SummaryNew analysis from Avalere finds that Medicare beneficiaries are more likely to receive Part D autoimmune drugs and less likely to receive Part B autoimmune drugs from providers who are part of Accountable Care Organizations (ACOs) in the Medicare Shared Savings Program (MSSP) compared to non-ACO providers.
The MSSP is Medicare’s largest alternative payment model (APM) and is part of a broader government effort to shift healthcare payments away from a fee-for-service (FFS) model toward a value-driven payment and delivery approach. Today, 517 ACOs serve 11.2 million Medicare FFS beneficiaries in every state in the US.
As the MSSP is structured today, MSSP ACOs are responsible for the total annual Part A and Part B costs of patients attributed to them, which are compared to a benchmark to determine shared savings or losses. However, costs under Part D, Medicare’s prescription drug benefit, are not included in measuring an ACO’s total cost of care. The decision to exclude Part D costs in ACOs has been a point of discussion for the Centers for Medicare & Medicaid Services and other stakeholders for many years. Some stakeholders see value in including Part D costs to encourage providers to consider the full costs of care and avoid incentives to shift costs from Part B to Part D.
To better understand how this policy decision may influence providers’ prescribing habits, Avalere evaluated Medicare patients who received autoimmune drugs prescribed by ACO providers versus non-ACO providers. Autoimmune conditions such as rheumatoid arthritis or plaque psoriasis have both Part B and Part D treatment options available. From 2013 (the start of the MSSP) to 2016, the percentage of patients who received a Part D autoimmune drug from ACO providers increased from 43.9% in 2013 to 51.9% in 2016, while the percentage of patients who received a Part D drug from non-ACO providers remained relatively constant from 42.9% in 2013 to 44.5% in 2016.
As Figure 2 illustrates, however, the percentage of patients who received a Part B autoimmune drug from ACO providers decreased from 56.9% in 2013 to 49.3% in 2016.
The percentage increase in patients who received a Part D drug and the decrease in patients who received a Part B drug from ACO providers suggest that the structure of the MSSP may be influencing providers’ prescribing habits. Incentives to reduce Part A and Part B costs appear to produce a trend away from Part B drugs to Part D drugs when therapeutic alternatives exist. The analysis suggests that the model seems to influence prescribing behavior even when there is fairly limited financial risk via downside risk arrangements. In 2016, only 5% of ACOs were in a downside risk arrangement. Despite the small number of ACOs at risk, Avalere observed a change in the percentage of patients who received Part B and Part D drugs. That change will likely persist as more ACOs assume greater risk. Today, 37% of ACOs are in downside risk arrangements.
While this study did not control for the full array of factors that could account for the differences in prescribing patterns between ACO and non-ACO providers, the study’s findings highlight the potential for APMs to impact prescribing decisions. Furthermore, incentives to prescribe Part D drugs instead of Part B medications could intensify under payment models with greater risk. When designing, participating, and engaging with providers participating in ACOs and other APMs, it is important to understand how the specific payment models impact their preference for certain therapeutic options. Looking forward, it will be critical for stakeholders to evaluate the scope, method, and risk structure of these programs and the downstream implications on care patterns and patient access.
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The data sources for this analysis included the 2013–2016 100% Medicare Part B Carrier claims files, the 100% Medicare Prescription Drug Event (PDE) data, and the MSSP ACO provider files. For Medicare FFS beneficiaries receiving any autoimmune drug, Avalere calculated the percentage receiving a Part B autoimmune drug versus a Part D autoimmune drug from physicians affiliated with ACOs and physicians not affiliated with ACOs. The definition of autoimmune drugs includes specialty treatments indicated for rheumatoid arthritis, psoriatic arthritis, plaque psoriasis, Crohn’s disease, ulcerative colitis, and ankylosing spondylitis. These drugs were identified by Healthcare Common Procedure Coding System codes in the Part B data and by generic name in the PDE data. ACO affiliation was determined by linking the prescribing physician National Provider Identifier (NPI) to the NPIs in the ACO provider files.
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