Medicare's hospital outpatient prospective payment system rates will increase by a net 2.6% in 2020.
Despite successful legal challenges by stakeholders, hospitals will see continued cuts to the 340B drug savings program and reductions in reimbursements for off-campus clinic visits in 2020 under a final rule issued Friday by the Centers for Medicare & Medicaid Services.
In addition, CMS said it will issue a separate final rule on its requirement that hospitals disclose payer-specific negotiated rates, which was proposed under the Outpatient Prospective Payment System rule.
Overall, Medicare's hospital outpatient prospective payment system rates will increase by a net 2.6% in 2020, compared with 2019.
However, CMS will push ahead with its ongoing 22.5% payment rate cuts for some drugs under the 340B program, even though the policy was vacated by a federal court in May.
In addition, the second year of the two-year phase-in of the site-neutral cuts – which CMS says will save Medicare about $800 million in 2020 – will continue even though a federal court in September vacated the policy.
"I've never seen anything like what we are seeing now from CMS with OPPS payment policy, where the agency continues to double and triple down on cutting reimbursement to hospitals even when the legal system has spoken in favor of what providers have been saying for years," Jugna Shah, MPH, CHRI, president of Nimitt Consulting Inc., told Revenue Cycle Advisor.
“Given this, it is quite remarkable that the agency pushed its controversial price transparency proposals to a separate, yet-to-be released final rule,” Shah says.
Site-neutral Payments
The final rule completes the two-year phase-in of the site-neutral rate, which is 40% of the OPPS rate provided for grandfathered off-campus clinics in 2020.
CMS says the site-neutral policy will reduce cost-sharing by Medicare beneficiaries to $9, saving them about $14 for each off-campus clinic visit in 2020.
CMS may appeal the September ruling but said it will ensure that 2019 claims for clinic visits will be paid consistent with the court order.
"We do not believe it is appropriate at this time to make a change to the second year of the two-year phase-in of the clinic visit policy," CMS said. "The government has appeal rights, and is still evaluating the rulings and considering, at the time of this writing, whether to appeal from the final judgment."
American Hospital Association Executive Vice President Tom Nickels said the site-neutral cuts "not only threatens access to care, especially in rural and other vulnerable communities, but it goes against clear congressional intent to protect the majority of clinic services."
"There are many real and crucial differences between hospital outpatient departments and the patient populations they serve and other sites of care," Nickels said.
"Now that a federal court has sided with the AHA and found that these cuts exceed the Administration's authority, CMS should abandon further illegal cuts," he said. "Instead, as we urged in a letter to the Department of Justice (Thursday), CMS should promptly repay the affected hospitals the full OPPS rate to support the work they do for the patients they serve. And CMS should pay the full OPPS rate for all clinic visit claims going forward."
340B Cuts Continue
In May, U.S. District Court Judge Rudolph Contreras again ruled that the 340B drug reimbursement rate under Medicare Part B that Health and Human Services set in the 2019 OPPS rule was unlawful and "in contravention of the Medicare Act's plain text."
CMS has acknowledged the ruling, which it has appealed, but said the cuts would continue even as it "solicited comments for a potential remedy for CYs 2018 and 2019 in the event of an unfavorable decision."
"We also announced in our intent to conduct a 340B hospital survey to collect drug acquisition cost data for CY 2018 and 2019, and data from that survey may be used to craft a remedy," CMS said.
After finalizing the policy without precise data regarding hospital acquisition costs for 340B drugs in this program, the agency is crowdsourcing ideas for how to reimburse hospitals as ordered by the court, though an appeal is currently pending, Revenue Cycle Advisor reports.
Health and Human Services Secretary Alex Azar says the cuts are needed because the 340B program has created a large profit margin between the price that hospitals pay for 340B drugs and the reimbursement paid by Medicare, which he said incentivizes hospitals to overprescribe the discounted drugs.
That concern was validated by a Government Accountability Office report in 2015 which showed that Medicare Part B drug spending was substantially higher at 340B hospitals.
Maureen Testoni, president and CEO of 340B Health, said CMS has for three years "ignored the needs of patients and the safety-net hospitals that care for them to pursue an unlawful reduction in Medicare payments to 340B hospitals."
"A federal court has ruled repeatedly that these cuts are inconsistent with the Medicare statute and must be reversed," she said. "A bipartisan majority in both houses of Congress has agreed. It's time to stop this unfunny version of 'Groundhog Day' and restore Medicare payments for 340B hospitals to their legal, statutory level."
