Publications by authors named "John Z Ayanian"

260 Publications

Crucial Questions for US Health Policy in the Next Decade.

Authors:
John Z Ayanian

JAMA 2021 Apr;325(14):1397-1399

Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor.

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http://dx.doi.org/10.1001/jama.2021.1470DOI Listing
April 2021

Beneficiaries' perspectives on improved oral health and its mediators after Medicaid expansion in Michigan: a mixed methods study.

J Public Health Dent 2021 Mar 22. Epub 2021 Mar 22.

University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA.

Objective: To investigate self-reported improved oral health and its mediators, and job-related outcomes, of Medicaid expansion beneficiaries in Michigan.

Methods: This cross-sectional mixed-methods study of adult "Healthy Michigan Plan" (HMP) Medicaid expansion beneficiaries included qualitative interviews with a convenience sample of 67 beneficiaries enrolled for ≥6 months, a stratified random sample survey of 4,090 beneficiaries enrolled for ≥12 months; and Medicaid claims data. We examined unadjusted associations between demographic variables and awareness of dental coverage, self-reported dental care access, dental visits, and self-reported oral health; and between improved oral health and job seeking and job performance. Multivariate analysis examined factors associated with self-reported oral health improvement, adjusting for sociodemographic characteristics, prior health insurance, and having at least one dental visit claim.

Results: Among surveyed beneficiaries, 60 percent received ≥1 dental visit and 40 percent reported improved oral health. Adjusted odds ratios (aOR) for improved oral health were higher for African-American beneficiaries [aOR = 1.61; confidence interval (CI) = 1.28-2.03] and those previously uninsured for ≥12 months (aOR = 1.96; CI = 1.58-2.43). Beneficiaries reporting improved oral health were more likely to report improved job seeking (59.9 percent vs 51 percent; P = 0.04) and job performance (76.1 percent vs 65.0 percent; P < 0.001) due to HMP. Interviewees described previously unmet oral health needs, and treatments that improved oral health, functioning, appearance, confidence, and employability.

Conclusion: Michigan's Medicaid expansion contributed to self-reported improved oral health, which was associated with improved job outcomes. Policymakers should consider the importance of Medicaid dental coverage in reducing oral health disparities and improving the health and socioeconomic well-being of low-income adults and communities when considering this optional benefit.
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http://dx.doi.org/10.1111/jphd.12447DOI Listing
March 2021

Use of diabetes medications in traditional Medicare and Medicare Advantage.

Am J Manag Care 2021 03 1;27(3):e80-e88. Epub 2021 Mar 1.

Department of Health Care Policy, Harvard Medical School, 180 Longwood Ave, Boston, MA 02215. Email:

Objectives: To compare use of diabetes medications between beneficiaries enrolled in Medicare Advantage (MA) and traditional Medicare (TM).

Study Design: Retrospective cohort analysis of Medicare enrollment and Part D event claims during 2015-2016.

Methods: Data came from 1,027,884 TM and 838,420 MA beneficiaries who received at least 1 prescription for an oral or injectable diabetes medication. After matching MA and TM enrollees by demographic characteristics and geography, we analyzed use of medication overall, choices of first diabetes medication for those new to medication, and patterns of adding medications.

Results: Overall and for patients on 1, 2, or 3 diabetes medications, use of metformin was higher in MA by about 3 percentage points, but use of newer medication classes was 5.1 percentage points higher in TM overall (21.3% vs 16.2%). Use of guideline-recommended first-line agents was higher in MA. For those who started metformin first, use of a sulfonylurea as a second medication was 7.8 percentage points higher in MA than TM (61.5% vs 53.7%), whereas use of medications from newer classes was 7.7 percentage points lower (22.0% vs 29.7%). Mean total spending was $149 higher in TM for those taking 1 medication and $298 higher for those taking 2 medications. Differences in spending among MA plans were of similar magnitude to the MA-TM differences.

Conclusions: MA enrollees are more likely to be treated with metformin and sulfonylureas and less likely to receive costly newer medications than those in TM, but there also is substantial variation within MA. A limitation of the study is that we could not assess glucose control using glycated hemoglobin levels.
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http://dx.doi.org/10.37765/ajmc.2021.88602DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7967940PMC
March 2021

Threats to the Affordable Care Act and surgical care: What has been gained, and what could be lost.

Surgery 2021 Feb 27. Epub 2021 Feb 27.

Institute for Healthcare Policy and Innovation, University of Michigan Medical School, Ann Arbor, MI; Division of General Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI. Electronic address: https://twitter.com/jzayanian.

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http://dx.doi.org/10.1016/j.surg.2021.01.031DOI Listing
February 2021

ACO Awareness and Perceptions Among Specialists Versus Primary Care Physicians: a Survey of a Large Medicare Shared Savings Program.

J Gen Intern Med 2021 Jan 26. Epub 2021 Jan 26.

Dow Division of Health Services Research, Department of Urology, University of Michigan Medical School, Ann Arbor, MI, USA.

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http://dx.doi.org/10.1007/s11606-020-06556-wDOI Listing
January 2021

Evaluating a Widely Implemented Proprietary Deterioration Index Model among Hospitalized COVID-19 Patients.

Ann Am Thorac Soc 2020 Dec 24. Epub 2020 Dec 24.

University of Michigan Medical School, 12266, Ann Arbor, Michigan, United States.

Rationale: The Epic Deterioration Index (EDI) is a proprietary prediction model implemented in over 100 U.S. hospitals that was widely used to support medical decision-making during the COVID-19 pandemic. The EDI has not been independently evaluated, and other proprietary models have been shown to be biased against vulnerable populations.

Objective: To independently evaluate the EDI in hospitalized COVID-19 patients overall and in disproportionately affected subgroups.

