Vulnerable Populations Have Less Access to ACO Physicians

Laurie Barclay, MD

August 12, 2016

Physicians have lower participation in accountable care organizations (ACOs) in vulnerable than in affluent communities, highlighting the need to reduce healthcare disparities, according to a database analysis published in the August issue of Health Affairs.

In an ACO, members of a physician (and often a hospital) network share financial and medical responsibility for coordinated patient care, aiming to improve care quality while reducing unnecessary costs. In the United States, ACOs are becoming more widespread, particularly in more affluent communities.

"While enthusiasm for ACOs is growing, some stakeholders warn of possible unintended consequences," write Laura C. Yasaitis, PhD, from the Perelman School of Medicine, University of Pennsylvania, Philadelphia, and colleagues. "In particular, there are concerns that ACOs may worsen existing disparities in health care quality."

Vulnerable patients, or those with lower income, Medicaid or no coverage, disability, and belonging to racial minorities, are at greater risk for poor health. Yet relatively few providers tend to provide their care, and these clinicians tend to have fewer financial and healthcare resources and poorer performance on quality measures than those caring for more affluent patients.

Across hospital referral regions, physicians' participation in Medicare and commercial ACOs varied widely, from nearly 0% to more than 85%.

Physicians practicing in Zip code tabulation areas in which proportionately more people were black, living in poverty, uninsured, disabled, and had not graduated high school had significantly lower rates of ACO participation than physicians in other areas, after adjustment for individual physician and practice factors.

"Greater consideration is warranted in creating policies to encourage the development of ACOs and physicians' participation in them in areas with vulnerable populations," the study authors write. "Additionally, any changes in the care and health outcomes of these populations should be monitored to assess the potential effects of ACO implementation on health care disparities."

Black, not Hispanic, Populations Predict Physician ACO Participation

A telephone-verified database of 521,543 US office-based physicians included data regarding their participation in public or commercial ACOs. Factors associated with ACO participation (25.9%) were female sex; large, multispecialty, or primary care practices; and location in the Northeast, mid-Atlantic, upper Midwest, and West.

Residents in hospital referral regions with lower vs higher physician participation rates in ACOs were less likely to have completed high school and more likely to be living in poverty, black, or disabled. Nationwide, physicians' ACO participation was inversely related to the percentage of the population that had these characteristics or were uninsured.

Hispanic population levels did not consistently predict physician participation rates in ACOs. Black population levels were the strongest predictor, with 30.8% of all physicians (35.7% of primary care physicians) participating in an ACO in areas with the lowest quartile of black population vs 22.9% of all physicians (26.4% of primary care physicians) in the highest quartile (P < .001 for both).

Limiting the analyses to within–hospital referral region differences attenuated these associations but did not abolish them.

Strategies to Reduce ACO Disparities

"Our results suggest that vulnerable patients have less access to physicians who participate in ACOs and thus less access to the potential benefits of ACOs, compared to other patients," the authors write.

They suggest that ACOs may be more likely to develop in areas with more affluent populations, and that emerging ACOs may be more likely to contract with local physicians serving more affluent patients, thus excluding disadvantaged patients.

"Given that it may be hard to meet some benchmarks for quality of care among hard-to-treat, vulnerable populations, ACOs may be less likely to locate in regions with these populations than elsewhere," the authors write.

To ensure that ACOs treat populations in which it is feasible to achieve high scores on quality measures, ACOs themselves may exclude physicians likely to care for vulnerable patients. Physicians may choose not to join ACOs in difficult-to-treat populations, particularly when capital is limited.

To help close the healthcare disparity gap, the researchers suggest policy interventions such as offering physicians serving vulnerable populations additional incentives to form an ACO or assistance with start-up costs and risk-adjusting ACO-linked quality indicators for patients' sociodemographic factors.

Limitations of this study include use of general population characteristics of Zip code tabulation areas as a marker for served patient populations, use of self-reported physician data, and relatively short study period preventing determining whether ACO participation rates were increasing over time in physicians serving vulnerable populations.

The National Institute on Aging supported this study. The authors have disclosed no relevant financial relationships.

Health Aff. 2016;35:1382-1390. Abstract

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