual eligibility, 2035.8 [2110.6] vs 1040.9 [1084.2] person-years; with disability, 3341.1 [3474.9] vs 1705.1 [1664.9] person-years; in racial and ethnic minoritized groups, 3690.6 [4118.4] vs 2515.1 [2762.9] person-years), with fewer primary care visits (mean [SD], 9956.6 [1926.3] vs 10 858.8 [2383.4] per 1000 person-years), more emergency department visits (mean [SD], 771.6 [190.9] vs 657.2 [160.0] per 1000 person-years), and lower levels of several quality measures. In the difference-in-differences analysis, 43 ACOs included FQHCs for the first time. Including first FQHCs was associated with increases of 872.9 dual-eligible (95% CI, 345.9-1399.8), 1137.6 disability (95% CI, 390.1-1885.1), and 1350.8 racial and ethnic minority (95% CI, 447.4-2254.1) person-years, with increases in rates of influenza immunization (5.9 percentage points [pp]; 95% CI, 1.4-10.4 pp), tobacco screening and cessation intervention (11.8 pp; 95% CI, 3.7-20.0 pp), and depression screening and follow-up (8.9 pp; 95% CI, 0.5-17.4 pp). No associations were observed between FQHC inclusion and utilization or expenditure.Conclusions and RelevanceIn this repeated cross-sectional study, MSSP ACOs with FQHC participation served more socioeconomically disadvantaged Medicare beneficiaries than those without FQHC participation. The inclusion of first FQHCs was associated with increased rates of several preventive services without increasing costs. Participation of safety net practices appeared to improve access to ACOs among beneficiaries from underserved communities.

IMPORTANCE Despite momentum for pediatric value-based payment models, little is known about tailoring design elements to account for the unique needs and utilization patterns of children and young adults. OBJECTIVE To simulate attribution to a hypothetical pediatric accountable care organization (ACO) and describe baseline demographic characteristics, expenditures, and utilization patterns over the subsequent year. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used Medicaid claims data for children and young adults aged 1 to 20 years enrolled in North Carolina Medicaid at any time during 2017. Children and young adults receiving at least 50% of their primary care at a large academic medical center (AMC) in 2017 were attributed to the ACO. Data were analyzed from April 2020 to March 2021. MAIN OUTCOMES AND MEASURES Primary outcomes were total cost of care and care utilization during the 2018 performance year. RESULTS Among 930 266 children and young adults (377 233 children [40.6%] aged 6-12 years; 470 612 [50.6%] female) enrolled in Medicare in North Carolina in 2017, 27 290 children and young adults were attributed to the ACO. A total of 12 306 Black non-Hispanic children and young adults (45.1%), 6308 Hispanic or Latinx children and young adults (23.1%), and 6531 White non-Hispanic children and young adults (23.9%) were included. Most attributed individuals (23 133 individuals [84.7%]) had at least 1 claim in the performance year. The median (IQR) total cost of care in 2018 was $347 ($107-$1123); 272 individuals (1.0%) accounted for nearly half of total costs. Compared with children and young adults in the lowest-cost quartile, those in the highest-cost quartile were more likely to have complex medical conditions (399 individuals [6.9%] vs 3442 individuals [59.5%]) and to live farther from the AMC (median [IQR distance, 6.0 [4.6-20.3] miles vs 13.9 [4.6-30.9] miles). Total cost of care was accrued in home (43%), outpatient specialty (19%), inpatient (14%) and primary (8%) care. More than half of attributed children and young adults received care outside of the ACO; the median (IQR) cost for leaked care was $349 ($130-$1326). The costliest leaked encounters included inpatient, ancillary, and home health care, while the most frequently leaked encounters included behavioral health, emergency, and primary care. CONCLUSIONS AND RELEVANCE This cohort study found that while most children attributed to the hypothetical Medicaid pediatric ACO lived locally with few health care encounters, a small group of children with medical complexity traveled long distances for care and used frequent and costly home-based and outpatient specialty care. Leaked care was substantial for all attributed children, with the cost of leaked care being higher than the total cost of care. These pediatric-specific clinical and utilization profiles have implications for future pediatric ACO design choices related to attribution, accounting for children with high costs, and strategies to address leaked care.

