Healthcare systems have been expanding, not only with regard to the numbers of people covered, but also the complexity of care across a lifespan. At the same time, healthcare has been shifting from traditional fee-for-service models to value-based systems that evaluate outcomes and costs.

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) was a prime driver of the transition to value-based systems, by repealing the traditional sustainable growth rate (SGR) methodology for updating calculations for the Medicare physician fee schedule.1 

In its place, MACRA set standards for annual flat fee updates over the course of a decade, with a 2-track fee schedule update called the Quality Payment Program, which will be implemented in 2019 and provide new tools, models, and resources to help providers make the best decisions for individual patients.1,2

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Accountable Care Organization Models

Accountable Care Organizations (ACOs) are increasingly taking responsibility for healthcare management, recordkeeping, and payment.1,2 These organizations generally take on administrative functions that support care management and risk analysis designed to keep costs down. 

In adapting to Medicaid changes, multiple states have adopted different types of ACO systems. A recent issue of JAMA Internal Medicine featured coverage of 3 variations of ACO payment models. McConnell, et al 3 conducted an assessment of Oregon’s federally funded Coordinated Care System compared with Colorado’s Medicaid Accountable Care Collaborative (ACC), while McWilliams and colleagues4 reviewed the Medicare Shared Savings Program (MSSP) used by many ACOs to manage post-acute care.

Oregon vs Colorado Systems

In 2012, the state of Oregon moved to a network of 16 Coordinated Care Organizations (CCOs) largely funded by $1.9 billion in federal aid. Colorado reorganized in 2011 into 7 Regional Care Collaborative Organizations (RCCOs) that receive support for matching Medicaid patients with providers. The McConnell study evaluated the care provided for a total of 782,882 patients in the 2 systems — 452,371 from Oregon and 350,511 from Colorado.3

Both programs demonstrated reductions in expenditures from 2010 to 2014, with key differences in methods. “The reforms were similar in their regional focus and emphasis on primary care, but the Oregon program was more comprehensive in its scope of benefits covered as well as its use of global budgets and downside financial risk as a mechanism for cost control,” the investigators wrote. Oregon made substantial investment in data infrastructure and the hiring of new personnel support for administration and training to implement the program.

The demographics were similar in the 2 state cohorts: 55% female overall, with a mean age of 16.74 (standard deviation [SD] 14.41) that was slightly lower in the Colorado group. There was no significant difference in standardized monthly expenditures per patient member between the 2 groups after adjusting for demographics and health risk ($2.00; 95% CI, −$0.79-$4.78); however, costs in Oregon than in Colorado were higher in the second year of implementation ($4.37; 95% CI, $0.01-$8.73).

This article originally appeared on Neurology Advisor