Medicare ACOs that treat a greater proportion of racial, ethnic minorities are more likely to exit program: study

In 2017, accountable care organizations participating in a risk-adjusted shared savings program for Medicare beneficiaries began to have their efforts compared with other ACOs in a region rather than with their own historical performance.

That meant ACOs serving a higher number of lower-income and minority Medicare beneficiaries—individuals with historically more complex and costly care needs—would be compared to ACOs with enrollees that didn’t struggle as much.

That’s the main reason many ACOs serving those high-risk patients dropped out of the Medicare Shared Savings Program (MSSP), according to a recent study in JAMA Health Forum.

Researchers with Washington University School of Medicine concluded that “ACOs with a higher proportion of beneficiaries of racial and ethnic minority groups were significantly more likely to exit the MSSP program. High-proportion ACOs were also more likely to care for patients with greater disease severity and complexities. These findings suggest that an equity-centered approach to policy design and evaluation is needed to ensure that the benefits of health reform efforts and innovative care delivery models are more equitably distributed.”

The Centers for Medicare & Medicaid Services (CMS) made the change in 2017 despite simulations suggesting that ACOs caring for racial and ethnic groups would drop out of MSSP, a voluntary program. In addition, CMS in 2018 announced that all Medicare ACOs would have to take on downside risk, meaning that they’d lose money if benchmarks were not met.

“Consequently, MSSP ACOs that serve a higher proportion of racial and ethnic minority groups may have been more likely to exit,” the study states.

Researchers examined 589 ACOs that participated in MSSP from January 2012 to December 2018. They found that 145 (25%) of those ACOs served the highest proportion of racial and ethnic minorities, while 444 (75%) were designated as low-proportion ACOs.

“In unadjusted analysis, a 10–percentage point increase in the proportion of beneficiaries of racial and ethnic minority groups was associated with a 1.12-fold increase in the odds of an ACO exit (95% CI, 1.00-1.25; P = .04),” the study states. “In adjusted analysis, there were significant associations among high-proportion ACOs between characteristics such as patient comorbidities, disability, and clinician composition and a higher likelihood of exit.”

Researchers relied on data from the MSSP Beneficiary-Level Research Identifiable File to identify those ACOs that served the highest number of racial and ethnic minorities which allowed them to mine Medicare enrollment database codes taken from beneficiaries’ social security data. They hope that their findings will be considered by policymakers especially in light of CMS’ goal of having all Medicare beneficiaries in risk-bearing models by 2030.

Researchers add that their findings “suggest that the introduction of regional adjustments to MSSP benchmarks implemented in 2017 may have made it more difficult for high-proportion ACOs to reach cost targets. Coupled with the acceleration of timelines for taking on downside risk, this study raises concern about the retention of high-proportion ACOs" in the program.

Since its launch in 2012, about 30% of ACOs quit the program for various reasons, including flawed leadership structure, a failure to earn shared savings and the makeup of their clinician panels.

ACOs with a larger number of racial and ethnic minority groups might benefit from programs that address some of the social determinants of health by providing transportation and social work services to beneficiaries, the study states.

“The introduction of regional benchmarking without adequate social risk adjustment may have made it more difficult for high-proportion ACOs to earn shared savings, potentially leading to a higher rate of program exit in 2017,” the study states. “This study underscores the importance of effective risk-adjustment methods that incorporate not only medical but also social risk factors to ensure that ACOs are not penalized for taking on patients with complexities, especially because a disproportionately high percentage of these patients are likely to be members of racial and ethnic minority groups.”