Proportion of Minority Patients in ACO Tied to Quality Performance

Researchers have found that accountable care organizations (ACOs) with a higher proportion of minority patients tend to score worse on Medicare’s quality performance measures. In an article published in Health Affairs, researchers, led by Valerie A. Lewis, PhD, of The Dartmouth Institute, looked at the share of an ACO's patients who are a racial or ethnic minority and the ACO’s performance on Medicare’s quality performance measures.

Previous research has found that providers who serve a higher proportion of patients in an ethnic or racial minority tend to perform worse on quality outcomes. There had been no research into how ACOs impact the healthcare disparities facing ethnic and racial minorities.

On one hand, the researchers wrote, ACOs and similar reforms may, theoretically, lead to reduced disparities in quality and financial incentives for quality care to drive an improvement in care among low-quality providers serving large proportions of minority patients. However, on the other hand, providers who serve more minority patients may struggle to meet performance targets because they do not have the resources they need to transform care.

“In this case, lagging performance under new payment models by providers with large proportions of minority patients could exacerbate disparities in quality and call into question the viability of payment and delivery reforms,” the authors wrote.

They used data from the first and second year of each ACO’s contract in the Medicare Shared Savings Program, plus available information on the characteristics of each ACO’s patient population and providers. In addition, they used data from the National Survey of Accountable Care Organizations.

The researchers found that 17.8% of patients attributed to ACOs were minority (10.2% black, 2.6% Hispanic, 0.2% Native American, 2.4% Asian, and another 2.4% patients of another race), and a small number of ACOs had a very high proportion of minority patients. Patients in ACOs with a high proportion of minority patients tended to be younger than 65, dually eligible for Medicare and Medicaid, disabled, and female. They also were more likely to have end-stage renal disease.

“Overall, these results indicate that ACOs serving a high proportion of minority patients had patients who were higher risk, somewhat sicker or more costly, and perhaps disadvantaged in other ways (for example, on Medicaid), compared to other ACOs,” the authors wrote.

The association between proportion of minority patients and quality performance was strongest in the area of preventive health and at-risk populations, they found. Furthermore, the quality performance gap between ACOs with a high proportion of minority patients and other ACOs did not diminish over time. In other words, these ACOs did not improve more or more rapidly than other ACOs and were not able to catch up in quality.

The troubling aspect of these findings, the authors wrote, is that ACO programs are voluntary, but Medicare is making the move toward increasing participation in alternative payment models, including ACOs, and providers may not be capable or ready to participate.

“Policy makers could use this study and additional data to stimulate discussions about and consideration of the role of healthcare equity in new payment models that focus largely on improving the efficiency of the healthcare system,” the authors concluded.