Integrated pain management (IPM) programs can help to reduce the substantial population health burden of musculoskeletal pain, but are poorly implemented. Lessons learned from existing programs can inform efforts to expand IPM implementation. This qualitative study describes how health care systems, payers, providers, health policy researchers, and other stakeholders are overcoming barriers to developing and sustaining IPM programs in real-world settings. Primary data were collected February 2020 through September 2021 from a multi-sector expert panel of 25 stakeholders, 53 expert interviews representing 30 distinct IPM programs across the United States, and 4 original case studies of exemplar IPM programs. We use a consensual team-based approach to systematically analyze qualitative findings. We identified 4 major themes around challenges and potential solutions for implementing IPM programs: navigating coverage, payment, and reimbursement; enacting organizational change; making a business case to stakeholders; and overcoming regulatory hurdles. Strategies to address payment challenges included use of group visits, linked visits between billable and nonbillable providers, and development of value-based payment models. Organizational change strategies included engagement of clinical and administrative champions and co-location of services. Business case strategies involved demonstrating the ability to initially break even and potential to reduce downstream costs, while improving nonfinancial outcomes like patient satisfaction and provider burnout. Regulatory hurdles were overcome with innovative credentialing methods by leveraging available waivers and managed care contracting to expand access to IPM services. Lessons from existing programs provide direction on to grow and support such IPM delivery models across a variety of settings. PERSPECTIVE: Integrated pain management (IPM) programs face numerous implementation challenges related to payment, organizational change, care coordination, and regulatory requirements. Drawing on real-world experiences of existing programs and from diverse IPM stakeholders, we outline actionable strategies that health care systems, providers, and payers can use to expand implementation of these programs.

Value-based payment (VBP) reform remains an increasingly relevant path for health care transformation. VBP aligns financial incentives with higher quality care at a lower cost for patient populations. This bipartisan commitment to VBP remains a top priority for the Centers for Medicare and Medicaid Services (CMS) with a goal to include all Medicare beneficiaries in a VBP model with accountability for total cost of care and quality by 2030. 1 Brooks-LaSure C Fowler E Seshamani M Tsai D. Innovation at the centers for medicare and medicaid services: avision for the next 10 years | health affairs. Health Affairs Blog. 2021; (Published Accessed November 2, 2021)https://www.healthaffairs.org/do/10.1377/hblog20210812.211558/full/ Google Scholar Further, the COVID-19 public health emergency highlighted the dependency of the fee-for-service (FFS) payment system on patient volume. Practices reliant on FFS faced severe financial challenges when in-person visits were not feasible.

Background Alternative Payment Models (APMs) piloted by the Centers for Medicare and Medicaid Services (CMS) such as ACO Realizing Equity, Access and Community Health (REACH) seek to improve care and quality of life among seriously ill populations (SIP). Days at Home (DAH) was proposed for use in this model to evaluate organizational performance. It is important to assess the utility and feasibility of person-centered outcomes measures, such as DAH, as CMS seeks to advance care models for seriously ill beneficiaries. We leverage existing Accountable Care Organization (ACO) contracts to evaluate the feasibility of ACO-level DAH measure and examine characteristics associated with ACOs with more DAH. Methods We calculated DAH for Medicare fee-for-service beneficiaries aged 68 and over who were retrospectively attributed to a Medicare ACO between 2014 and 2018 and met the seriously ill criteria. We then aggregated to the ACO level DAH for each ACO's seriously ill beneficiaries and risk-adjusted this aggregated measure. Finally, we evaluated associations between risk-adjusted DAH per person-year and ACO, beneficiary, and market characteristics. Results ACOs' seriously ill beneficiaries spent an average of 349.3 risk-adjusted DAH per person-year. Risk-adjusted ACO variation, defined as the interquartile range, was 4.21 days (IQR = 347.32-351.53). Beneficiaries of ACOs are composed of a less racially diverse beneficiary cohort, opting for two-sided risk models, and operating in markets with fewer hospital and Skilled Nursing Facility beds had more DAH. Conclusions Substantial variation across ACOs in the DAH measure for seriously ill beneficiaries suggests the measure can differentiate between high and low performing provider groups. Key to the success of the metric is accurate risk adjustment to ensure providers have adequate resources to care for seriously ill beneficiaries. Organizational factors, such as the ACO size and level of risk, are strongly associated with more days at home.

