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Background In 2012, Medicare introduced Shared Savings Program (MSSP) accountable care organizations (ACO) model to improve the value of health care services as a part of the national comprehensive Accountable Care Act. While the effect of the MSSP on primary care has been extensively analyzed, little is known about the effect of the MSSP on cost and quality of surgical care, in particular the use of high-cost robotic surgical modalities. Hospitals routinely market robotic procedures as an indicator of high quality, despite limited evidence of their clinical value. This study examines the relationship between hospital participation in the MSSP and use of robotic surgery. Methods We conducted a retrospective analysis using 2016–2019 publicly available data on hospital MSSP participation and use of robotic-assisted procedures in New York State. Using bivariate and multivariate approaches, we identified hospital characteristics associated with the use of robotic technique and hospital quality. Results Of the 157 general hospitals in NYS, 83 (53%) offered robotic surgery and 73 (47%) participated in the MSSP. MSSP-affiliated hospitals were more selective in the type of robotic procedures than non-MSSP hospitals, favoring procedures with stronger evidence-base such as prostatectomies. Hospitals that performed robotic surgery selectively had significantly lower spending per patient ( p  = 0.04). Higher volume of robotic procedures correlated with higher hospital ranking. Conclusions MSSP participation is associated with more selective use of robotic procedures and lower hospital spending. More research is needed to understand the relationship between hospital investments in quality improvement, use of robotic surgery and hospital performance rankings.

We aim to assess the healthcare value achieved from a shared savings program for pediatric appendectomy. All appendectomy patients covered by our health plan were included. Quality targets were 15% reduction in time to surgery, length of stay, readmission rate, and patient satisfaction. Quality targets and costs for an appendectomy episode in two 6-month performance periods (PP1, PP2) were compared to baseline. 640 patients were included (baseline:317, PP1:167, PP2:156). No quality targets were met in PP1. Two quality targets were met during PP2: readmission rate (−57%) and patient satisfaction. No savings were realized because the cost reduction threshold (−9%) was not met during PP1 (+1.7%) or PP2 (−0.4%). Payer-provider partnerships can be a platform for testing value-based reimbursement models. Setting achievable targets, identifying affectable quality metrics, considering case mix index, and allowing sufficient time for interventions to generate cost savings should be considered in future programs. •Assessed the medical value of a Shared Savings Program for pediatric appendicitis.•Quality targets included time to surgery, length of stay, readmission, and patient satisfaction.•Two quality targets were met during the study period, readmission and satisfaction.•However, no savings were realized because the cost threshold was not met.•Payer-provider partnerships can be a platform for testing value-based reimbursement.

In 2012, the Centers for Medicare and Medicaid Services (CMS) initiated the Medicare Shared Savings Program (MSSP) and Pioneer Accountable Care Organization (ACO) programs. Organizations in the MSSP model shared cost savings they generated with CMS, and those in the Pioneer program shared both savings and losses. It is largely unknown what hospital and environmental characteristics are associated with the development of CMS ACOs with one- or two-sided risk models. The aim of this study was to assess the organizational and environmental characteristics associated with hospital participation in the MSSP and Pioneer ACOs. Hospitals participating in CMS ACO programs were identified using primary and secondary data. The ACO hospital sample was linked with the American Hospital Association, Health Information and Management System Society, and other data sets. Multinomial probit models were estimated that distinguished organizational and environmental factors associated with hospital participation in the MSSP and Pioneer ACOs. Hospital participation in both CMS ACO programs was associated with prior experience with risk-based payments and care management programs, advanced health information technology, and location in higher-income and more competitive areas. Whereas various health system types were associated with hospital participation in the MSSP, centralized health systems, higher numbers of physicians in tightly integrated physician-organizational arrangements, and location in areas with greater supply of primary care physicians were associated with Pioneer ACOs. Favorable hospital characteristics were, in the aggregate, more important than favorable environmental factors for MSSP participation. MSSP ACOs may look for broader organizational capabilities from participating hospitals that may be reflective of a wide range of providers participating in diverse markets. Pioneer ACOs may rely on specific hospital and environmental characteristics to achieve quality and spending targets set for two-sided contracts. Hospital and ACO leaders can use our results to identify hospitals with certain characteristics favorable to their participation in either one- or two-sided ACOs.