Methods: We studied adult patients admitted with COVID-19 to non-ICU care at a large academic medical center from March 9 through May 20, 2020. We used the EDI, calculated at 15-minute intervals, to predict a composite outcome of ICU-level care, mechanical ventilation, or in-hospital death. In a subset of patients hospitalized for at least 48 hours, we also evaluated the ability of the EDI to identify patients at low risk of experiencing this composite outcome during their remaining hospitalization.

Results: Among 392 COVID-19 hospitalizations meeting inclusion criteria, 103 (26%) met the composite outcome. Median age of the cohort was 64 (IQR 53-75) with 168 (43%) Black patients and 169 (43%) women. Area under the receiver-operating-characteristic curve (AUC) of the EDI was 0.79 (95% CI 0.74-0.84). EDI predictions did not differ by race or sex. When exploring clinically-relevant thresholds of the EDI, we found patients who met or exceeded an EDI of 68.8 made up 14% of the study cohort and had a 74% probability of experiencing the composite outcome during their hospitalization with a sensitivity of 39% and a median lead time of 24 hours from when this threshold was first exceeded. Among the 286 patients hospitalized for at least 48 hours who had not experienced the composite outcome, 14 (13%) never exceeded an EDI of 37.9, with a negative predictive value of 90% and a sensitivity above this threshold of 91%.

Conclusions: We found the EDI identifies small subsets of high- and low-risk COVID-19 patients with good discrimination although its clinical utility as an early warning system is limited by low sensitivity. These findings highlight the importance of independent evaluation of proprietary models before widespread operational use among COVID-19 patients.
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http://dx.doi.org/10.1513/AnnalsATS.202006-698OCDOI Listing
December 2020

Medicaid Expansion and Surgical Care-Evaluating the Evidence.

JAMA Surg 2020 Sep 23. Epub 2020 Sep 23.

Department of Surgery, University of Michigan, Ann Arbor.

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http://dx.doi.org/10.1001/jamasurg.2020.1995DOI Listing
September 2020

JAMA Health Forum and COVID-19.

Authors:
John Z Ayanian

JAMA 2020 09;324(12):1155-1156

Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor.

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http://dx.doi.org/10.1001/jama.2020.18432DOI Listing
September 2020

Non-spousal family support, marital status, and heart problems in adulthood.

Psychol Health 2020 Sep 15:1-18. Epub 2020 Sep 15.

Department of Human Development and Family Studies, College of Health and Human Development, The Pennsylvania State University, University Park, PA, USA.

Objectives: Support from one's spouse has long been documented as a significant determinant of health for married individuals. However, non-spousal family support may play an important role in health particularly for unmarried individuals. Therefore, this study examined whether the association between non-spousal family support and diagnosis of heart problems differed by marital status and whether gender and education moderated these associations.

Design: Data came from the first two waves of the Midlife in the United States (MIDUS) study. This study selected respondents who participated in both waves of MIDUS and were not diagnosed with a heart problem at Wave 1 (N = 3,119).

Main Outcome Measures: Participants reported whether they had any heart trouble. Discrete-time event history analysis was used to examine the risk of heart problems between MIDUS Waves 1 and 2.

Results: A higher level of non-spousal family support was associated with a lower risk of developing a heart problem only among unmarried women and unmarried individuals with high school education or less, and not for married individuals.

Conclusion: Findings highlight the importance of considering specific sources of family support when studying heart health, and the health-protective role of non-spousal family support for those who are not married.
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http://dx.doi.org/10.1080/08870446.2020.1809660DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7956915PMC
September 2020

Changes in Health Care Access and Utilization for Low-SES Adults Age 51-64 after Medicaid Expansion.

J Gerontol B Psychol Sci Soc Sci 2020 Aug 10. Epub 2020 Aug 10.

Department of Internal Medicine, University of Michigan.

Objectives: Whether the Affordable Care Act (ACA) insurance expansions improved access to care and health for adults age 51-64 has not been closely examined. This study examined longitudinal changes in access, utilization, and health for low-socioeconomic status adults age 51-64 before and after the ACA Medicaid expansion.

Methods: Longitudinal difference-in-differences (DID) study before (2010-2014) and after (2016) Medicaid expansion, including N=2,088 noninstitutionalized low-education adults age 51-64 (N=633 in Medicaid expansion states, N=1,455 in non-expansion states) from the nationally representative biennial Health and Retirement Study. Outcomes included coverage (any, Medicaid, private), access (usual source of care, difficulty finding doctor, foregone care, cost-related medication nonadherence, out-of-pocket costs), utilization (outpatient visit, hospitalization), and health status.

Results: Low-education adults age 51-64 had increased rates of Medicaid coverage (+10.6 percentage points [pp] in expansion states, +3.2 pp in non-expansion states, DID +7.4 pp, p=0.001) and increased likelihood of hospitalizations (+9.2 pp in expansion states, -1.1 pp in non-expansion states, DID +10.4 pp, p=0.003) in Medicaid expansion compared with non-expansion states after 2014. Those in expansion states also had a smaller increase in limitations in paid work/housework over time, compared to those in non-expansion states (+3.6 pp in expansion states, +11.0 pp in non-expansion states, DID -7.5 pp, p=0.006). There were no other significant differences in access, utilization or health trends between expansion and non-expansion states.

Discussion: After Medicaid expansion, low-education status adults age 51-64 were more likely to be hospitalized, suggesting poor baseline access to chronic disease management and pent-up demand for hospital services.
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http://dx.doi.org/10.1093/geronb/gbaa123DOI Listing
August 2020

Examination of Changes in Health Status Among Michigan Medicaid Expansion Enrollees From 2016 to 2017.

JAMA Netw Open 2020 07 1;3(7):e208776. Epub 2020 Jul 1.

Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor.

Importance: Evidence about the health benefits of Medicaid expansion has been mixed and has largely come from comparing expansion and nonexpansion states.

Objective: To examine the self-reported health of enrollees in Michigan's Medicaid expansion, the Healthy Michigan Plan (HMP), over time.

