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Implementation of accountable care organizations (ACOs) cialis cost per pill has been occurring unevenly across the http://www.veganmonster.com/buy-cialis-over-the-counter nation, with rural areas lagging behind their more urban counterparts in ACO establishment (for example, see here, here, and here). To help establish ACOs in more areas of the country, the Centers for Medicare and Medicaid Services (CMS) developed the ACO Investment Model (AIM) to provide participating ACOs with up-front and ongoing monthly payments over 24 months to fund ACO infrastructure investments and staffing. As part of the Medicare Shared Savings Program (SSP), the payments were to be recouped through any shared savings earned by the ACOs that sufficiently decreased costs relative to a financial benchmark, as specified by SSP regulations cialis cost per pill. Forty-one new SSP ACOs, primarily located in rural and underserved health care markets, joined AIM in 2016 (exhibit 1).In this blog post, we discuss several noteworthy observations from our evaluation of the AIM ACO implementation and impacts over the three performance years (2016 to 2018), pertaining to:AIM ACOs’ close partnerships with management companies;Strategies—beyond local care coordination—for reducing spending in dispersed markets.

AndThe extent to which single-sided financial risk may suffice to induce care transformations.The full report is available here.Exhibit 1. AIM accountable care organization geographic locations in cialis cost per pill 2018Source. Authors’ analysis of Centers for Medicare and Medicaid Services data. Notes.

Figure shows primary care service areas (PCSAs) in which AIM ACOs’ assigned beneficiaries resided. We included PCSAs for which at least 0.5 percent of an ACO’s attributed beneficiaries resided. There was one AIM ACO with providers and assigned beneficiaries located in Guam, which is not shown in the figure.Small, Rural ACOs Relied Heavily On Management CompaniesA majority of AIM ACOs (35 of 41, or 85 percent) used specialized consulting firms (or management companies) to assist with setting up and operating the ACO. Management companies typically coordinated reporting, conducted claims-based analytics, and served as the liaison between the ACO participants and CMS officials.

Caravan Health managed 21 of the AIM ACOs, providing a fairly standard set of shared services to all of its client ACOs. Services included training for care coordinators and patient navigators, population health coaching, learning networks and workshops, analytics support through a centralized health information technology platform, and financial reporting. By contrast, a study analyzing data from the National Survey of ACOs, which surveyed ACOs formed between 2012 and 2015, showed that around one-third of ACOs had a management partner.In interviews with leaders from all 41 AIM ACOs, many stated that management companies played an important role by supporting them in navigating ACO start-up, managing ongoing operations, and providing access to services shared with other ACOs. AIM ACO leadership expressed general satisfaction with management company services.

At the same time, some AIM ACOs emphasized the need for greater due diligence when making larger investments in management company offerings. For example, some AIM ACOs found elements of the health information technology system and services selected by their management companies too costly given the capabilities offered.We also found that some AIM ACOs had become less dependent on their management companies over time and had developed sufficient internal capacity and expertise to function more independently. However, for those ACOs still requiring management company services, it is unclear whether ACOs can continue to pay for them without ongoing AIM-type funding. Furthermore, while management companies may have provided important services in the initial years of AIM, 27 of the 35 (77 percent) AIM ACOs with management company affiliations exited SSP by 2020.

CMS and other researchers should continue to investigate the relationships among ACOs and management companies—and how they evolve.Dispersed, Rural ACOs Sought Alternatives To Local Care Coordination To Reduce SpendingThrough interviews with ACO leadership and staff, we determined that about 90 percent of the 41 AIM ACOs were collections of independent practices rather than large organizations owning many practices. Thus, one might expect these practices to have been centrally located. However, many ACOs were composed of practices that spanned multiple local markets, at least in part as a result of management company involvement. Management companies had the ability to—and did—bring together unrelated entities, sometimes across regions or states to meet the minimum SSP requirement of 5,000 attributed beneficiaries and spread financial risk.

