Effect of Attribution Length on the Use and Cost of Health Care for a Pediatric Medicaid Accountable Care Organization | Geriatrics | JAMA Pediatrics | JAMA Network
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1.
US Department of Health and Human Services.  About the Affordable Care Act.http://www.hhs.gov/healthcare/about-the-law/index.html. Last reviewed August 13, 2015. Accessed September 15, 2015.
2.
Centers for Medicare & Medicaid Services.  Fact sheets: Medicare ACOs provide improved care while slowing cost growth in 2014.https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-08-25.html. Published August 25, 2015. Accessed September 4, 2015.
3.
Song  Z, Safran  DG, Landon  BE,  et al.  Health care spending and quality in year 1 of the alternative quality contract.  N Engl J Med. 2011;365(10):909-918.PubMedGoogle ScholarCrossref
4.
McWilliams  JM, Chernew  ME, Landon  BE, Schwartz  AL.  Performance differences in year 1 of Pioneer accountable care organizations.  N Engl J Med. 2015;372(20):1927-1936.PubMedGoogle ScholarCrossref
5.
Nyweide  DJ, Lee  W, Cuerdon  TT,  et al.  Association of Pioneer Accountable Care Organizations vs traditional Medicare fee for service with spending, utilization, and patient experience.  JAMA. 2015;313(21):2152-2161.PubMedGoogle ScholarCrossref
6.
McWilliams  JM, Landon  BE, Chernew  ME, Zaslavsky  AM.  Changes in patients’ experiences in Medicare accountable care organizations.  N Engl J Med. 2014;371(18):1715-1724.PubMedGoogle ScholarCrossref
7.
Colla  CH, Wennberg  DE, Meara  E,  et al.  Spending differences associated with the Medicare Physician Group Practice Demonstration.  JAMA. 2012;308(10):1015-1023.PubMedGoogle ScholarCrossref
8.
Maeng  DD, Graham  J, Graf  TR,  et al.  Reducing long-term cost by transforming primary care: evidence from Geisinger’s medical home model.  Am J Manag Care. 2012;18(3):149-155.PubMedGoogle Scholar
9.
Maeng  DD, Khan  N, Tomcavage  J, Graf  TR, Davis  DE, Steele  GD.  Reduced acute inpatient care was largest savings component of Geisinger Health System’s patient-centered medical home.  Health Aff (Millwood). 2015;34(4):636-644.PubMedGoogle ScholarCrossref
10.
Christensen  EW, Dorrance  KA, Ramchandani  S,  et al.  Impact of a patient-centered medical home on access, quality, and cost.  Mil Med. 2013;178(2):135-141.PubMedGoogle ScholarCrossref
11.
Hoff  T, Weller  W, DePuccio  M.  The patient-centered medical home: a review of recent research.  Med Care Res Rev. 2012;69(6):619-644.PubMedGoogle ScholarCrossref
12.
Averill  RF, Goldfield  NI, Vertrees  JC, McCullough  EC, Fuller  RL, Eisenhandler  J.  Achieving cost control, care coordination, and quality improvement through incremental payment system reform.  J Ambul Care Manage. 2010;33(1):2-23.PubMedGoogle ScholarCrossref
13.
Cole  ES, Campbell  C, Diana  ML, Webber  L, Culbertson  R.  Patient-centered medical homes in Louisiana had minimal impact on Medicaid population’s use of acute care and costs.  Health Aff (Millwood). 2015;34(1):87-94.PubMedGoogle ScholarCrossref
14.
Allen  S.  Medicaid and pediatric accountable care organizations: a case study.  Accountable Care News.2010;1(5):1-4.Google Scholar
15.
Kelleher  KJ, Cooper  J, Deans  K,  et al.  Cost saving and quality of care in a pediatric accountable care organization.  Pediatrics. 2015;135(3):e582-e589.PubMedGoogle ScholarCrossref
16.
Raphael  JL, Giardino  AP.  Accounting for kids in accountable care: a policy perspective.  Clin Pediatr (Phila). 2013;52(8):695-698.PubMedGoogle ScholarCrossref
17.
Homer  CJ, Patel  KK.  Accountable care organizations in pediatrics: irrelevant or a game changer for children?  JAMA Pediatr. 2013;167(6):507-508.PubMedGoogle ScholarCrossref
18.
Johns Hopkins Bloomberg School of Public Health. The Johns Hopkins ACG System, Technical Reference Guide. Version 10.0. http://acg.jhsph.org/public-docs/ACGv10.0TechRefGuide.pdf. Published December 2011. Accessed August 27, 2015.
19.
Agency for Healthcare Research and Quality.  Healthcare Cost and Utilization Project (HCUP): Clinical Classification Software (CCS) for ICD-9-CM.http://www.hcup-us.ahrq.gov/toolssoftware/ccs/ccs.jsp. Last modified June 1, 2015. Accessed August 27, 2015.
20.
Agency for Healthcare Research and Quality.  Healthcare Cost and Utilization Project (HCUP): Chronic Condition Indicator (CCI) for ICD-9-CM.https://www.hcup-us.ahrq.gov/toolssoftware/chronic/chronic.jsp. Last modified June 1, 2015. Accessed August 27, 2015.
21.
Casalino  LP.  Accountable care organizations: the risk of failure and the risks of success.  N Engl J Med. 2014;371(18):1750-1751.PubMedGoogle ScholarCrossref
22.
Toussaint  J, Milstein  A, Shortell  S.  How the Pioneer ACO model needs to change: lessons from its best-performing ACO.  JAMA. 2013;310(13):1341-1342.PubMedGoogle ScholarCrossref
23.
Congressional Budget Office.  Lessons from Medicare’s demonstration projects on disease management, care coordination, and value-based payment. https://www.cbo.gov/sites/default/files/112th-congress-2011-2012/reports/01-18-12-MedicareDemoBrief.pdf. Accessed August 27, 2015.
24.
Kocot  SL, Dang-Vu  C, White  R, McClellan  M.  Early experiences with accountable care in Medicaid: special challenges, big opportunities.  Popul Health Manag. 2013;16(suppl 1):S4-S11.PubMedGoogle ScholarCrossref
Original Investigation
February 2016

