CH B AR THE LEONARD DAVIS INSTITUTE R ES E RI EF of HEALTH ECONOMICS Penn LDI 20 13 16 - N o. Physicians’ Participation In ACOs Is Lower In Places With Vulnerable Populations Than In More Affluent Communities Laura C. Yasaitis, William Pajerowski, Daniel Polsky, and Rachel M. Werner Health Affairs, August 2016 KEY FINDINGS: In 2013, physician participation in accountable care organizations (ACOs) was inversely related to the percentage of the local population that was black, living in poverty, uninsured, or disabled or that had less than a high school LDI RESEARCH BRIEF education. This risks exacerbating disparities in the quality of care received by these vulnerable populations. Percentages of hospital referral region populations with THE QUESTION selected sociodemographic characteristics, by geographic access to physicians participating in an accountable care organization in 2013 Early evidence suggests that accountable care organizations (ACOs) - networks of doctors and hospitals whose members share responsibility for providing coordinated care to patients - improve health care quality and constrain costs. ACOs are increasingly common in the U.S., both for Medicare and commercially insured patients. However, there are concerns that ACOs may worsen existing disparities in health care quality if disadvantaged patients have less access to physicians who participate in them. Does physicians’ ACO participation relate to the sociodemographic characteristics of their patient population, and if so, why? The proportion of physicians in each HRR who reported participating in any ACO. The authors divided HRRs into quartiles THE FINDINGS weighted by the total resident population, with Quartile 1 indicating the lowest level of physician participation (0-13 percent) and Quartile 4 the highest (31-87 percent). [Source: Health Affairs, Nationally, nearly 26 percent of physicians reported that they August 2016] participated in an ACO. Participation was more common among female physicians than their male counterparts; physicians in In the Zip Code Tabulation Area with the lowest quartile of large and multispecialty practices; and primary care physicians, black population, 30.8 percent of all physicians (35.7 percent compared to those in other specialties. of primary care physicians) were participating in an ACO, compared to the areas with the highest proportion of black The authors examined physicians’ ACO participation at the population where 22.9 percent of all physicians (26.4 percent levels of hospital referral region (HRR) as well as Zip Code of primary care physicians) were participating in an ACO. Tabulation Area, the general geographic area covered by a zip There was no consistent relationship of ACO participation to code. After adjusting for physician characteristics, they find Hispanic population levels. Areas with higher physician ACO significantly lower rates of ACO participation in areas where a participation tended to have a greater supply of all types of higher percentage of the population was black, living in poverty, physicians but a lower supply of acute care hospital beds. uninsured, or disabled or had less than a high school education. Research to Improve the Nation’s Health System. DATA DRIVEN. POLICY FOCUSED. ldi.upenn.edu THE IMPLICATIONS Current ACO expansion in Medicaid and federally qualified health centers may also serve to alleviate potential disparities. This study suggests that vulnerable patients have less access to physicians who participate in ACOs, and therefore less access THE STUDY to any of the potential benefits of ACOs. This could exacerbate existing disparities in health care quality. The authors used a telephone-verified national database of U.S. office-based physicians that included self-reported The authors offer two potential explanations for why physicians information about their participation in an ACO, both public serving populations with relatively high rates of disadvantaged and commercial. The data used was collected during 2013 and people could be excluded from emerging ACOs: ACOs may be included more than 500,000 physicians, the vast majority of more likely to form in regions where the overall patient population those currently practicing. The authors estimated physicians’ is more affluent; or ACOs may be more likely to contract with ACO participation at the level of the hospital referral region physicians who serve more affluent patients. (HRR) as well as the more targeted Zip Code Tabulation Area level, and found that variations in ACO penetration largely They expand on this to suggest possible mechanisms contributing followed HRR boundaries. LDI RESEARCH BRIEF to the variation in physician participation in ACOs: The authors used summary statistics of the Zip Code Tabulation Given that it may be hard to meet some benchmarks for quality Area [of the physician’s practice location] from the American of care among hard-to-treat, vulnerable populations, ACOs Community Survey for 2009-2013 as a proxy for the may be less likely to locate in regions with these populations sociodemographic characteristics of the population that the than elsewhere. At the same time, even within areas with physician was likely to care for. The population characteristics ACOs, the organizations may exclude physicians likely to included: the percentages of the population that had less care for vulnerable populations in an effort to ensure that the than a high school education and that were black, Hispanic, organizations care for populations that will make it possible living in poverty, uninsured, or disabled. They also examined to achieve high scores on specific quality measures. Rates and controlled for physician-level variables: sex, number of of ACO participation may also be lower among physicians physicians in the practice, whether or not the practice was serving vulnerable populations, compared to other physicians, multispecialty, rurality of the practice location, and medical because of physician choice. Individual physicians or specialties. physician groups may choose to hold off on joining an ACO if Yasaitis LC, Pajerowski W, Polsky D, Werner RM. Physicians’ they deem it would be too difficult to achieve specific quality Participation In ACOs Is Lower In Places With Vulnerable Populations and spending goals with their patient populations. Finally, Than In More Affluent Communities. DOI: 10.1377/hlthaff.2015.1635. physician leaders of early ACOs reported that limited capacity Health Affairs, August 2016. was a major hurdle to entering an ACO contract. As ACOs proliferate, policy interventions are needed to prevent LEAD AUTHOR: DR. LAURA YASAITIS them from contributing to the worsening of health disparities. The authors suggest providing physician groups that serve vulnerable Laura Yasaitis, PhD, is a Postdoctoral populations with additional incentives to form an ACO or Researcher in Health Policy at the Perelman assistance with start-up costs. Participation might be encouraged School of Medicine. Her research interests by risk-adjusting ACO-linked quality indicators for patients’ include the study of large datasets, including sociodemographic characteristics, or rewarding improvements surveys and administrative data, to better over time. understand the quality and outcomes of health care in the United States. She is also interested in the application of spatial The authors looked at a snapshot of participation in 2013, so they analysis methods to further our understanding of local trends in could not test whether rates of ACO participation were increasing health and health care. over time among physicians who serve vulnerable populations. Connect With Us: ldi.upenn.edu Since 1967, the Leonard Davis Institute of Health Economics (LDI) has been the leading university institute dedicated to data-driven, • ldi.upenn.edu/health-policysense policy-focused research that improves our nation’s health and health • @PennLDI care. 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