Beth Feldpush, senior vice president of policy and advocacy at America's Essential Hospitals, blasted CMS for "plowing ahead with damaging cuts to hospitals in the 340B Drug Pricing Program and ignoring clear congressional intent by expanding cuts to grandfathered provider-based outpatient clinics.
"CMS undermines the foundation of care for the nation's most vulnerable people," Feldpush said. "The agency also prolongs confusion and uncertainty for hospitals by maintaining unlawful policies it has been told to abandon in clear judicial directives."
In the 2020 OPPS proposed rule, CMS solicited comment from stakeholders on methods to devise a remedy for hospitals if its appeal is denied. With CMS redistributing money saved from the reimbursement cut throughout the OPPS since 2018, the agency does not want to simply reimburse hospitals at the more traditional ASP plus 6%. CMS says it will consider stakeholder comments and the survey data as it weighs possible new policies and remedies, Revenue Cycle Advisor reports.
Therapy Services
CMS is also finalizing its proposal to change the required level of supervision for all outpatient therapeutic services provided in outpatient and critical access hospitals from direct to general, according to Revenue Cycle Advisor.
General supervision means that the procedure is furnished under the physician's overall direction and control, but that the physician's presence is not required during the performance of the procedure.
"This is one of the few things that CMS proposed and finalized that should receive three cheers from the hospital community," Shah told the publication.
Hospitals may choose to require higher levels of supervision for certain services as it deems appropriate.
The JOC would have extended to clinics and facilities owned by both religious nonprofit health systems in six Northern California counties.
A proposed joint operating company that would manage Adventist Health System/West and St. Joseph Health System facilities in Northern California has been rejected by the state's attorney general.
In aletter Thursday to leadership at the two health systems, Chief Assistant Attorney General Matthew Rodriquez said regulators had concluded "among other things, that the proposed transaction is not in the public interest, including, but not limited to the potential for increased health costs and concerns over access and availability of healthcare services."
Adventist Health and St. Joseph Health issued a joint statement saying they're "very disappointed in the outcome of this decision."
"Our intent has always been to better serve our communities, increase access to services, and create a stronger safety net for families in Northern California. At this time, our organizations will need to take a step back and determine implications of this decision. The well-being of our communities remains our top priority," the health systems said.
The JOC would have extended to clinics and facilities owned by both religious nonprofit health systems in Humboldt, Mendocino, Sonoma, Lake, Napa, and Solano counties.
Under the proposal put forward in April 2018, Adventist Health and St. Joseph Health would have retained existing hospital names, licenses, capital assets and employees. The two systems hope to have the deal finalized by the end of the year. Financial terms were not disclosed.
In an interview last year with HealthLeaders, Jeff Eller, Adventist Health president of the Northern California region, said the JOC "really is about a population health strategy and securing and strengthening healthcare access in these smaller rural communities."
"We are coming together to form an organization that will manage the day-to-day operations, that will help develop strategies, and ultimately help us to create value back in the communities that we both serve," he said.
Among the allegations, former executives at Outcome lied to outside auditors about revenue for 2015 and 2016 in order to secure debt financing.
Outcome Health, the Chicago-based healthcare digital advertiser, will pay $70 million to resolve allegations that it lied to drug companies and investors about the reach of its advertising inventory, the Department of Justice said.
The privately held company – which provides physician waiting rooms with video screens featuring health tips and drug ads – admitted that from 2012 to 2017 former executives and employees perpetrated a scheme that under-delivered on its advertising campaigns, but continued to bill its clients, mostly drug makers, as if it had delivered in full.
To conceal the fraud, Outcome employees falsified affidavits and proofs of performance to make it appear the company was delivering advertising content to the number of screens in its clients' contracts, DOJ said.
The company also inflated patient engagement metrics with Outcome devices, and altered studies given to clients to make it appear that the campaigns were more effective than they were.
To cover their tracks, the former executives at Outcome lied to outside auditors about revenue for 2015 and 2016. The auditor signed off on the numbers because the schemers fabricated data to conceal the fraud.
In the resolution agreement, Outcome admitted that former executives used the bogus revenue figures to raise $110 million in debt financing in April 2016, $375 million in debt financing in December 2016, and $487.5 million in equity financing in early 2017.
Outcome Health co-founders Rishi Shah and Shradha resigned in 2018 after the company reached a fraud settlement with investors.
"Outcome Health deceived its lenders and investors, and overbilled its clients, by fraudulently misrepresenting both the quality and quantity of its advertising services and concealing those misrepresentations from auditors," Principal Deputy Assistant Attorney General John P. Cronan said in a media release.
