Study finds possible cause of racial and ethnic gaps in Medicare’s quality program

Medicare has been pushing for better quality and lower costs for the past 10 years by encouraging health care providers to join Accountable Care Organizations. The result today is that ACOs coordinate the care of 11 million people, most with traditional Medicare coverage. ACOs receive financial incentives for improving the health outcomes of their patients.

Despite showing improvement, these improved outcomes have not reached all older Americans equally. ACOs that include a higher percentage of patients who are Black, Hispanic, Native American, or Asian have lagged behind those with higher percentage of white patients in providing preventive care and keeping patients out of the hospital.

A study from the University of Michigan shows that some of this inequity stems from how an ACO’s patients get their primary care. Even if they see specialist physicians who belong to an ACO, older adults aren’t required to see a primary care provider who belongs to the same ACO. The results were presented in the JAMA Health Forum.

The study shows that ACOs with higher percentages of members of racial and ethnic minority groups also tended to have higher percentages of out-of-network primary care. That meant the patient’s routine care was delivered by a provider with no connection to the ACO, and therefore no potential financial benefit if they hit the quality benchmarks.

The study used data from nearly four million Medicare participants whose providers belong to 538 ACOs in the Shared Savings Program. The percentage of patients who got their primary care outside the ACO was nearly 13% in the ACOs that had the highest percentage of participants from racial or ethnic minorities, compared with about 10% of the patients in the other ACOs.

But even when the researchers left out the ACOs that had the highest percentage of out-of-network primary care, they still saw differences in quality of care. Older adults in ACOs with the highest percentages of minority participants were less likely to get diabetes and cholesterol checks, and those who had been hospitalized were more likely to end up back in the hospital within a month.

On the other hand, in the ACOs that had the lowest percentage of patients who got their primary care out of the ACO network, there were no differences in quality performance between ACOs with different percentages of members from minority groups.

The authors concluded that organizational efforts to increase in-network primary care at ACOs serving more patients of racial and ethnic minority groups could serve as a tangible, accessible corrective for reducing health care disparities.

According to the report, there are numerous ways in which ACOs serving more patients of racial and ethnic minority groups could do this. For example, they could offer after-hours and weekend access to medical services for beneficiaries, which has been shown to improve care continuity and limit ED utilization and admissions for ambulatory care–sensitive conditions. Alternatively, ACOs serving more patients of racial and ethnic minority groups could use financial incentives, such as lower copayments, that encourage their assigned beneficiaries to see in-network primary care clinicians. Clearly, any of these efforts would need to be balanced with the preservation of patient choice, which is a defining characteristic of SSP ACOs.

The Centers for Medicare and Medicaid Services, the federal agency that oversees Medicare and the ACO program, recently announced a new kind of ACO that will launch in 2023, called ACO REACH. It specifically focuses on health equity and bringing the benefits of the ACO model to underserved communities.