Changes in patients' experiences in Medicare Accountable Care Organizations

Abstract

Background: Incentives for accountable care organizations (ACOs) to limit health care use and improve quality may enhance or hurt patients' experiences with care.

Methods: Using Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey data covering 3 years before and 1 year after the start of Medicare ACO contracts in 2012 as well as linked Medicare claims, we compared patients' experiences in a group of 32,334 fee-for-service beneficiaries attributed to ACOs (ACO group) with those in a group of 251,593 beneficiaries attributed to other providers (control group), before and after the start of ACO contracts. We used linear regression and a difference-in-differences analysis to estimate changes in patients' experiences in the ACO group that differed from concurrent changes in the control group, with adjustment for the sociodemographic and clinical characteristics of the patients.

Results: After ACO contracts began, patients' reports of timely access to care and their primary physicians' being informed about specialty care differentially improved in the ACO group, as compared with the control group (P=0.01 and P=0.006, respectively), whereas patients' ratings of physicians, interactions with physicians, and overall care did not differentially change. Among patients with multiple chronic conditions and high predicted Medicare spending, overall ratings of care differentially improved in the ACO group as compared with the control group (P=0.02). Differential improvements in timely access to care and overall ratings were equivalent to moving from average performance among ACOs to the 86th to 98th percentile (timely access to care) and to the 82nd to 96th percentile (overall ratings) and were robust to adjustment for group differences in trends during the preintervention period.

Conclusions: In the first year, ACO contracts were associated with meaningful improvements in some measures of patients' experience and with unchanged performance in others. (Funded by the National Institute on Aging and others.).

Figure 1. Survey and Study Periods Relative to the Start of Accountable Care Organization (ACO) Contracts in 2012

The Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey of fee-for-service Medicare beneficiaries is administered annually from March through May; in the period from 2010 through 2013, a total of 82.2% of the respondents were surveyed by the end of April. The 2013 survey was administered 8 to 14 months after Medicare Shared Savings Program (MSSP) ACO contracts started in April or July of 2012 (the first and second rounds, respectively) and 14 to 17 months after Pioneer ACO contracts started in January 2012. The 2012 survey was administered an average of 3 months after the start of Pioneer ACO contracts, but the reference period included up to 4 months before the start dates because the CAHPS questions on patients’ experiences refer to the preceding 6 months of care. We did not expect substantial changes in patients’ experiences within 3 months after exposure to ACO contract incentives, and the 2012 survey reference period overlapped minimally with the MSSP ACO contract periods. Accordingly, we defined the preintervention period to include survey data from the period from 2010 through 2012 and the postintervention period to include 2013 survey data.