As described in the agreement, after reviewing the Company's cooperation and remediation efforts, among other considerations, the DOJ determined not to prosecute Outcome Health for the past misconduct of the Company's founders and select former employees, all of whom are no longer affiliated with the Company.
Outcome CEO Matt McNally said the company is "thrilled to resolve this matter, as it enables us to move forward and focus on our mission to be the indispensable partner to patients, providers and industry partners during moments of care."
For the past two years, Outcome has overhauled its compliance and campaign-reporting policies, McNally said.
"These actions included engaging third-party auditors to ensure reporting accuracy, investing in partnerships with organizations like BPA Worldwide to validate key performance indicators, overhauling internal controls to improve the reliability of reporting, and forming an all-new leadership team, myself included," he said.
Outcome has already repaid drug makers about $65.5 million using cash payments and in-kind services, and has set aside $4.5 million to compensate any other claimants.
The resolution doesn't require Outcome to compensate scammed lenders and investors because many of them now own the company.
More than 1,500 hospitals will get higher Medicare payments from the program in FY 2020.
Hospitals could receive as much as $1.9 billion from the federal government in 2020 under projections put forward this week for the Hospital Value-based Purchasing Program, the Centers for Medicare & Medicaid Services announced.
In FY 2020, more than 1,500 hospitals – about 55% of participants – will get higher Medicare payments from the program, which is in its eighth year.
The law sets aside 2% of Inpatient Prospective Payment System payments for the approximately 2,700 participating hospitals, which is then distributed to hospitals based on the quality and cost for inpatient care.
The Total Performance Score for hospitals is based on performance scores in four metrics; clinical outcomes, safety, person and community engagement, and efficiency and cost reduction. Each metric accounts for 25% to the total score.
Almost 60% of hospitals will see a small fluctuation in Medicare payments between -0.5% and 0.5% percent, with an average net payment adjustment of 0.16%. The average net increase is 0.60%, and the average net decrease is -0.39%.
The highest performing hospital in FY 2020 will receive a net increase of 2.93%, and the lowest performing hospital will see a net decrease of -1.72%.
The incentive payments earned back will depend on each hospital’s Total Performance Score, value-based incentive payment percentage, and money available under the program.
The payments will depend upon:
How hospitals performed—compared to peers—on quality and cost metrics during a performance period.
How much they have improved the quality of patient care over time.
Hospitals must have a domain score for at least three of the four TPS metrics to have a TPS calculated. Hospitals that don't do not have their payments adjusted in the corresponding fiscal year.
For FY 2020, the average TPS across all participating hospitals increased to 38.5 from 38.1 in FY 2019.
Rural hospitals performed better in the Safety, Person and Community Engagement, and Efficiency and Cost Reduction domains, while urban hospitals performed better in the Clinical Outcomes domain.
For FY 2020, the average TPS across all rural hospitals of 42.8 was greater than the national average TPS.
Smaller hospitals also performed better in the Safety, Person and Community Engagement, and Efficiency and Cost Reduction domains and had higher overall TPS. Urban hospitals performed better in the Clinical Outcomes domain.
For FY 2020, the average TPS across all rural hospitals is 42.8, which is greater than the national average TPS.
Medicare patients treated by clinicians who are later banned for fraud and abuse are 14% to 17% more likely to die than patients treated by non-excluded clinicians.
New research shows that Medicare fraud and abuse costs more than wasted tax dollars.
Johns Hopkins researchers estimate that Medicare fee-for-service patients treated by clinicians who later are banned from the federal healthcare program for fraud were as much as 17% more likely to die than patients treated by non-excluded clinicians.
In 2013, that fraud and abuse contributed to 6,700 premature deaths, and study lead author Lauren Nicholas says that number is a low-ball estimate because it does not factor in other government-sponsored health insurance, commercial health insurance or the uninsured.
"The biggest take home message for us was the extent to which fraud and abuse should really be thought of not only is a financial problem, but as a public health challenge," says Nicholas, an assistant professor in the Johns Hopkins Bloomberg School’s Department of Health Policy and Management.
The study also found that patients treated by later-banned providers were 11% to 30% more likely to experience an emergency hospitalization within a year.
Nicholas says the higher mortality rates of patients of later-banned clinicians are "directly related to the crimes that these perpetrators are committing in order to bill Medicare for additional revenue."