National Clinician Scholars Program, Duke University, Durham, North Carolina, USA Department of Surgery, Division of Urology, Duke University School of Medicine, Durham, North Carolina, USA Health Services Research and Development, Durham VA Healthcare System, Durham, North Carolina, USA Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA Department of Family Medicine and Community Health, Duke University School of Medicine, Durham, North Carolina, USA Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA Department of Orthopedic Surgery, Duke University School of Medicine, Durham, North Carolina, USA Duke Clinical Research Institute, Durham, North Carolina, USA Duke Cancer Institute, Durham, North Carolina, USA Sanford School of Public Policy, Duke University, Durham, North Carolina, USA

The experience of the coronavirus disease 2019 (Covid-19) pandemic will shape the new administration's health care policies and impact health care for years to come, specifically in 2 ways. First, the pandemic widened disparities in access, quality, and outcomes, disproportionately affecting low-income and minority populations and demanding a greater focus on equity and a more comprehensive approach to care delivery. Second, the pandemic highlighted the benefits of shifting to a more resilient, innovative health care system. Many providers struggled to adjust to the new Covid realities such as decreased procedural revenue and increased reliance on non–face-to-face care; in contrast, many participants in alternative payment models shifted quickly, using more flexible financing and new virtual technologies to provide care that patients needed.1Roiland R. Japinga M. Singletary E. et al.Value-based care in the COVID-19 era: enabling health care response and resilience. Duke-Margolis Center for Health Policy.https://healthpolicy.duke.edu/sites/default/files/2020-07/best_practices_brief_final.pdfDate: 2020Date accessed: July 31, 2021Google Scholar These experiences support the administration's key policy goal: to strengthen primary care and bolster infrastructure to help more practices deliver accessible, equitable care. We outline how these experiences are influencing the administration's policies in the following areas: (1) Covid-19 response, (2) value-based payment, (3) telehealth, and (4) access and equity. The American Rescue Plan Act (ARPA) was a $1.9 trillion economic stimulus bill signed by President Biden into law in March of 2021. Although the bill was designed in part to provide short-term pandemic relief, it also may have significant long-term impact on health care policy. For example, the legislation expands subsidies for 2 years to consumers who purchase health insurance on state exchanges and caps premium payments at 8.5% of income. Expanded subsidies will benefit all exchange participants, but particularly older adults with higher incomes. Affordable Care Act rules previously did not allow for subsidies beyond 400% of the federal poverty level. Now, under ARPA, a 60-year-old with an income of 430% of the federal poverty level would see more than a 50% reduction in premiums for gold or silver plans.2Rae M. Cox C. Claxton G. et al.How the American Recue Plan Act affects subsidies for marketplace shoppers and people who are uninsured. Kaiser Family Foundation.https://www.kff.org/health-reform/issue-brief/how-the-american-rescue-plan-act-affects-subsidies-for-marketplace-shoppers-and-people-who-are-uninsuredDate: March 2020Date accessed: July 31, 2021Google Scholar The administration hopes to make these increases permanent in the pending reconciliation legislation. In addition, ARPA provides $350 billion in total funding to states for Covid-19 recovery and vaccination efforts, and public health and economic initiatives. States have opportunities to invest funds into economic recovery, health care infrastructure, and safety net programs. North Carolina, for instance, plans to put some relief funds toward health research innovation, health and wellness promotion, and food security programs for at-risk residents.3A shared recovery for a stronger NC. North Carolina Office of State Budget and Management.https://www.osbm.nc.gov/media/1876/openDate accessed: July 31, 2021Google Scholar A Center for Medicare and Medicaid Innovation (CMMI) review found that payment models that delivered substantial savings tended to have broader population focus with greater shifts from fee-for-service.4Smith B. CMS Innovation Center at 10 years. Progress and lessons learned.N Engl J Med. 2021; 384: 759-764Crossref PubMed Scopus (52) Google Scholar In that context, the emerging strategy of the Centers for Medicare and Medicaid Services (CMS) emphasizes moving to a streamlined