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ACOs with high share of minority patients struggle with quality performance, study says

Higher proportion of minority patients was associated with worse scores on 25 of 33 Medicare quality performance measures.

Jeff Lagasse, Associate Editor

Accountable Care Organizations with a high share of minority patients may struggle with quality performance under ACO contracts, especially during their early years of participation, according to new research published in Health Affairs.

Using data from Medicare and a national survey of ACOs, the authors found that having a higher proportion of minority patients was associated with worse scores on 25 of 33 Medicare quality performance measures. Yet those ACOs were similar to the rest when it came to things such as provider compensation, services and clinical capabilities.

Based on the research, the authors said it's likely that providers serving large proportions of minority patients may not have the resources necessary to transform care at the needed rate. They may also struggle to meet performance targets set by Medicare or commercial payers. If this is the case, lagging performance under new payment models by providers with large proportions of minority patients could exacerbate disparities in quality and call into question the viability of payment and delivery reforms.

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Authors said other underlying socioeconomic factors may also be at work. Compared to patients in other ACOs, patients in ACOs with a high proportion of minorities were, on average, more likely to be younger than 65, dually eligible for Medicare and Medicaid, disabled and female, and to have end-stage renal disease.

Overall, the results indicate that ACOs serving a high proportion of minorities had patients who were higher risk, somewhat sicker or more costly, and perhaps disadvantaged in other ways as compared to other ACOs. There were no significant differences between the two groups of ACOs in terms of number of clinicians or proportion of primary care physicians.

On average, ACOs with a high proportion of minority patients also had a lower overall quality composite score, the research showed, meaning that they were eligible for a smaller share of the cost savings they generated. And when it came to improving their quality performance, they were unable to catch up to other ACOs, although they also didn't fall further behind. This difference in performance occurred across many types of measures, including both clinical and process measures.

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The study had some limitations. Certain patient-level characteristics, like income and education, weren't measured, and those could contribute to or partially explain the association between the racial composition of an ACO's patient population and the organization's performance. Further, the association could be be reduced by implementing certain interventions, such as improving social supports, transportation, housing supports, supportive employment and education programs.

Still, the authors were troubled by the implications. Providers may decide not to participate in programs such as ACOs if they are concerned about their ability to meet performance metrics, they said. Or they might be unprepared or incapable of participating in the programs successfully. As Medicare tries to move an increasing share of healthcare providers to alternative payment models, the uneven mix and diversity of providers participating in ACO programs could have implications for patient-level disparities and outcomes.

The authors recommended several steps to address the issue, such as using additional risk adjustment for quality outcomes to take into account the socioeconomic characteristics of patients, such as race or income. This adjustment, they said, could make comparisons of provider quality more fair by taking into account factors that are beyond a provider's control, such as patients' financial resources.

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They said it's also crucial to identify the ideal model for financially rewarding quality performance. Policymakers, they said, should seek to understand the extent to which current quality measures encourage high performance among all providers, instead of penalizing providers for their patient population.

Twitter: @JELagasse

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