"A lot of these perpetrators do things like illegally disseminate dangerous drugs. There are cases where they're doing medically contraindicated surgery because surgery is a lucrative thing to bill for, or they're using fraudulent make-your-own chemotherapy," she says. "It's hard to believe some of the things that people will do to be able to bill for it, and these things are incredibly dangerous for the patients who then get exposed to it."
“We found that even a single visit with a provider later excluded for fraud and abuse increased the risk of dying compared to someone who lived in the same county and had the same health status but did not see an excluded provider,” Nicholas says.
In the analysis, the Johns Hopkins researchers looked at providers banned from Medicare for fraud and abuse by the Department of Health and Human Services’ Office of the Inspector General between 2012 and 2018.
The researchers linked the banned providers to a random sample of the Medicare patients treated by excluded providers.
The study sample included 8,204 Medicare FFS patients who were first treated by a provider later banned for fraud and abuse in 2013 and a comparison group of 296,298 patients treated by a randomly selected provider who had not been banned for fraud and abuse.
Before the fraud exposure, the two groups were in similar health. Nicholas and her colleagues followed patients for up to three years to identify differences in mortality and hospitalization.
Nearly one-quarter—23%—of patients seen by banned providers were non-white while 16.5% of patients treated by non-excluded providers were non-white.
Patients treated by banned providers were more likely to be disabled, (27.2% vs. 18.6%) and dually enrolled in Medicare and Medicaid, (34.7% vs. 21.9%).
More than 47,000 clinicians have been banned from Medicare and Medicaid, and the fraud and abuse associated with the program costs as much as $140 billion a year.
A further breakdown of the patient-clinician mix shows that 60% of patients in the sample were treated by providers committing fraud. Of those patients, 14% were treated by providers who had committed patient harm, and 24% were treated by providers practicing with a revoked license.
Providers excluded for fraud had the highest mortality rate. Their patients were 17.3% more likely to die than patients not treated by a banned provider.
Patients treated by providers banned for patient harm were 13.7% more likely to die, and patients who were treated by providers banned for revoked licenses were 14.8% more likely to die.
Residents who experience mistreatment during training have greater risks of burnout and suicidal thoughts.
Half of general surgery residents reported experiencing workplace harassment at least a few times a year, with much of the mistreatment coming from patients and their families, and attending surgeons.
The survey of 7,409 residents in 262 residency training programs across the nation — more than 99% of general surgery residents in the United States — found the most common workplace mistreatment were sex discrimination (32%), verbal abuse/bullying (30%), racial discrimination (16.6%), and sexual harassment (10.3%).
"Exposure to workplace mistreatment was the largest driver of surgical residents' burnout," study principal investigator Karl Y. Bilimoria, MD, said in comments accompanying the report.
"Preventing these types of mistreatment could reduce the huge problem of burnout in the specialty of surgery," said Bilimoria, director of the Surgical Outcomes and Quality Improvement Center at Northwestern University Feinberg School of Medicine, Chicago.
The survey findings presented Monday at the American College of Surgeons Clinical Congress 2019 in San Francisco and published on the New England Journal of Medicine website.
The survey found that:
Nearly 31% of residents reported the frequency of mistreatment as a few times per year, and 19% reportedly experienced mistreatment a few times or more each month.
Women, who represent less than 40% of the survey respondents, were twice as likely to report mistreatment as their male colleagues: 70.6% versus 36%.
Nearly half (47.4%) of the racial discrimination complaints and 43.6% of sexual harassment complaints were prompted by interactions with patients and their families.
Attending surgeons were the most frequent sources for verbal or physical abuse toward residents (52%) and sexual harassment (27.2%).
Symptoms of burnout—emotional exhaustion and depersonalization—occurred weekly among 38.5$ of residents.
Residents reported a 4.5% rate of suicidal thoughts during the past year.
Women were 33% more likely to report burnout symptoms. However, Bilimoria said that when the findings were adjusted for exposure to mistreatment, there was no sex-based difference in burnout frequency, suggesting that more frequent harassment explains women residents' higher incidence of burnout.
The prevalence of surgical residents' mistreatment is concerning, Bilimoria said, but he noted that some residency programs had very low or no rates of mistreatment, which he said shows that improvements are doable.
Bilimoria said he was surprised to learn from the survey that patients and their families accounted for the bulk of racial and sex discrimination for residents.
"It completely changes how we should intervene," he said. "We need to arm residents with the skills and ability to address discrimination from patients and patients' families affecting them and their colleagues."
Chronic Disease Fund, Inc., and Patient Access Network Foundation allegedly worked with drug makers to funnel money to Medicare patients taking drugs the companies sold.