set of payment reforms that prioritizes patient-centered models in which providers are accountable for quality and total cost of care, aligns quality measures with patient goals, advances health equity through better data analytics, and an enhanced focus on improving access to community resources for social needs.5Brooks-LaSure C. Fowler E. Seshamani M. et al.Innovation at the Centers for Medicare and Medicaid Services: a vision for the next 10 years. Health Affairs Blog.https://www.healthaffairs.org/do/10.1377/hblog20210812.211558/fullDate: August 12, 2021Date accessed: September 21, 2021Google Scholar Notable CMS actions for specialty care likely will occur through the Merit-based Incentive Payment System (MIPS), which will enter its sixth year in 2022. CMS has proposed Value Pathways for measures with the goal of reducing provider burden, allowing providers to choose measures relevant to their practice, and providing the ability to compare measure performance against similar providers. If finalized, the initial pathways would begin in the 2023 performance year and remain voluntary for the first 2 years. Gastroenterology is not included in the initial pathways, which cover rheumatology, stroke care and prevention, heart disease, chronic disease management, emergency medicine, lower-extremity joint repair, and anesthesia, but it may be included in an upcoming phase. Beyond MIPS changes, there have not been announcements about new specialty-focused alternative payment models. The Bundled Payments for Care Improvement–Advanced model, which currently includes 4 gastrointestinal (GI) surgical procedures, accepted its second and likely last cohort in January 2020. Part of the reason that new models are not forthcoming for specialized care, in addition to the immediate priorities around advanced primary care and population health, may be the unanswered questions in which specialty-focused payment models are most effective. Although some procedure-based episode reforms have achieved savings and quality improvements, many specialty reform models have had limited savings or even added spending for Medicare.6Agarwal R. Liao J.M. Gupta A. et al.The impact of bundled payments on health care spending, utilization, and quality: a systematic review.Health Aff (Millwood). 2020; 39: 50-57Crossref PubMed Scopus (101) Google Scholar Although new CMMI specialty bundles have not been announced, GI clinicians likely will see bundled payment programs and value-based networks expand in their commercial and Medicare Advantage health plans. CMS also will prioritize alternative payment models that advance comprehensive care, which may lead to an increased emphasis on encouraging primary care and specialty coordination. GI physicians used by a hospital-based system or in a multispecialty practice may see their organizations participate in more advanced Accountable Care Organizations, another CMS advanced primary care model, or more comprehensive reforms such as direct contracting—either in CMMI's proposed new model or with employers. Those models likely will emphasize effective use of prevention, early treatment, and efficient collaboration with primary care. Specialized GI practices are likely to see their referring primary care practices pay more attention to the total costs and coordination for their patients. In addition to payment models, complementary benefit reforms are being proposed for longitudinal and preventive care, specifically phasing out coinsurance requirements for colorectal cancer screening tests that become diagnostic tests when additional services are needed. The proposed change would reduce coinsurance beginning in 2022, and reach zero by 2030. Telehealth utilization increased rapidly during the pandemic. Although utilization has fallen from its peak, it remains considerably higher than before the pandemic, a sign that telehealth is here to stay. CMS will continue to cover telehealth services allowed during the pandemic and expand telehealth coverage for mental health care.7Grimm D. CMS proposed rule addressed permanent expansion of certain telehealth services.https://www.jdsupra.com/legalnews/cms-proposed-rule-addresses-permanent-3384951Date: 2021Date accessed: July 31, 2021Google Scholar However, there are cost, quality, and logistical concerns around telehealth coverage. In addition, there is substantial debate about the best approach to turn an abrupt Covid-era shift to a sustainable and effective reform, especially given concerns about the potential for waste, fraud, and abuse.8Japinga M. Singletary E. McClellan M. How telehealth expansion can support comprehensive virtual care. NEJM Catalyst Innovations in Care Delivery 