Specialists Help Drive Skilled Nursing Usage Cuts in ACOs

Multiple analyses have demonstrated that accountable care organizations (ACOs) reduce the use of skilled nursing facilities and other institutional post-acute care settings, and a new study may have identified a subtle culprit for the trend: specialist physicians.

ACOs with the highest proportion of specialist visits had demonstrably lower rates of hospital admissions, skilled nursing encounters, and emergency room visits, a team from the University of Massachusetts-Amherst found.

Conversely, those with the lowest concentration of specialist visits — and a greater proportion of primary care physician (PCP) visits — had the highest usage of SNFs, emergency rooms, and other costlier sites of care, the team determined in findings published last week in the journal JAMA Network Open.


“The finding of high expenditures among ACOs with the lowest specialist encounter proportion suggests patients in this group received outpatient care (predominantly delivered by PCPs) associated with higher ED, hospital, and SNF encounter rates,” they wrote. “Although PCPs may play an important role in the coordination and management of patient care, particularly for those with chronic illness, active specialist involvement in the continuum of patient care (eg, acute diagnosis consultations, specialist-provided procedures, or co-management of complex conditions) may be important in improving outcomes.”

In theory, ACOs work by fostering cooperation among providers up and down the care continuum, encouraging them to work together to reduce episodic costs and improve patient outcomes. But so far, the Medicare Shared Savings Program (MSSP) — under which ACOs operate — has appeared to create winners and losers, with SNFs often on the short end of the stick.

For instance, a 2018 study from consulting firm Leavitt Partners determined that the most successful ACOs were the ones that worked to reduce SNF utilization: For every 1% decline in skilled nursing spending, the ACOs boosted their savings rate by 0.82%.


“We also found that although all MSSP ACOs are shifting their expenditures, the ACOs that improved their savings rate most rapidly were those that had shifted SNF and inpatient expenditures more dramatically,” the researchers wrote. “This finding indicates that the degree to which ACOs shift their expenditures matters, and that significant additional savings can be gained by shifting inpatient and SNF spending toward physician services.”

Another analysis, published last spring, determined that ACOs in markets across the country had begun enforcing a strict 17-day cap on skilled nursing lengths of stay, mirroring similar actions by Medicare Advantage (MA) plans.

“It’s not just the MA plans,” researcher Denise Tyler told SNN at the time. “It almost seems from our interviews that the ACOs were a little bit more strict in terms of ‘You’ve got your 17 days and that’s it.’ Whereas with the MA plans, there was some flexibility. You had to jump through a lot of hoops if you were the SNF, but [the SNFs] were able to have flexibility.”

The UMass-Amherst team focused on MSSP data from 2012 to 2017, probing the proportion of office visits conducted by specialists as opposed to a PCPs in 620 different ACOs. In terms of pure spending, ACOs on either side of the spectrum had the highest costs, with a sweet spot of around 40% to 45% specialist visits creating the most savings.

The team concluded that policymakers should implement more incentives for specialists to participate in the ACO model — a shift that’s easier said than done given current structures, according to researcher Vishal Shetty.

“There aren’t strong incentives as it stands now for specialists to join ACOs,” Shetty said in a release announcing the results. “Fee-for-service reimbursement is still a higher incentive.”