Profiling ACO Success: PCP Visits
Primary care physicians are at the core of ACO management; they help manage chronic diseases, foster patient health engagement, and coordinate proactive care services. Effective primary care management will then impact the spend and utilization of higher-cost services downstream.4
One place where we see the impact of the COVID-19 pandemic is in the reduction of PCP visits. While the trends identified in 2019 still continued in 2020, we saw an overall reduction of PCP visits across the board by 10-15%.
In 2019, we saw the top quintile of ACOs having 12,000 PCP visits per 1,000 beneficiaries which was also more than any other quintile. However in 2020, we see a reduction in PCP visits per 1,000 across all quintiles, with the top quintile having only about 10k/1k. The bottom quintile actually obtained more PCP visits than any other quintile except the top with 9,772. One trend that we notice among top-performing ACOs is a higher utilization of primary care, but this data is also a reminder that what actually takes place during the PCP visits is important, as well. As we see in the next section, despite having almost as many PCP visits per 1k than the top quintile, the bottom quintile of ACOs still had lower compliance with preventive care and care management services.
Profiling ACO Success: Are Preventative Care & Care Management services being leveraged?
The next step of our analysis included how ACOs are performing on two different categories of care: Preventative Treatment such as Annual Wellness Visits & Flu Shots, and Care Management including Transitional Care Management & Advanced Care Planning visits. These services enable primary care practices to help patients stay healthy and out of the hospital by spending more time focused on prevention and wellness and, where appropriate, coordinate resources to ensure proper post-acute care management.5 Below, we see how these performances break out across quintiles.
The first and most important takeaway is that Annual Wellness Visit (AWV) compliance was 5% higher for the top quintile of ACOs than it was for the second quintile, and 8% higher than it was for the bottom quintile of ACOs. AWVs are a special type of primary care visit where providers work with patients to perform a Health Risk Assessment (HRA) and create or update a patient’s Personalized Prevention Plan.1 Annual Wellness Visits are crucial to better clinical care. A study conducted by Aledade found that patients who received their first AWV experienced a meaningful reduction in adjusted total healthcare costs of 5.7 percent, with the greatest association seen for the highest-risk patients.5Additionally, overall AWV compliance decreased for the first, second, and fifth quintile of ACOs from 2019 to 2020, but increased for the third and fourth.
Flu shot compliance however, increased year over year with an average increase of approximately 3% across quintiles. While we can clearly see the impact of COVID in the reduction of AWVs and PCP visits, we see that it had little negative impact, or possibly even positive impact on the number of flu shots. As we prepare to evaluate 2021 performance of the MSSP program, adding COVID vaccination rate will be another key metric that we will assess. Stay tuned for information in a follow-up post.
Other visit types include Transitional Care Management (TCM) and Advanced Care Planning (ACP). TCM is intended for primary care physicians to help facilitate the hand-off period following an inpatient, SNF or other facility stay into a home or community setting. TCM visits can help prevent readmissions and reduce costs by ensuring a smooth transition of care.6 Through our data, we see that TCM compliance mostly held steady from 2019 to 2020 with the top quintile of ACOs maintaining their 24% compliance rate. All the while, the top quintile ACOs maintained higher rates of TCM compliance, with the bottom quintile having the lowest TCM performance.
ACP visits are used to establish the medical wishes of a patient if they become unable to make decisions.7 The trend in ACP services is clear however, with the top quintile of ACOs having the highest ACP compliance, followed by a clear downward trend through the quintiles. As shown in the data above, ACOs with higher savings are more frequently leveraging ACP visits, and while it remains underutilized across the industry, we see a modest 1% uptick in usage with ACP compliance since 2019 in every quintile except the second quintile where it remained even.
One interesting trend: for the top quintile of ACOs, having more PCP visits is associated with higher rates of AWV, Flu Shot, TCM, and ACP compliance. But for the bottom quintile, more PCP visits is associated with a lower rate of AWV, Flu Shot, TCM, and ACP compliance. Visiting a PCP more often is usually beneficial, but it does not necessarily mean that the visits are accomplishing effective care management. It appears that not only is it necessary to have patients visit their PCP, but also that those visits accomplish important care management activities. The top performing ACOs are often making investments in provider performance management, using tools like CareJourney’s Provider Performance Index to provide feedback and coaching.
Profiling ACO Success: The Distressed Community Index
The Distressed Community Index is a five-part scale created by the Economic Innovation Group that examines economic well-being at the county level in order to illuminate the state of American prosperity. It incorporates seven components including high school graduation rates, vacant housing, prime age employment, median income ratio, changes in employment and business, and the poverty rate. The DCI labels communities prosperous, comfortable, mid-tier, at-risk, and distressed.
CareJourney has overlaid our data on the Medicare FFS population with the Distressed Community Index to determine the relationship between Distressed Communities and ACO Performance. The results are striking. At a high level we see top performing ACOs with better cost performance in distressed communities than in prosperous communities, while also having the majority of the beneficiaries in prosperous and comfortable communities. The chart below compares ACO patient volumes and PMPY across ACO Performance Quintiles and DCI Indexes.
When we analyze the data, we find that while the ACOs are operating fairly evenly across distressed communities in terms of cost, with the greatest variance in PMPY differences between quintiles coming through their PMPY costs in distressed communities. In the below chart, we show the variance in PMPY for distressed communities.
Next, when we examine the variances in PMPY among the top- and bottom-performing ACOs we see that not only is there large variance in PMPY within the DCI there are also large differences across the DCI, with the largest variance coming within the most distressed communities.
The below chart shows the difference in Average Total PMPY between the top quintile of ACOs and the bottom quintile of ACOs for each community.
Taken together, this information tells us that ACOs are performing best on PMPY measures in Distressed communities, while deriving most of their volume from the least distressed communities.