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Original Investigation
April 2017

Early Performance in Medicaid Accountable Care OrganizationsA Comparison of Oregon and Colorado

Author Affiliations
  • 1Center for Health Systems Effectiveness, Oregon Health & Science University, Portland
  • 2Department of Family Medicine, Oregon Health & Science University, Portland
  • 3Jefferson Center for Mental Health, Office of Healthcare Transformation, Wheat Ridge, Colorado
  • 4OHSU-PSU School of Public Health, Oregon Health & Science University, Portland
  • 5Hatfield School of Government, Portland State University, Portland
  • 6Department of Health Systems, Management and Policy, School of Public Health, University of Colorado, Denver
JAMA Intern Med. 2017;177(4):538-545. doi:10.1001/jamainternmed.2016.9098
Key Points

Question  How have expenditures, utilization, and quality changed in Oregon’s Medicaid Accountable Care Organization model in comparison with Colorado’s Medicaid Accountable Care Organization model?

Findings  In this study of 770 000 Medicaid enrollees, standardized expenditures for selected services decreased in both states during the years 2010-2014, with no significant difference between the states, although Oregon’s Medicaid Accountable Care Organization improved in some measures of access and quality compared with Colorado.

Meaning  Two years into implementation, Oregon’s Medicaid Accountable Care Organization, characterized by a large federal investment and movement to global budgets, exhibited improvements in some measures of care but no apparent differences in savings compared with the Colorado Medicaid Accountable Care Organization model, which was more limited in scope and implemented without substantial federal investments.

Abstract

Importance  Several state Medicaid reforms are under way, but the relative performance of different approaches is unclear.

Objective  To compare the performance of Oregon’s and Colorado’s Medicaid Accountable Care Organization (ACO) models.

Design, Setting, and Participants  Oregon initiated its Medicaid transformation in 2012, supported by a $1.9 billion investment from the federal government, moving most Medicaid enrollees into 16 Coordinated Care Organizations, which managed care within a global budget. Colorado initiated its Medicaid Accountable Care Collaborative in 2011, creating 7 Regional Care Collaborative Organizations that received funding to coordinate care with providers and connect Medicaid enrollees with community services. Data spanning July 1, 2010, through December 31, 2014 (18 months before intervention and 24 months after intervention, treating 2012 as a transition year) were analyzed for 452 371 Oregon and 330 511 Colorado Medicaid enrollees, assessing changes in outcomes using difference-in-differences analyses of regional focus, primary care homes, and care coordination. Oregon’s Coordinated Care Organization model was more comprehensive in its reform goals and in the imposition of downside financial risk.

Exposures  Regional focus, primary care homes, and care coordination in Medicaid ACOs.

Main Outcomes and Measures  Performance on claims-based measures of standardized expenditures and utilization for selected services, access, preventable hospitalizations, and appropriateness of care.

Results  In a total of 782 882 Medicaid enrollees, 45.0% were male, with mean (SD) age 16.74 (14.41) years. Standardized expenditures for selected services declined in both states during the 2010-2014 period, but these decreases were not significantly different between the 2 states. Oregon’s model was associated with reductions in emergency department visits (−6.28 per 1000 beneficiary-months; 95% CI, −10.51 to −2.05) and primary care visits (−15.09 visits per 1000 beneficiary-months; 95% CI, −26.57 to −3.61), improvements in acute preventable hospital admissions (−1.01 admissions per 1000 beneficiary-months; 95% CI, −1.61 to −0.42), 3 of 4 measures of access (well-child visits, ages 3-6 years, 2.69%; 95% CI, 1.20% to 4.19%; adolescent well-care visits, 6.77%; 95% CI, 5.22% to 8.32%; and adult access to preventive ambulatory care, 1.26%; 95% CI, 0.28% to 2.25%), and 1 of 4 measures of appropriateness of care (avoidance of head imaging for uncomplicated headache, 2.59%; 95% CI, 1.35% to 3.83%).

Conclusions and Relevance  Two years into implementation, Oregon’s and Colorado’s Medicaid ACO models exhibited similar performance on standardized expenditures for selected services. Oregon’s model, marked by a large federal investment and movement to global budgets, was associated with improvements in some measures of utilization, access, and quality, but Colorado’s model paralleled Oregon’s on several other metrics.

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