Design, Setting, And Participants: A telephone survey from January 1 to October 31, 2016 (response rate, 53.7%), and a follow-up survey from March 1, 2017, to January 31, 2018 (response rate, 83.4%), were conducted in Michigan, which expanded Medicaid in 2014 through a Section 1115 waiver permitting state-specific modifications. Four thousand ninety HMP beneficiaries aged 19 to 64 years with at least 12 months of HMP coverage and at least 9 months in a Medicaid health plan were eligible to participate. Data were analyzed from April 1 to November 30, 2018.

Main Outcomes And Measures: Surveys measured demographic characteristics and health status. Analyses included weights for sampling probability and nonresponse. Comparisons between 2016 and 2017 included those who responded to both surveys (n = 3097).

Results: Of the 3097 respondents to the 2017 follow-up survey, 2388 (77.1%) were still enrolled in HMP (current enrollees) and 709 (22.9%) were no longer enrolled when surveyed (former enrollees). Among all follow-up respondents, a weighted 37.5% (95% CI, 35.3%-39.9%) were aged 19 to 34 years, 34.0% (95% CI, 31.8%-36.2%) were aged 35 to 50 years, and 28.5% (95% CI, 26.7%-30.3%) were aged 51 to 64 years; 53.0% (95% CI, 50.8%-55.3%) were female. Respondents who reported fair or poor health decreased from 30.7% (95% CI, 28.7%-32.8%) in 2016 to 27.0% (95% CI, 25.1%-29.0%) in 2017 (adjusted odds ratio [AOR], 0.66 [95% CI, 0.53-0.81]; P < .001), with the largest decreases observed in respondents who were non-Hispanic black (from 31.5% [95% CI, 27.1%-35.9%] in 2016 to 26.0% [95% CI, 21.9%-30.1%] in 2017; P = .009), from the Detroit metropolitan area (from 30.7% [95% CI, 27.0%-34.4%] in 2016 to 24.9% [95% CI, 21.6%-28.3%] in 2017; P = .001), and with an income of 0% to 35% of the federal poverty level (from 37.6% [95% CI, 34.2%-40.9%] in 2016 to 32.3% [95% CI, 29.1%-35.5%] in 2017; P < .001). From 2016 to 2017, the mean number of days of poor physical health in the past month decreased significantly from 6.9 (95% CI, 6.5-7.4) to 5.7 (95% CI, 5.3-6.0) (coefficient, -6.10; P < .001), including among current (from 7.0 [95% CI, 6.5-7.5] to 5.6 [95% CI, 5.1-6.0]; P < .001) and former (from 6.8 [95% CI, 5.9-7.7] to 5.8 [95% CI, 5.0-6.7]; P = .02) enrollees, those with 2 or more chronic conditions (from 9.9 [95% CI, 9.3-10.6] to 8.5 [95% CI, 7.8-9.1]; P < .001), across all age groups (19-34 years, from 4.3 [95% CI, 3.7-4.9] to 3.0 [95% CI, 2.5-3.5]; P < .001; 35-50 years, from 8.2 [95% CI, 7.3-9.0] to 6.9 [95% CI, 6.1-7.7]; P = .002; 51-64 years, from 9.0 [95% CI, 8.2-9.8] to 7.6 [95% CI, 6.9-8.3]; P = .001), and among non-Hispanic white (from 7.5 [95% CI, 7.0-8.1] to 6.1 [95% CI, 5.6-6.6]; P < .001) and black (from 5.9 [95% CI, 5.1-6.8] to 4.4 [95% CI, 3.6-5.1]; P < .001) respondents. No changes in days of poor mental health or usual activities missed owing to poor physical or mental health were observed.

Conclusions And Relevance: These findings suggest that HMP enrollees in Michigan have experienced improvements in self-reported health over time, including minority groups with a history of health disparities and enrollees with chronic health conditions.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.8776DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7352154PMC
July 2020

Validating a Widely Implemented Deterioration Index Model Among Hospitalized COVID-19 Patients.

medRxiv 2020 Apr 29. Epub 2020 Apr 29.

Introduction: The coronavirus disease 2019 (COVID-19) pandemic is straining the capacity of U.S. healthcare systems. Accurately identifying subgroups of hospitalized COVID-19 patients at high- and low-risk for complications would assist in directing resources.

Objective: To validate the Epic Deterioration Index (EDI), a predictive model implemented in over 100 U.S. hospitals that has been recently promoted for use in COVID-19 patients.

Methods: We studied adult patients admitted with COVID-19 to non-ICU level care at a large academic medical center from March 9 through April 7, 2020. We used the EDI, calculated at 15-minute intervals, to predict a composite adverse outcome of ICU-level care, mechanical ventilation, or death during the hospitalization. In a subset of patients hospitalized for at least 48 hours, we also evaluated the ability of the EDI (range 0-100) to identify patients at low risk of experiencing this composite outcome during their remaining hospitalization. We evaluated model discrimination and calibration using both raw EDI scores and their slopes.

Results: Among 174 COVID-19 patients meeting inclusion criteria, 61 (35%) experienced the composite outcome. Area under the receiver-operating-characteristic curve (AUC) of the EDI was 0.76 (95% CI 0.68-0.84). Patients who met or exceeded an EDI of 64.8 made up 17% of the study cohort and had an 80% probability of experiencing the outcome during their hospitalization with a median lead time of 28 hours from when the threshold was first exceeded to the outcome. Employing the EDI slope lowered the AUCs to 0.68 (95% CI 0.60-0.77) and 0.67 (95% CI 0.59-0.75) for slopes calculated over 4 and 8 hours, respectively. In a subset of 109 patients hospitalized for at least 48 hours and who had not experienced the composite outcome, 14 (13%) patients who never exceeded an EDI of 37.9 had a 93% probability of not experiencing the outcome throughout the rest of their hospitalization, suggesting low risk.