2021;7.https://catalyst.nejm.org/doi/abs/10.1056/CAT.21.0129Date accessed: July 31, 2021Google Scholar Telehealth also cannot be widely adopted without support for greater broadband access, given disparities in access for less-populous areas. The $1.2 trillion bipartisan Infrastructure Investment and Jobs Act signed by President Biden in November of 2021 includes $65 billion for broadband infrastructure and initiatives to increase affordability and adoption. The momentum surrounding telehealth fits into a broader movement toward innovative home-care models that incorporate virtual elements, but questions remain about exactly how large the government's investment will be. The proposed reconciliation bill initially included $400 billion to improve home care infrastructure, increase the number of home care workers, and increase the amount of take-home pay many of them receive, but this number is expected to be much lower in the final version. There also are opportunities to continue innovative home-based care delivery innovations from the public health emergency, including GI-focused care models. For instance, before the pandemic, Upstate Homecare and a team of Golisano Children's Hospital gastroenterologists began piloting home infusion therapies for pediatric patients with conditions such as Crohn's disease and ulcerative colitis. During the pandemic, many families requested to participate in the pilot. Advocates see this pilot study as further reason to expand home-based care options for specialty and chronic condition patients, including those with GI diseases.9Shaw G. After turbulent year, home infusion providers urge Biden administration to prioritize home-based care. Gastroenterol Endosc News.https://www.gastroendonews.com/In-the-News/Article/05-21/After-Turbulent-Year-Home-Infusion-Providers-Urge-Biden-Administration-To-Prioritize-Home-Based-Care/63413Date: 2021Date accessed: July 31, 2021Google Scholar To complement CMMI's work on value-based payment models, CMS is further prioritizing improving coverage, access, and health equity. In terms of coverage, CMS expanded coverage to an additional 2 million Americans via the health exchanges through a 6-month special enrollment period, although that has not yet resulted in a substantial change in the overall number of uninsured. CMS also revoked the Section 1115 waiver approval for Medicaid work requirements in several states, stating its concern that such waivers are barriers for historically disadvantaged populations. CMS also hopes to improve infrastructure around health equity to help providers refer patients for assistance with the nonmedical factors that contribute to disparities, such as limited access to transportation, food and housing insecurity, and unsafe home environments. The agency is seeking feedback on what infrastructure support and data collection tools could help assess and improve impact on equity and disparities. Although the Administration's priorities will help make some advancements in payment and delivery reform, other major legislative reforms are less likely. The American Rescue Plan Act and the bipartisan infrastructure bill did not include provisions for significant pricing reforms in Medicare, and unified Democratic support for specific drug price proposals has not yet come together. Drug pricing certainly will receive public attention—including with a new Alzheimer disease drug priced at $56,000 per Medicare patient annually—but the prospects for major legislation using an international reference price for many new drugs appear to be low. However, some changes may come in areas such as payment incentives to use less costly biosimilars and program integrity in the 340B drug pricing program. The Biden Administration earmarked $17 million to create oversight protocols for the 340B drug discount program, with $7 million allocated toward creating a dispute and resolution process. Overall, the policy priorities of the Biden administration show a continued commitment to value-based care, with investments and regulations that adapt longer-term priorities to address challenges in the care system exposed by Covid-19 while simultaneously leveraging some of the innovations that came from it. These efforts will start in primary care. Although this could mean gastroenterology may see limited targeted reforms, proposed reforms to programs such as MIPS show change could be on the horizon. Gastroenterologists should consider how they can partner with primary care to play a role in comprehensive care reforms and increase their focus on addressing health disparities. Those that do will be best positioned to incorporate new innovations into a better aligned and more collaborative health care system.