Indeed, only around 30 percent of AIM ACOs were composed of participants that were located in geographically proximate counties. While a common perception has been that local coordination of care among providers within an ACO would be a major driver of ACO financial success, ACOs serving relatively small, dispersed, and rural populations may have needed to use other strategies to improve care and earn shared savings.Looking at different care settings helps to elucidate how AIM ACOs reduced spending. We found statistically significant reductions across a number of spending components (the following reflect results from the final performance year, 2018), including acute inpatient (-4 percent), hospital outpatient and ambulatory surgery centers (-4 percent), skilled nursing facilities (SNFs) (-8 percent), and home health (-8 percent). This breakdown is similar to that found for programwide savings in the first three years of the SSP among physician group ACOs, which similarly exhibited greater relative reductions in areas thought to be greater sources of wasteful care (for example, postacute facility care) and was not clearly attributable to prevention efforts.

Admissions for ambulatory care–sensitive conditions were not reduced, and spending reductions were not concentrated among high-risk patients targeted by case management programs. Our findings for AIM are similarly consistent with efforts to directly limit certain types of care use and the much stronger incentives physician practices have to do so. Physician practices do not incur offsetting losses in fee-for-service profits when reducing spending on care provided by hospitals, SNFs, or home health agencies. In short, the less of the care continuum provided by an ACO, the stronger its incentives to lower spending.Our evaluation thus highlights that, in spite of a lack of geographic proximity, AIM ACOs overall were able to significantly reduce costs.

Moreover, management company executives and ACO staff stated in interviews that they did not think proximity mattered for ACO success. In interviews, executives from two management companies, which collectively managed 25 of the 41 AIM ACOs, had similar responses when we asked them about the topic of geographic contiguity of providers within a given ACO. They stated that the geographic distribution of providers minimally influenced the ACOs’ abilities to reduce unnecessary care and, ultimately, costs. One management company reported that it implemented a standard set of practice management services, tools, and approaches to transforming clinic workflows, which would have been similar whether the ACO providers were located in the same city or more dispersed.The fact that ACOs may be successful without substantial collaboration in their localities may encourage rural providers that are considering value-based payment models but lack a concentrated local network of potential collaborators.

At the same time, management companies may play important roles in facilitating care transformations by pooling risk and overcoming fixed costs—for a price.Does One-Sided Risk Provide Sufficient Inducement For Rural Providers To Offer Quality Accountable Care?. When the Medicare Shared Savings Program was redesigned under Pathways to Success, it allowed for newly formed and small ACOs to still start in a one-sided (shared savings–only) risk track but required them to move to two-sided risk (both shared savings and losses) more quickly than under the prior program rules. Two-sided financial risk strengthens incentives for ACOs to lower spending. However, among smaller ACOs, uncertainty about spending is amplified and rural providers in particular may struggle to participate in voluntary models that come with a 10 percent chance of having to repay CMS millions of dollars each year.

As rural providers are not subject to Quality Payment Program adjustments, they face weaker incentives to participate in a risk track that qualifies as an Advanced Alternative Payment Model. That is, opting to decline participation in a two-sided risk model does not mean incurring the costs of complying with the complex Merit-based Incentive Payment System (MIPS). It is possible that one-sided financial risk might suffice to spur development of ACOs that improve care efficiency in areas that previously had little accountable care activity. In fact, the added protection of one-sided financial risk might be necessary to induce ACOs to form in such areas.

Our multiyear, mixed-methods evaluation (reports can be found here), which integrated findings from ACO surveys and interviews, as well as claims data analyses, showed that rural providers are capable of reducing some wasteful spending when sufficient investments are made, thereby supporting delivery system improvements that are at least budget neutral. Specifically, AIM ACOs that took on only one-sided financial risk were consistently able to decrease spending and maintain quality for three straight years. We found that AIM resulted in net savings to CMS of $382 million through 2018 (that is, gross savings less earned shared savings and unrecouped payments from CMS)—an average annual reduction of 2.5 percent compared to baseline spending levels.Many of the ACOs we interviewed were hesitant to take on two-sided financial risk, even at the end of AIM. This is not surprising, given only 54 percent of AIM ACOs earned any shared savings.