Conclusion: In this validation study, we found the EDI identifies small subsets of high- and low-risk patients with fair discrimination. These findings highlight the need for hospitals to carefully evaluate prediction models before widespread operational use among COVID-19 patients.
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http://dx.doi.org/10.1101/2020.04.24.20079012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7277006PMC
April 2020

Availability of Statistical Code From Studies Using Medicare Data in General Medical Journals.

JAMA Intern Med 2020 06;180(6):905-907

Michigan Integrated Center for Health Analytics and Medical Prediction, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor.

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http://dx.doi.org/10.1001/jamainternmed.2020.0671DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7154950PMC
June 2020

Association of Medicaid Expansion With Enrollee Employment and Student Status in Michigan.

JAMA Netw Open 2020 01 3;3(1):e1920316. Epub 2020 Jan 3.

Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor.

Importance: Medicaid community engagement requirements (work, school, job searching, or community service) are being implemented by several states for the first time, but the association of Medicaid coverage with enrollees' employment and school attendance is unclear.

Objective: To assess longitudinal changes in enrollees' employment or student status after Michigan's Medicaid expansion.

Design, Setting, And Participants: This survey study included 4090 nonelderly, adult Healthy Michigan Plan enrollees from March 1, 2017, to January 31, 2018.

Main Outcomes And Measures: Self-reported employment or student status. Proportionate sampling was stratified by income and geographic region. Mixed-effects regression models with time indicators were used to assess longitudinal changes in the proportion of enrollees who were employed or students.

Results: The response rate for the initial survey was 53.7% and for the follow-up survey was 83.4%. Of the 3104 respondents to the 2017 follow-up survey (mean [SD] age in 2017, 42.2 [13.0] years; 1867 [53.0%] female), 54.3% were employed or students in 2016, and this number increased to 60.0% in 2017 (percentage point change, 5.7; P < .001). Non-Hispanic black enrollees had significantly larger gains in employment or student status compared with non-Hispanic white enrollees (percentage point change, 10.7 vs 3.5; P = .02). Changes in employment or student status were not associated with improved health status.

Conclusions And Relevance: Employment or student status increased from 2016 to 2017 among Michigan Medicaid expansion enrollees. These findings provide information about whether Medicaid coverage or community engagement requirements are best to promote the desired outcomes of employment and student status.
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http://dx.doi.org/10.1001/jamanetworkopen.2019.20316DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7042869PMC
January 2020

Looking Back to Improve Access to Health Care Moving Forward.

Authors:
John Z Ayanian

JAMA Intern Med 2020 03;180(3):448-449

Institute for Healthcare Policy and Innovation and the Division of General Medicine, University of Michigan, Ann Arbor.

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http://dx.doi.org/10.1001/jamainternmed.2019.6764DOI Listing
March 2020

Health Risk Assessments in Michigan's Medicaid Expansion: Early Experiences in Primary Care.

Am J Prev Med 2020 03 15;58(3):e79-e86. Epub 2020 Jan 15.

Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan; Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan. Electronic address:

Introduction: Michigan is one of 3 states that have implemented health risk assessments for enrollees as a feature of its Medicaid expansion, the Healthy Michigan Plan. This study describes primary care providers' early experiences with completing health risk assessments with enrollees and examines provider- and practice-level factors that affect health risk assessment completion.

Methods: All primary care providers caring for ≥12 Healthy Michigan Plan enrollees (n=4,322) were surveyed from June to November 2015, with 2,104 respondents (55.5%). Analyses in 2016-2017 described provider knowledge, attitudes, and experiences with the health risk assessment early in Healthy Michigan Plan implementation; multivariable analyses examined relationships of provider- and practice-level characteristics with health risk assessment completion, as recorded in state data.

Results: Of the primary care provider respondents, 73% found health risk assessments very or somewhat useful for identifying and discussing health risks, although less than half (47.2%) found them very or somewhat useful for getting patients to change health behaviors. Most primary care provider respondents (65.3%) were unaware of financial incentives for their practices to complete health risk assessments. Nearly all primary care providers had completed at least 1 health risk assessment. The mean health risk assessment completion rate (completed health risk assessments/number of Healthy Michigan Plan enrollees assigned to that primary care provider) was 19.6%; those who lacked familiarity with the health risk assessment had lower completion rates.

Conclusions: Early in program implementation, health risk assessment completion rates by primary care providers were low and awareness of financial incentives limited. Most primary care provider respondents perceived health risk assessments to be very or somewhat useful in identifying health risks, and about half of primary care providers viewed health risk assessments as very or somewhat useful in helping patients to change health behaviors.
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http://dx.doi.org/10.1016/j.amepre.2019.10.021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7085853PMC
March 2020

Primary Care, Health Promotion, and Disease Prevention with Michigan Medicaid Expansion.

J Gen Intern Med 2020 03 2;35(3):800-807. Epub 2019 Dec 2.

Division of General Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA.

Background: Medicaid expansion in Michigan, known as the Healthy Michigan Plan (HMP), emphasizes primary care and preventive services.

Objective: Evaluate the impact of enrollment in HMP on access to and receipt of care, particularly primary care and preventive services.

Design: Telephone survey conducted during January-November 2016 with stratified random sampling by income and geographic region (response rate = 53.7%). Logistic regression analyses accounted for sampling and nonresponse adjustment.

Participants: 4090 HMP enrollees aged 19-64 with ≥ 12 months of HMP coverage MAIN MEASURES: Surveys assessed demographic factors, health, access to and use of health care before and after HMP enrollment, health behaviors, receipt of counseling for health risks, and knowledge of preventive services' copayments. Utilization of preventive services was assessed using Medicaid claims.