This cross-sectional study evaluates how policy changes for Medicare Advantage plans affected supplemental benefit availability across geographic social vulnerability, membership diversity, and rebates from 2019 to 2022.

This cross-sectional study examines the uptake of several newly allowable Medicare Advantage benefits in 2021 as well as geographic differences in benefit offerings between rural and urban areas, plan penetration, and social vulnerability.

EXECUTIVE SUMMARY Accountable care organizations (ACOs) need confidence in their return on investment to implement changes in care delivery that prioritize seriously ill and high-cost Medicare beneficiaries. The objective of this study was to characterize spending on seriously ill beneficiaries in ACOs with Medicare Shared Savings Program (MSSP) contracts and the association of spending with ACO shared savings. The population included Medicare fee-for-service beneficiaries identified with serious illness (N = 2,109,573) using the Medicare Master Beneficiary Summary File for 100% of ACO-attributed beneficiaries linked to MSSP beneficiary files (2014-2016). Lower spending for seriously ill Medicare beneficiaries and risk-bearing contracts in ACOs were associated with achieving ACO shared savings in the MSSP. For most ACOs, the seriously ill contribute approximately half of the spending and constitute 8%-13% of the attributed population. Patient and geographic (county) factors explained $2,329 of the observed difference in per beneficiary per year spending on seriously ill beneficiaries between high- and low-spending ACOs. The remaining $12,536 may indicate variation as a result of potentially modifiable factors. Consequently, if 10% of attributed beneficiaries were seriously ill, an ACO that moved from the worst to the best quartile of per capita serious illness spending could realize a reduction of $1,200 per beneficiary per year for the ACO population overall. Though the prevalence and case mix of seriously ill populations vary across ACOs, this association suggests that care provided for seriously ill patients is an important consideration for ACOs to achieve MSSP shared savings.

BACKGROUND:Quality measurement has become a priority for national healthcare reform, and valid measures are necessary to discriminate hospital performance and support value-based healthcare delivery. The Commission on Cancer (CoC) is the largest cancer-specific accreditor of hospital quality in the United States and has implemented Quality of Care Measures to evaluate cancer care delivery. However, none has been formally tested as a valid metric for assessing hospital performance based on actual patient outcomes. METHODS:Eligibility and compliance with the Quality of Care Measures are reported within the National Cancer Database, which also captures data for robust patient-level risk adjustment. Hospital-level compliance was calculated for the core measures, and the association with patient survival was tested using Cox regression. RESULTS:Seven hundred sixty-eight thousand nine hundred sixty-nine unique cancer cases were included from 1323 facilities. Increasing hospital-level compliance was associated with improved survival for only two measures, including a 35% reduced risk of mortality for the gastric cancer measure G15RLN (HR 0.65, 95% CI 0.58-0.72) and a 19% reduced risk of mortality for the colon cancer measure 12RLN (HR 0.81, 95% CI 0.77-0.85). For the lung cancer measure LNoSurg, increasing compliance was paradoxically associated with an increased risk of mortality (HR 1.14, 95% CI 1.08-1.20). For the remaining measures, hospital-level compliance demonstrated no consistent association with patient survival. CONCLUSION:Hospital-level compliance with the CoC's Quality of Care Measures is not uniformly aligned with patient survival. In their current form, these measures do not reliably discriminate hospital performance and are limited as a tool for value-based healthcare delivery.