Effect of Attribution Length on the Use and Cost of Health Care for a Pediatric Medicaid Accountable Care Organization

Author Affiliations
  • 1Department of Research and Sponsored Programs, Children’s Hospitals and Clinics of Minnesota, Minneapolis
JAMA Pediatr. 2016;170(2):148-154. doi:10.1001/jamapediatrics.2015.3446
Abstract

Importance  Little is known about the effect of pediatric accountable care organizations (ACOs) on the use and costs of health care resources, especially in a Medicaid population.

Objective  To assess the association between the length of consistent primary care (length of attribution) as part of an ACO and the use and cost of health care resources in a pediatric Medicaid population.

Design, Setting, and Participants  A retrospective study of Medicaid claims data for 28 794 unique pediatric patients covering 346 277 patient-attributed months within a single children’s hospital. Data were collected for patients attributed from September 1, 2013, to May 31, 2015. The effect of the length of attribution within a single hospital system’s ACO on the use and costs of health care resources were estimated using zero-inflated Poisson distribution regression models adjusted for patient characteristics, including chronic conditions and a measure of predicted patient use of resources.

Exposures  Receiving a plurality of primary care at an ACO clinic during the preceding 12 months (attribution to the ACO).

Main Outcomes and Measures  The primary outcome measure was the length of attribution at an ACO clinic compared with subsequent inpatient hospitalization and subsequent use and cost of outpatient and ancillary health care resources.

Results  Among the 28 794 pediatric patients receiving treatment covering 346 277 patient-attributed months during the study period, continuous attribution to the ACO for more than 2 years was associated with a decrease (95% CI) of 40.6% (19.4%-61.8%) in inpatient days but an increase (95% CI) of 23.3% (2.04%-26.3%) in office visits, 5.8% (1.4%-10.2%) in emergency department visits, and 15.3% (12.5%-18.0%) in the use of pharmaceuticals. These changes in the use of health care resources combined resulted in a cost reduction of 15.7% (95% CI, 6.6%-24.8%). At the population level, the impact of consistent primary care was muted by the many patients in the ACO having shorter durations of participation.

Conclusions and Relevance  These findings suggest significant and durable reductions of inpatient use and cost of health care resources associated with longer attribution to the ACO, with attribution as a proxy for exposure to the ACO’s consistent primary care. Consistent primary care among the pediatric Medicaid population is challenging, but these findings suggest substantial benefits if consistency can be improved.

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