Key Results: In the 12 months prior to HMP enrollment, 33.0% of enrollees reported not getting health care they needed. Three quarters (73.8%) of enrollees reported having a regular source of care (RSOC) before enrollment; 65.1% of those reported a doctor's office/clinic, while 16.2% reported the emergency room. After HMP enrollment, 92.2% of enrollees reported having a RSOC; 91.7% had a doctor's office/clinic and 1.7% the emergency room. One fifth (20.6%) of enrollees reported that, before HMP enrollment, it had been over 5 years since their last primary care visit. Enrollees who reported a visit with their primary care provider after HMP enrollment (79.3%) were significantly more likely than those who did not report a visit to receive counseling about health behaviors, improved access to cancer screening, new diagnoses of chronic conditions, and nearly all preventive services. Enrollee knowledge that some services have no copayments was also associated with greater utilization of most preventive services.

Conclusions: After enrolling in Michigan's Medicaid expansion program, beneficiaries reported less forgone care and improved access to primary care and preventive services.
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http://dx.doi.org/10.1007/s11606-019-05370-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7080942PMC
March 2020

Engagement with Health Risk Assessments and Commitment to Healthy Behaviors in Michigan's Medicaid Expansion Program.

J Gen Intern Med 2020 02 2;35(2):514-522. Epub 2019 Dec 2.

Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.

Background: Health risk assessments (HRAs) and healthy behavior incentives are increasingly used by state Medicaid programs to promote enrollees' health.

Objective: To evaluate enrollee experiences with HRAs and healthy behavior engagement in the Healthy Michigan Plan (HMP), a state Medicaid expansion program.

Design: Telephone survey conducted in Michigan January-October 2016.

Participants: A random sample of HMP enrollees aged 19-64 with ≥ 12 months of enrollment, stratified by income and geographic region.

Main Measures: Self-reported completion of an HRA, reasons for completing an HRA, commitment to a healthy behavior, and choice of healthy behavior.

Key Results: Among respondents (N = 4090), 49.3% (95% CI 47.3-51.2%) reported completing an HRA; among those with a primary care provider (PCP) (n = 3851), 85.2% (95% CI 83.5-86.7%) reported visiting their PCP during the last 12 months. Most enrollees having a recent PCP visit reported discussing healthy behaviors with them (91.1%, 95% CI 89.6-92.3%) and were more likely to have completed an HRA than enrollees without a recent PCP visit (52.7%, 95% CI 50.5-52.8% vs. 36.2%, 95% CI 31.7-41.1%; p < 0.01). Among enrollees completing an HRA, nearly half said they did it because their PCP suggested it (45.9%, 95% CI 43.2-48.7%), and most reported it helped their PCP understand their health needs (89.7%). Awareness of financial incentives was limited (28.1%, 95% CI 26.3-30.0%), and very few reported it as the primary reason for HRA completion (2.5%, 95% CI 1.8-3.4%). Most committed to a healthy behavior (80.7%, 95% CI 78.5-82.8%), and common behaviors chosen were nutrition/diet (57.2%, 95% CI 54.2-60.2%) and exercise/activity (52.6%, 95% CI 49.5-55.7%).

Conclusions: In the Healthy Michigan Plan, PCPs appeared influential in enrollees' completion of HRAs and healthy behavior engagement, while knowledge of financial incentives was limited. Additional study is needed to understand the relative importance of financial incentives and PCP engagement in impacting healthy behaviors in state Medicaid programs.
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http://dx.doi.org/10.1007/s11606-019-05562-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7018899PMC
February 2020

Low-Value Care and Clinician Engagement in a Large Medicare Shared Savings Program ACO: a Survey of Frontline Clinicians.

J Gen Intern Med 2020 01 8;35(1):133-141. Epub 2019 Nov 8.

Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.

Background: Although the Medicare Shared Savings Program (MSSP) created new incentives for organizations to improve healthcare value, Accountable Care Organizations (ACOs) have achieved only modest reductions in the use of low-value care.

Objective: To assess ACO engagement of clinicians and whether engagement was associated with clinicians' reported difficulty implementing recommendations against low-value care.

Design: Cross-sectional survey of ACO clinicians in 2018.

Participants: 1289 clinicians in the Physician Organization of Michigan ACO, including generalist physicians (18%), internal medicine specialists (16%), surgeons (10%), other physician specialists (27%), and advanced practice providers (29%). Response rate was 34%.

Main Measures: Primary exposures included clinicians' participation in ACO decision-making, awareness of ACO incentives, perceived influence on practice, and perceived quality improvement. Our primary outcome was clinicians' reported difficulty implementing recommendations against low-value care.

Results: Few clinicians participated in the decision to join the ACO (3%). Few clinicians were aware of ACO incentives, including knowing the ACO was accountable for both spending and quality (23%), successfully lowered spending (9%), or faced upside risk only (3%). Few agreed (moderately or strongly) the ACO changed compensation (20%), practice (19%), or feedback (15%) or that it improved care coordination (17%) or inappropriate care (13%). Clinicians reported they had difficulty following recommendations against low-value care 18% of the time; clinicians reported patients had difficulty accepting recommendations 36% of the time. Increased ACO awareness (1 standard deviation [SD]) was associated with decreased difficulty (- 2.3 percentage points) implementing recommendations (95% confidence interval [CI] - 3.8, - 0.7), as was perceived quality improvement (1 SD increase, - 2.1 percentage points, 95% CI, - 3.4, - 0.8). Participation in ACO decision-making and perceived influence on practice were not associated with recommendation implementation.

Conclusions: Clinicians participating in a large Medicare ACO were broadly unaware of and unengaged with ACO objectives and activities. Whether low clinician engagement limits ACO efforts to reduce low-value care warrants further longitudinal study.
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http://dx.doi.org/10.1007/s11606-019-05511-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6957659PMC
January 2020

Macroeconomic Feedback Effects of Medicaid Expansion: Evidence from Michigan.

J Health Polit Policy Law 2020 02;45(1):5-48

University of Michigan.