The Affordable Care Act played a major role in transitioning American health care away from fee-for-service payment. We explore the spread of payment reforms since the implementation of the ACA, both nationally and in North Carolina; the corresponding effects on health care costs and quality; and further steps needed to achieve greater transformation.

Stroke is one of the leading causes of morbidity and mortality in the United States. While age-adjusted stroke mortality was falling, it has leveled off in recent years due in part to advances in medical technology, health care options, and population health interventions. In addition to adverse trends in stroke-related morbidity and mortality across the broader population, there are sociodemographic inequities in stroke risk. These challenges can be addressed by focusing on predicting and preventing modifiable upstream risk factors associated with stroke, but there is a need to develop a practical framework that health care organizations can use to accomplish this task across diverse settings. Accordingly, this article describes the efforts and vision of the multi-stakeholder Predict & Prevent Learning Collaborative of the Value in Healthcare Initiative, a collaboration of the American Heart Association and the Robert J. Margolis, MD, Center for Health Policy at Duke University. This article presents a framework of a potential upstream stroke prevention program with evidence-based implementation strategies for predicting, preventing, and managing stroke risk factors. It is meant to complement existing primary stroke prevention guidelines by identifying frontier strategies that can address gaps in knowledge or implementation. After considering a variety of upstream medical or behavioral risk factors, the group identified 2 risk factors with substantial direct links to stroke for focusing the framework: hypertension and atrial fibrillation. This article also highlights barriers to implementing program components into clinical practice and presents implementation strategies to overcome those barriers. A particular focus was identifying those strategies that could be implemented across many settings, especially lower-resource practices and community-based enterprises representing broad social, economic, and geographic diversity. The practical framework is designed to provide clinicians and health systems with effective upstream stroke prevention strategies that encourage scalability while allowing customization for their local context.

• Implementing new child-focused APMs will require overcoming challenges such as legal and regulatory restrictions on financing streams (requiring combining and coordinating funds from different sources, often referred to as “blending and braiding”); collaborating across sectors that often have very different cultures and histories; and sharing different types and sources of data (to which different privacy regulations may frequently apply). However, there are examples of organizations that have overcome these challenges, as this brief sets forth below.

OBJECTIVES: Since 2019, the Medicare Shared Savings Program (MSSP) has allowed accountable care organizations (ACOs) to choose either retrospectively or prospectively attributed ACO populations. To understand how ACOs' choice of attribution method affects incentives for care among seriously ill Medicare beneficiaries, this study compares beneficiary characteristics and Medicare per capita expenditures between prospective and retrospective ACO populations. STUDY DESIGN: This retrospective, cross-sectional analysis describes survival, patient characteristics, and Medicare spending for Medicare fee-for-service beneficiaries identified with serious illness (n = 1,600,629) using 100% Medicare Master Beneficiary Summary and MSSP beneficiary files (2014-2016). METHODS: We used generalized linear models with ACO and year fixed effects to estimate the average within-ACO difference between potential retrospective and prospective ACO populations. RESULTS: Dying in the first 90 days of the performance year was associated with reduced odds of retrospective ACO attribution (odds ratio [OR], 0.24; 95% CI, 0.24-0.25) relative to beneficiaries surviving 270 days or longer. Similarly, hospice use was associated with reduced odds of retrospective assignment (OR, 0.80; 95% CI, 0.79-0.80). Among ACOs that did not achieve shared savings, average per capita Medicare expenditures (after truncation) were $ 2459 (95% CI, $2192-$2725) higher for prospective vs retrospective ACO populations. The difference was $834 (95% CI, $402-$1266) greater per capita among ACOs that achieved shared savings. CONCLUSIONS: The difference in survival and spending for ACO populations captured by prospective vs retrospective attribution methods means that ACOs may need to employ different care management strategies to improve performance depending on their attribution method.