Reducing low-value cardio services among Pioneer ACO successes

There were modest reductions in low-value services provided by Medicare Pioneer ACOs in the first year of the program, according to an article published online by JAMA Internal Medicine.  Cardiovascular testing and procedures were among the leading drivers of savings.

J. Michael McWilliams, MD, PhD, and Aaron L. Schwartz, PhD, of Harvard Medical School in Boston, and coauthors examined the use of 31 low-value care services, which provide minimal clinical benefit to patients, in the Pioneer ACO program. These included certain cancer screenings, preoperative testing, imaging, cardiovascular testing and other procedures.

The authors measured annual service counts and annual service spending per 100 beneficiaries from before (2009-2011) and after (2012) Pioneer ACO contracts began.

The differential reductions were statistically significant for three clinical categories: cancer screening, imaging, and cardiovascular testing and procedures. The greatest absolute reductions in service use occurred for the most frequently delivered services, cancer screening and imaging, according to the findings. However, cardiovascular testing and procedures saw the greatest relative differential reduction (−6.3 percent for the ACO group; P = .05).

The first year of ACO contracts was associated with a reduction of 0.8 low-value services per 100 beneficiaries for the ACO group, which was a 1.9 percent reduction in service quantity and a 4.5 percent reduction in spending on low-value services.

Following are the cardiovascular services detailed in the analysis and the mean annual count per 100 beneficiaries:

• Homocysteine testing in cardiovascular disease (.8)
• Echocardiography (.3)
• Stress testing for coronary artery disease (0.7)
• Percutaneous coronary intervention with balloon angioplasty or stent placement for stable coronary disease (0.1)
• Renal artery angioplasty or stenting (0.1)
• Carotid endarterectomy for asymptomatic patients (.05)
• Inferior vena cava filters for the prevention of pulmonary embolism (.2)
• Pulmonary artery catheterization in the ICU (.001)

Organizations previously providing more low-value care saw greater reductions. The authors reported a decline of 1.2 services per 100 beneficiaries in ACOs with higher baseline use of low-value care service than their service area compared with a decline of 0.2 services per 100 beneficiaries at ACOs with lower baseline rates, according to the results.

Organizations volunteering for the Pioneer program may have been well-positioned to identify and reduce wasteful practices, the authors noted as a study limitation. Despite that, they said that their findings indicate that participating in the alternative payment model led to improved overall value of healthcare provided.