Context: Medicaid expansion has costs and benefits for states. The net impact on a state's budget is a central concern for policy makers debating implementing this provision of the Affordable Care Act. How large is the state-level fiscal impact of expanding Medicaid, and how should it be estimated?

Methods: We use Michigan as a case study for evaluating the state-level fiscal impact of Medicaid expansion, with particular attention to the importance of macroeconomic feedback effects relative to the more straightforward fiscal effects typically estimated by state budget agencies. We combine projections from the state of Michigan's House Fiscal Agency with estimates from a proprietary macroeconomic model to project the state fiscal impact of Michigan's Medicaid expansion through 2021.

Findings: We find that Medicaid expansion in Michigan yields clear fiscal benefits for the state, in the form of savings on other non-Medicaid health programs and increases in revenue from provider taxes and broad-based sales and income taxes through at least 2021. These benefits exceed the state's costs in every year.

Conclusions: While these results are specific to Michigan's budget and economy, our methods could in principle be applied in any state where policy makers seek rigorous evidence on the fiscal impact of Medicaid expansion.
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http://dx.doi.org/10.1215/03616878-7893555DOI Listing
February 2020

Study protocol for a Community Health Worker (CHW)-led comprehensive neighborhood-focused program for medicaid enrollees in detroit.

Contemp Clin Trials Commun 2019 Dec 30;16:100456. Epub 2019 Sep 30.

Department of Internal Medicine, University of Michigan Medical School, 1600 Plymouth Road, Ann Arbor, MI, 48109, USA.

Residents of low income neighborhoods disproportionately experience poor health, and many have unmet social needs. Clinical trials have shown the efficacy of Community Health Worker (CHW) programs in improving outcomes for a variety of health conditions. An important next step is developing and evaluating financially sustainable CHW program models in real-life settings. This program evaluation examines health care utilization among participants in a geographically targeted program led by salaried CHWs from three Medicaid health plans. Beneficiaries who reside in the Cody Rouge neighborhood of Detroit and had more than 3 Emergency Department (ED) visits or at least 1 ambulatory care-sensitive hospitalization in the prior 12 months are eligible for the program. Health plan CHWs assigned to the program reach out to eligible beneficiaries to provide an assessment; link them to resources; and provide follow-up. At 12-month follow up, claims data on ED visits, ambulatory care-sensitive hospitalizations, primary care visits, and related costs will be compared between beneficiaries who participated and eligible beneficiaries randomized to receive usual outreach. We hypothesize that patients enrolled in the CHW intervention will experience a reduction in acute care usage resulting in cost savings compared to those receiving usual health plan outreach. This study is among the first to evaluate the impact on health care utilization of augmented services delivered by health plan CHWs for high-utilizing health plan members as part of a health plan-community-academic partnership. This study will provide important information on CHW program sustainability and provide insights into effective implementation of such programs.

Trial Registration: NCT03924713.
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http://dx.doi.org/10.1016/j.conctc.2019.100456DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6804462PMC
December 2019

Association of Expanded Medicaid Coverage With Health and Job-Related Outcomes Among Enrollees With Behavioral Health Disorders.

Psychiatr Serv 2020 01 25;71(1):4-11. Epub 2019 Sep 25.

Institute for Healthcare Policy and Innovation (Tipirneni, Patel, Goold, Kieffer, Ayanian, Clark, Lee, Bryant, Kirch, Solway), School of Public Health (Patel), School of Social Work (Kieffer), Child Health Evaluation and Research Center (Clark), and Institute for Social Research (Lee), all at the University of Michigan, Ann Arbor; Department of Internal Medicine (Tipirneni, Goold, Ayanian, Bryant, Luster), Center for Bioethics and Social Sciences in Medicine (Lewallen), and Department of Psychiatry (Zivin), all at the University of Michigan Medical School, Ann Arbor; Center for Clinical Management Research, U.S. Department of Veterans Affairs Ann Arbor Healthcare System, Ann Arbor (Zivin).

Objectives: The study objective was to assess the impact of Medicaid expansion on health and employment outcomes among enrollees with and without a behavioral health disorder (either a mental or substance use disorder).

Methods: Between January and October 2016, the authors conducted a telephone survey of 4,090 enrollees in the Michigan Medicaid expansion program and identified 2,040 respondents (48.3%) with potential behavioral health diagnoses using claims-based diagnoses.

Results: Enrollees with behavioral health diagnoses were less likely than enrollees without behavioral health diagnoses to be employed but significantly more likely to report improvements in health and ability to do a better job at work. In adjusted analyses, both enrollees with behavioral health diagnoses and those without behavioral health diagnoses who reported improved health were more likely than enrollees without improved health to report that Medicaid expansion coverage helped them do a better job at work and made them better able to look for a job. Among enrollees with improved health, those with a behavioral health diagnosis were as likely as those without a behavioral health diagnosis to report improved ability to work and improved job seeking after Medicaid expansion.

Conclusions: Coverage interruptions for enrollees with behavioral health diagnoses should be minimized to maintain favorable health and employment outcomes.
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http://dx.doi.org/10.1176/appi.ps.201900179DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6939140PMC
January 2020

Diagnosis and Care of Chronic Health Conditions Among Medicaid Expansion Enrollees: a Mixed-Methods Observational Study.

J Gen Intern Med 2019 11 11;34(11):2549-2558. Epub 2019 Sep 11.

Institute for Healthcare Policy and Innovation (IHPI), University of Michigan, Ann Arbor, MI, USA.

Background: It is uncertain how Medicaid expansion under the Affordable Care Act influences the diagnosis of chronic health conditions, and the care and health of enrollees with chronic conditions.

Objective: Describe the prevalence of new and pre-existing chronic health conditions among Medicaid expansion enrollees. Examine whether perceived changes in specific types of access and self-rated health status differed between enrollees with chronic conditions and those without. Examine how gaining Medicaid coverage affected chronic disease management and well-being.

Design: Mixed-methods study including a telephone survey and semi-structured interviews.