Two foundations will pay a combined $6 million to settle allegations that they enabled pharmaceutical companies to pay kickbacks to Medicare patients, the Department of Justice said.
The foundations – Chronic Disease Fund, Inc. doing business as Good Days from CDF, and Patient Access Network Foundation – will pay $2 million and $4 million, respectively, to resolve the alleged violations of the False Claims Act, federal prosecutors in Boston said.
The government alleged that the two foundations worked with several drug makers to design and operate funds that funneled money from the companies to patients taking the specific drugs the companies sold.
"These schemes enabled the pharmaceutical companies to ensure that Medicare patients did not consider the high costs that the companies charged for their drugs," DOJ said. "The schemes also minimized the possibility that the companies' money would go to patients taking competing drugs made by other companies."
Federal prosecutors said that, from 2010 through 2014, CDF conspired with five pharmaceutical companies – Novartis, Dendreon, Astellas, Onyx, and Questcor – to pay kickbacks to Medicare patients taking their drugs.
Prosecutors also allege that, from 2011 through 2014, PANF permitted four pharmaceutical companies– Bayer, Astellas, Dendreon, and Amgen – to use PANF as a conduit to pay kickbacks to Medicare patients taking their drugs.
The settlements were determined based on analysis of each foundation's ability to pay.
The Anti-Kickback Statute bans drug makers and third-party co-pay foundations from paying any remuneration to induce Medicare patients to purchase the companies' drugs.
Andrew E. Lelling, U.S. Attorney for the District of Massachusetts, said the government's allegations made plain that "CDF and PANF functioned not as independent charities, but as pass-throughs for specific pharmaceutical companies to pay kickbacks to Medicare patients taking their drugs."
"As a result, CDF and PANF enabled their 'donors' (the pharmaceutical companies) to undermine the Medicare program at the expense of American taxpayers," Lelling said.
The curriculum addresses financial and regulatory issues facing rural hospital in Georgia.
A new law in Georgia requires rural hospital executives and board members to attend eight hours of classroom time to bone up on the issues and economics that smaller hospitals face.
The law, which allows the state to withhold funding and tax credits for hospitals that don't comply, was passed by the state legislature last year, and comes as the Peachtree State has seen seven rural hospitals shuttered since 2010. Another 26 small hospitals are considered to be at "high financial risk,"according to the consulting firm Navigant.
Chuck Adams, a former rural hospital CEO and now executive vice president of the Georgia Hospital Association, and director of the Center for Rural Health, spoke with HealthLeaders about the program, and what it hopes to achieve. The following is a lightly edited transcript.
HLM: Where did this idea come from?
Adams: The state set up a $60 million a year rural hospital tax credit program that allows companies and individuals to donate directly to the hospital and get that tax credit back. Because of that and because the state was putting other resources into rural healthcare they wanted to make sure that the education and resources at the local level were adequate. The legislators felt like it would set a baseline and help our rural hospitals.
The landscape of rural healthcare is changing, and these boards and leaders need to be open to all the new technology and new models that are out there.
HLM: How long is the course, and what does it cover?
Adams: It's very flexible. They selected Mercer School of Medicine in Macon, Georgia to be the institution that develops the Georgia Rural Health Innovation Center, which then developed the curriculum and training guidelines.
The guidelines came out in June and it involves eight hours of training for eight different standards. Current board members have to be trained by the end of 2020. They get their initial eight hours and it's good for two years.
It covers governance, regulatory agencies, financial and judiciary responsibilities, compliance, ethics, continuum of care, strategic planning, and grant management.
How much will this cost?
Adams: It's going to be about $2,500 per facility for unlimited participants. We're going to have training throughout the year in many different formats, live in person, live interactive webinars, on demand modules. We want it to be convenient for our hospitals and board members so they can do it on their own time.
HLM: This seems to be designed mostly for board members. Why should CEOs and CFOs be required to take these courses?
Adams: The state wants them to see the training that their board members are going through as well, so everybody's on the same page.
HLM: Describe is the typical rural hospital board member that this course is designed for.
Adams: They're leaders in the community who have a vested interest in that community and that hospital. They might not necessarily have a wealth of knowledge with respect to how hospital runs, but they've got the commitment.
HLM: What metrics will you use to determine if this program is working?
Adams: Every session will have a test. If they don't pass, they have to retake the course and can't go to the next course until they get through it. And there will be course evaluations that are the required. Every participant, once they take a course, will give us feedback so we can use our own quality control to make sure we're teaching what they need to be taught.