Accountable Care Organizations (ACOs) seek sustainable innovation through the testing of new care delivery methods that promote shared goals among value-based health care collaborators. The Morehouse Choice Accountable Care Organization and Education System (MCACO-ES), or (M-ACO) is a physician led integrated delivery model participating in the Medicare Shared Savings Program (MSSP) offered through the Centers for Medicare and Medicaid Services (CMS) Innovation Center. The MSSP establishes incentivized, performance-based payment models for qualifying health care organizations serving traditional Medicare beneficiaries that promote collaborative efficiency models designed to mitigate fragmented and insufficient access to health care, reduce unnecessary cost, and improve clinical outcomes. The M-ACO integration model is administered through participant organizations that include a multi-site community based academic practice, independent physician practices, and federally qualified health center systems (FQHCs). This manuscript aims to present a descriptive and exploratory assessment of health care programs and related innovation methods that validate M-ACO as a reliable simulator to implement, evaluate, and refine M-ACO’s integration model to render value-based performance outcomes over time. A part of the research approach also includes early outcomes and lessons learned advancing the framework for ongoing testing of M-ACO’s integration model across independently owned, rural, and urban health care locations that predominantly serve low-income, traditional Medicare beneficiaries, (including those who also qualify for Medicaid benefits (also referred to as “dual eligibles”). M-ACO seeks to determine how integration potentially impacts targeted performance results. As a simulator to test value-based innovation and related clinical and business practices, M-ACO uses enterprise-level data and advanced analytics to measure certain areas, including: 1) health program insight and effectiveness; 2) optimal implementation process and workflows that align primary care with specialists to expand access to care; 3) chronic care management/coordination deployment as an effective extender service to physicians and patients risk stratified based on defined clinical and social determinant criteria; 4) adoption of technology tools for patient outreach and engagement, including a mobile application for remote biometric monitoring and telemedicine; and 5) use of structured communication platforms that enable practitioner engagement and ongoing training regarding the shift from volume to value-based care delivery.

Financial incentives offered by insurers to health care providers have been identified as a key mechanism to lower costs while improving quality of care. How to effectively design incentive programs that can align the varying objectives of health care stakeholders, as well as predict program performance and stakeholders’ decision response is an unresolved research challenge. The objective of this paper was to establish the foundation for a novel approach based on multiscale decision theory (MSDT) that can effectively model and efficiently analyze such incentive programs, and the complex health care system in general. The MSDT model captures the interdependencies of stakeholders, their decision processes, uncertainties, and how incentives impact decisions and outcomes at the payer, hospital, physician and patient level. We illustrate the modeling approach by applying it to a specific incentive program, the Medicare Shared Savings Program (MSSP) for Accountable Care Organizations (ACOs), which was introduced by the Centers for Medicare and Medicaid Services (CMS) in the United States in 2012. We focus our analysis on computed tomography (CT) use by physicians, and CT scanner investment decisions by hospitals. We determine the conditions under which the incentive program leads to the desired outcomes of cost reduction and quality of care improvements. The results have policy and managerial implications for CMS, ACOs and their members, specifically hospitals and physicians.

Given the history and dynamics of the Patient Protection and Affordable Care Act, nursing homes have been left out of the business of Accountable Care Organization (ACO) development and implementation over the last year. Only now are ACOs, hospitals, and physicians realizing that an effective ACO needs long-term care and rehabilitation as a key component to maximize shared savings in the ACO environment. This article discusses the history of ACO development, examines why nursing homes may have been left out, and explains why nursing homes are critical participants in ACO effectiveness. The article also discusses how nursing homes will need to position their businesses for ACO participation.

Differences in financing mechanisms and sources and in the allocation and flows of funding are frequently cited as a major barrier for the implementation of more integrated approaches to service delivery. In response, countries have experimented with different financial instruments and mechanisms, such as setting aside dedicated resources to support the development and implementation of innovative care models, introducing new forms of paying providers in order to incentivise coordination and integration, shifting the responsibility for funding of particular components of service delivery between funding agencies, or introducing pooled budgets to integrate health and social care. This chapter provides an overview of the different ways countries have sought to change financing and payment mechanisms at different levels in order to enable better coordination among providers in the delivery of health services and between health and social care and thus support integration.

The U.S. healthcare system has a history of continuous organizational change. The result is by no means a perfect healthcare system. A byproduct of this history is a large number of experiments, making the U.S. probably the largest laboratory for healthcare delivery reform in the world. Both quality and costs are pressing issues for U.S. healthcare reform. Efforts to address these issues by means of integrated care delivery and innovative payment models are mostly driven by the Centers for Medicare and Medicaid Services (CMS). Many of CMS’s reform efforts can be linked to goals that are known as the Triple Aim: improving the experience of care and the health of populations while reducing per-capita costs. These aims conflict with traditional, fragmented delivery structures and fee-for-service (FFS) payments, which are still the norm for reimbursing providers. One of the most discussed alternative payment models is the accountable care organization (ACO). This chapter illustrates the concept of ACOs and discusses some preliminary findings on the impact of this mode of integrated care delivery.

Transformation of the US health-care system and payment models was inevitable. In 2013, US health-care spending reached $2.9 trillion annually, approaching 18 % of the gross domestic product. Prior to passage of the Affordable Care Act, it was widely acknowledged that the Medicare Trust fund would enter deficit spending by approximately 2017. At the same time, there was growing consumer recognition that the costs of health insurance and the amount of out-of-pocket co-pays and deductible payments were outpacing rates of wage growth. The ever-increasing expenditures on health care in the US were not sustainable and reports from the Institute of Medicine (http://resources.iom.edu/widgets/vsrt/healthcare-waste.html) highlighted that up to 30 % of health-care spending is wasted on things such as unnecessary clinical services, excessive administrative costs, inefficiently delivered services, prices that are too high, fraud, and missed prevention opportunities.