Setting: Michigan's Medicaid expansion, the "Healthy Michigan Plan" (HMP).

Participants: 4090 survey respondents (response rate 54%) with ≥ 12 months HMP enrollment and 67 interviewees with ≥ 6 months enrollment.

Main Measures: Self-reported chronic condition diagnoses, changes in physical/mental health, and healthcare access. Descriptive survey data were adjusted for survey design and nonresponse. Semi-structured interview questions about how gaining HMP coverage led to changes in health status.

Key Results: Among enrollees, 68% had a self-reported diagnosis of a chronic health condition; 42% of those were newly diagnosed since HMP enrollment. In multivariable models, enrollees with chronic conditions were significantly more likely to report improved physical (adjusted odds ratio (aOR) 1.70, 95% CI (1.40, 2.07)) and mental health (aOR 1.75, (1.43, 2.15)) since HMP enrollment than enrollees without chronic conditions. Among enrollees with chronic conditions, the strongest predictors of improvements in health were having seen a primary care physician, improved mental health care access, and improved medication access. Interviewees with chronic conditions described how increased access to health care led to improvements in both physical and mental health.

Conclusions: Enrollees with expanded Medicaid coverage commonly reported detection of previously undiagnosed chronic conditions. Perceived health status and access improved more often among enrollees with chronic health conditions. Improved access was associated with improved physical and mental health among this vulnerable group.
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http://dx.doi.org/10.1007/s11606-019-05323-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6848397PMC
November 2019

Performance in the Medicare Shared Savings Program After Accounting for Nonrandom Exit: An Instrumental Variable Analysis.

Ann Intern Med 2019 07 18;171(1):27-36. Epub 2019 Jun 18.

University of Michigan School of Public Health, Center for Evaluating Health Reform, Institute for Healthcare Policy and Innovation, Ann Arbor, Michigan (A.M.R.).

Background: Accountable care organizations (ACOs) in the Medicare Shared Savings Program (MSSP) are associated with modest savings. However, prior research may overstate this effect if high-cost clinicians exit ACOs.

Objective: To evaluate the effect of the MSSP on spending and quality while accounting for clinicians' nonrandom exit.

Design: Similar to prior MSSP analyses, this study compared MSSP ACO participants versus control beneficiaries using adjusted longitudinal models that accounted for secular trends, market factors, and beneficiary characteristics. To further account for selection effects, the share of nearby clinicians in the MSSP was used as an instrumental variable. Hip fracture served as a falsification outcome. The authors also tested for compositional changes among MSSP participants.

Setting: Fee-for-service Medicare, 2008 through 2014.

Patients: A 20% sample (97 204 192 beneficiary-quarters).

Measurements: Total spending, 4 quality indicators, and hospitalization for hip fracture.

Results: In adjusted longitudinal models, the MSSP was associated with spending reductions (change, -$118 [95% CI, -$151 to -$85] per beneficiary-quarter) and improvements in all 4 quality indicators. In instrumental variable models, the MSSP was not associated with spending (change, $5 [CI, -$51 to $62] per beneficiary-quarter) or quality. In falsification tests, the MSSP was associated with hip fracture in the adjusted model (-0.24 hospitalizations for hip fracture [CI, -0.32 to -0.16 hospitalizations] per 1000 beneficiary-quarters) but not in the instrumental variable model (0.05 hospitalizations [CI, -0.10 to 0.20 hospitalizations] per 1000 beneficiary-quarters). Compositional changes were driven by high-cost clinicians exiting ACOs: High-cost clinicians (99th percentile) had a 30.4% chance of exiting the MSSP, compared with a 13.8% chance among median-cost clinicians (50th percentile).

Limitation: The study used an observational design and administrative data.

Conclusion: After adjustment for clinicians' nonrandom exit, the MSSP was not associated with improvements in spending or quality. Selection effects-including exit of high-cost clinicians-may drive estimates of savings in the MSSP.

Primary Funding Source: Horowitz Foundation for Social Policy, Agency for Healthcare Research and Quality, and National Institute on Aging.
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http://dx.doi.org/10.7326/M18-2539DOI Listing
July 2019

Reducing Disparities in Healthy Aging Through an Enhanced Medicare Annual Wellness Visit.

Public Policy Aging Rep 2019 Jan 18;29(1):26-32. Epub 2018 Dec 18.

Division of General Medicine, University of Michigan Medical School, Ann Arbor.

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http://dx.doi.org/10.1093/ppar/pry048DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6529776PMC
January 2019

Factors influencing primary care providers' decisions to accept new Medicaid patients under Michigan's Medicaid expansion.

Am J Manag Care 2019 03;25(3):120-127

Division of General Medicine, Department of Internal Medicine, University of Michigan, North Campus Research Complex, Bldg 16, Room 419W, 2800 Plymouth Rd, Ann Arbor, MI 48109-2800. Email:

Objectives: Michigan expanded Medicaid under the Affordable Care Act (ACA) through a federal waiver that permitted state-mandated features, including an emphasis on primary care. We investigated the factors associated with Michigan primary care providers (PCPs)' decision to accept new Medicaid patients under Medicaid expansion.

Study Design: Statewide survey of PCPs informed by semistructured interviews.

Methods: After Michigan expanded Medicaid on April 1, 2014, we surveyed 2104 PCPs (including physician and nonphysician providers, such as nurse practitioners and physician assistants) with 12 or more assigned Medicaid expansion enrollees (response rate, 56%). To guide survey development and interpretation, we interviewed a separate group of 19 PCPs with Medicaid expansion enrollees from diverse urban and rural regions. Survey questions assessed PCPs' current acceptance of new Medicaid patients.