HLM: When does the course begin?
Adams: Right now they are no approved trainers in Georgia. Our application is in process and we know it will be approved. So, we're going to kick ours off on January 1st.
HLM: Are there penalties for hospitals that do not comply with the law?
Adams: If you read the legislation, it says the state "may" discontinue their involvement in the rural hospital tax credit program and other state funded grants.
HLM: If the Georgia Legislature is sincere about helping rural hospitals, why don't they expand Medicaid?
Adams: They're working on it. They did pass last year some legislation to begin the Medicaid waiver process, and the state has hired a consulting firm. We're hopeful that there will be some increased access of care through that.
As many as 5% of patients leaving the hospital with an infection have a 30-day readmission for that preexisting infection.
A disproportionately high number of seniors return to the hospital within 30 days of discharge for pre-existing infections that were presumably treated during the first hospital stay, according to a study from Michigan Medicine.
"We found that as many as 5% of patients leaving the hospital with an infection have a readmission for that preexisting infection—that's bad," said study lead author Geoffrey Hoffman, assistant professor in the U-M School of Nursing.
Hoffman and his colleagues looked Medicare records for more than 318,000 hospital discharges for patients 65 and older and found that 2.5% of them return because of linked infections.
The most common infection was Clostridioides difficile (roughly 5% readmission), followed by urinary tract infections (2.4% readmission).
The 2.5% readmission rate looks small, Hoffman said, but he stressed that hospitals know how to treat these infections, and know patient has the infection upon discharge.
"Presumably they've been treated for the infection since the hospital has already billed Medicare," Hoffman said. "Readmissions shouldn't be zero, but they should be much closer to zero."
The number of patients with the same diagnosis at readmission and discharge is very narrow, Hoffman said, so the number will by default be much smaller than overall hospital readmissions.
For instance, he said, heart failure and chronic obstructive pulmonary disease, or COPD, have about 10% and 8% linked readmission rates, respectively. Unlike infections, however, those complex conditions aren't entirely curable, so complications are more frequent.
Surprisingly, patients discharged home or to home care were 38% more likely to return with a linked infection than those discharged to skilled nursing facilities, Hoffman said.
"I was very surprised," he said. "This is somewhat conflated with the conventional wisdom, which is that skilled nursing facilities are warehouses for infection transmission."
"The fact that patients discharged to skilled nursing had lower readmission rates for Clostridioides difficile infections than people discharged home is pretty amazing, given that those patients by definition are sicker and would more likely to be readmitted than those discharged home," he said.
Hoffman said the findings show that infections spread at higher rates in SNFs, but they're also good at treating them.
"There are probably some gaps in self-care for patients going home with an infection from the hospital," he said. "This suggests home health care agencies aren't up to snuff with infection control and patients going home without home health care probably need better training, as do their caregivers."
The research was funded by the Agency for Healthcare Research and Quality, U-M Older Americans Independence Center Research Education Core and the U-M Pepper Center pilot.
ACOs with cardiologists may see lower spending for SNFs, ED visits, evaluation and management services and procedural care.
Medicare accountable care organizations that have cardiologists in their physician network save about $200 per patient per year when compared with ACOs that don't, new research shows.
Study senior author John Hollingsworth, MD, a urologist at Michigan Medicine, speculated that that the $200 annual savings in the ACOs with cardiologists was a result of lower spending for skilled nursing facilities, evaluation and management services and procedural care.
"While the mechanism is unclear, we speculate that ACOs with cardiologists may be more likely to develop efficient, appropriate, and value-centered referral pathways," Hollingsworth said in an email exchange with HealthLeaders.
The Agency for Healthcare Research and Quality-funded study looked at Medicare data for 1.6 million patients per year with cardiovascular disease, including heart attacks, atrial fibrillation, congestive heart failure and ischemic heart disease.
Although the number of ACOs more than tripled–from 114 in 2012 to 392 in 2015–from 2012 through 2015, the proportion of ACOs with cardiologist participation remained at 80% in 2012 to 83% in 2015.
Outcomes for heart failure admission rates, ED visits and hospital readmissions were the same between the two ACO models.
"We try to disentangle whether the reduced spending is related to cardiologist participation or other unmeasured characteristics of ACOs and find evidence to suggest the former," Hollingsworth said.
"For instance, in some practices, a new diagnosis of atrial fibrillation may lead to costly ED visits or hospitalizations, whereas in other practices it may be managed safely and effectively as an outpatient with expedited cardiology outpatient follow-up," he said.
