Medicare ACOs Underused Primary Care Docs

Barriers that ACOs may face in shifting visits to PCPs 'could include low numbers of PCPs contracted in the ACO, and existing referral patterns and patient relationships with specialists.'

Primary care physicians are supposed to play a key role providing cost-effective care under the Medicare accountable care organization model.

However, a new study from the University of Pittsburgh Graduate School of Public Health shows that a large proportion of Medicare ACO patients with chronic conditions skipped primary care management and evaluation consults and visited more expensive specialists instead.

"Many ACOs may underutilize PCPs, and thus could actively shift care to less expensive primary care for potential savings to payers," the study said.

The researchers analyzed data on 3.7 million visits to 219 ACOs by 1.1 million Medicare patients in 2013, one year after ACOs began under the Affordable Care Act. The patients had at least one of eight chronic conditions that can be managed by primary care, including: asthma, chronic kidney disease, chronic obstructive pulmonary disease, depression, diabetes, high cholesterol, high blood pressure, and osteoarthritis.

Study lead author Evan S. Cole, a researcher with the Graduate School of Public Health at the University of Pittsburgh, stressed that the study provides an "early look" at ACOs and that more recent data could show that care patterns have shifted toward primary care as ACOs mature and gain experience.

"Our study provided a snapshot of the distribution of visits for chronic conditions between primary care providers and specialists by ACO-attributed Medicare beneficiaries in 2013, and thus we cannot draw conclusions on whether that distribution shifted in any way in the following years," Cole said.

"I believe that is an important question to explore in future research and hope our study informs that research. I am personally not aware of other analyses that would indicate a shift towards or away from primary care for the management of chronic conditions within ACOs since 2013," he said.

The study found that:

• On average, 61% of chronic condition evaluation and management visits were to PCPs. However, that figure varied across ACOs from 34% to 81%.
   
• There was substantial variation by condition. PCPs accounted for most visits for hyperlipidemia, hypertension, and diabetes, but only 17.5% of visits for depression.
   

• Demographics and health factors of the ACOs’ patient populations were associated with the proportion of PCP visits.
   
• ACOs with a larger supply of specialists had lower proportions of visits for chronic conditions delivered by PCPs.
   
• On average, about half of providers contracted to provide care for ACOs were PCPs in 2013, but that figure varied from 13% to 100%.
   
• The share of visits for chronic conditions made to PCPs were higher at ACOs that had contracted with a higher proportion of PCPs.
   
• Overall, patterns of chronic condition visits were similar for ACO-attributed patients compared to similar non-ACO Medicare beneficiaries.

The researchers stressed that the study provides an "early look" ACOs, and that more-recent data could show that care patterns have shifted toward primary care as ACOs mature and gain experience.