Results: Of the 2104 surveyed PCPs, 78% reported that they were currently accepting additional Medicaid patients; 58% reported having at least some influence on the decision. Factors considered very/moderately important to the Medicaid acceptance decision included practice capacity to accept any new patients (69%), availability of specialists for Medicaid patients (56%), reimbursement amount (56%), psychosocial needs of Medicaid patients (50%), and illness burden of Medicaid patients (46%). PCPs accepting new Medicaid patients tended to be female, minorities, nonphysician providers, specialized in internal medicine, paid by salary, or working in practices with Medicaid-predominant payer mixes.

Conclusions: In the era after Medicaid expansion, PCPs placed importance on practice capacity, specialist availability, and patients' medical and psychosocial needs when deciding whether to accept new Medicaid patients. To maintain primary care access for low-income patients with Medicaid, future efforts should focus on enhancing the diversity of the PCP workforce, encouraging healthcare professional training in underserved settings, and promoting practice-level innovations in scheduling and integration of specialist care.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7169442PMC
March 2019

Medicaid Expansion and Mechanical Ventilation in Asthma, Chronic Obstructive Pulmonary Disease, and Heart Failure.

Ann Am Thorac Soc 2019 07;16(7):886-893

1 Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine.

The Affordable Care Act's Medicaid expansion has led to increased access to chronic disease care among newly insured adults. Despite this, its effects on clinical outcomes, particularly for patients with asthma, chronic obstructive pulmonary disease, and heart failure, are uncertain. To assess whether Medicaid expansion was associated with changes in mechanical ventilation rates among hospitalized patients with heart failure, asthma, and chronic obstructive pulmonary disease. Difference-in-differences analysis comparing discharge data from four states that expanded Medicaid in 2014 (Arizona, Iowa, New Jersey, and Washington) and three comparison states that did not (North Carolina, Nebraska, and Wisconsin) was performed. Models were adjusted for patient and hospital factors. Mechanical ventilation rates at baseline were 7.2% in nonexpansion states and 8.8% in expansion states. Medicaid expansion was associated with a decline in mechanical ventilation rates at -0.2% per quarter (95% confidence interval [CI], -0.3% to 0.0%;  = 0.010). We did not observe a change in the rate of ICU admission (-0.4% per quarter; 95% CI, -0.8% to 0.1%;  = 0.10) or in-hospital mortality (0.1% per quarter; 95% CI, 0.0% to 0.1%;  = 0.30). In a negative control among adults aged 65 years or older, changes in mechanical ventilation rates were similar, though the CIs crossed zero (-0.1%; 95% CI, -0.2% to 0.0%;  = 0.08). Medicaid expansion may have been associated with a decline in mechanical ventilation rates among uninsured and Medicaid-covered patients admitted with heart failure, chronic obstructive pulmonary disease, and asthma.
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http://dx.doi.org/10.1513/AnnalsATS.201811-777OCDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6600831PMC
July 2019

Trends in Hospital Utilization After Medicaid Expansion.

Med Care 2019 04;57(4):312-317

Institute for Healthcare Policy and Innovation.

Background: Medicaid expansion was associated with an increase in hospitalizations funded by Medicaid. Whether this increase reflects an isolated payer shift or broader changes in case-mix among hospitalized adults remains uncertain.

Reseearch Design: Difference-in-differences analysis of discharge data from 4 states that expanded Medicaid in 2014 (Arizona, Iowa, New Jersey, and Washington) and 3 comparison states that did not (North Carolina, Nebraska, and Wisconsin).

Subjects: All nonobstetric hospitalizations among patients aged 19-64 years of age admitted between January 2012 and December 2015.

Measures: Outcomes included state-level per-capita rates of insurance coverage, several markers of admission severity, and admission diagnosis.

Results: We identified 6,516,576 patients admitted during the study period. Per-capita admissions remained consistent in expansion and nonexpansion states, though Medicaid-covered admissions increased in expansion states (274.6-403.8 per 100,000 people vs. 268.9-262.8 per 100,000; P<0.001). There were no significant differences after Medicaid expansion in hospital utilization, based on per-capita rates of patients-designated emergent, admitted via the emergency department, admitted via clinic, discharged within 1 day, or with lengths of stay ≥7 days. Similarly, there were no differences in diagnosis category at admission, admission severity, comorbidity burden, or mortality associated with Medicaid expansion (P>0.05 for all comparisons).

Conclusions: Medicaid expansion was associated with a shift in payers among nonelderly hospitalized adults without significant changes in case-mix or in several markers of acuity. These findings suggest that Medicaid expansion may reduce uncompensated care without shifting admissions practices or acuity among hospitalized adults.
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http://dx.doi.org/10.1097/MLR.0000000000001082DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6417939PMC
April 2019

Risk Adjustment In Medicare ACO Program Deters Coding Increases But May Lead ACOs To Drop High-Risk Beneficiaries.

Health Aff (Millwood) 2019 02;38(2):253-261

Andrew M. Ryan ( ) is the UnitedHealthcare Professor of Health Care Management in the Department of Health Management and Policy, University of Michigan School of Public Health.

The Medicare Shared Savings Program (MSSP) adjusts savings benchmarks by beneficiaries' baseline risk scores. To discourage increased coding intensity, the benchmark is not adjusted upward if beneficiaries' risk scores rise while in the MSSP. As a result, accountable care organizations (ACOs) have an incentive to avoid increasingly sick or expensive beneficiaries. We examined whether beneficiaries' exposure to the MSSP was associated with within-beneficiary changes in risk scores and whether risk scores were associated with entry to or exit from the MSSP. We found that the MSSP was not associated with consistent changes in within-beneficiary risk scores. Conversely, beneficiaries at the ninety-fifth percentile of risk score had a 21.6 percent chance of exiting the MSSP, compared to a 16.0 percent chance among beneficiaries at the fiftieth percentile. The decision not to upwardly adjust risk scores in the MSSP has successfully deterred coding increases but might discourage ACOs to care for high-risk beneficiaries in the MSSP .
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http://dx.doi.org/10.1377/hlthaff.2018.05407DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6394223PMC
February 2019