ACOs rightly viewed one-sided risk-sharing contracts as carrying downside risk, particularly after AIM funding ceased—if they did not generate savings, they would not recoup the costs of trying. ACO leaders cited a host of concerns about. Size (in terms of attributed patients), their participant networks, operational capacities to handle the analytics they believed would be necessary to manage risk-taking, and other organizational factors. While management companies played key roles in helping new ACOs operate, only seven of the 41 AIM ACOs (17 percent) had accepted two-sided risk arrangements by the end of AIM in 2018.

This suggests that any mitigation of downside risk offered by management companies was prohibitively costly for AIM ACOs without continued investment funding.ConclusionThe ACO Investment Model demonstrated that underresourced providers can successfully reduce enough wasteful spending to offset the costs of delivery system investments, even under an upside-only financial risk model. Management companies played an important supportive role by providing services that individual ACOs lacked the necessary scale in which to invest. Looking forward, they may play additional roles in pooling risk to shield small providers with limited reserves from deleterious penalties, although doing so defeats the purpose of introducing downside risk at the provider level and could weaken incentives to participate if management companies must charge higher fees to cover potential losses.As ACO benchmarks increasingly reflect regional spending under “Pathways to Success,” management companies may be inclined to strategically include practices with low spending for their region. Thus, it will be important to track the implications of key features of ACO model design—such as benchmarking and risk adjustment—on ACO formation and evolution.

If geographic centralization is not integral to ACO success, it may open new doors in care delivery—an important finding in light of the ongoing cialis and renewed focus on telehealth.Authors’ NoteThe authors acknowledge David Nyweide and Catherine Hersey.This work was supported by the Centers for Medicare and Medicaid Services (CMS) (contract number, HHSM50020140026I. Task order number, HHSM500T0004). The statements contained herein are those of the authors and do not necessarily reflect the views or policies of CMS..

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"Some types of breast cancer, especially like triple negative, where the cancer is hormone receptor and HER2 negative, are not very responsive to treatment. So our goal was to see if surgery made a difference in metastatic breast cancers that were responsive to treatment."The researchers excluded patients who died within six months of their diagnoses, in order to ensure that treatment-responsive cancers were being studied. They found that patients with a surgical intervention tended to have a longer length of survival compared to patients with other treatment plans. Patients whose cancers were HER2 positive especially saw prolonged survival when their treatment plan included surgery.Stahl and her coauthors further analyzed the patients who received surgery to see whether receiving chemotherapy before or after surgery had an impact on their length of survival. They found that regardless of hormone receptor or HER2 status, patients who received systemic therapy -- including chemotherapy and targeted treatments -- before surgery tended to live longer than those who had surgery before systemic treatment."Not only did we find that surgery may be beneficial for treatment-responsive metastatic breast cancer patients, we also uncovered that getting chemotherapy before that surgery had the greatest survival advantage in patients with positive HER2 and estrogen and progesterone receptor status," said Shen, associate professor of surgery.The researchers said that randomized, controlled trials evaluating the role of surgery after systemic therapy in a younger demographic with minimally metastatic cancers could be used to confirm their results, but said that patient resistance to randomization in trials like this have resulted in poor study recruitment.

Therefore, they encourage clinicians to evaluate real-world evidence, including their study, to choose optimal treatment for metastatic breast cancer patients."Stage four breast cancer patients who are responsive to systemic therapy may be able to benefit from the addition of surgery regardless of their biologic subtype," Stahl said. Story Source. Materials provided by Penn State. Original written by Zachary Sweger. Note.

Content may be edited for style and length..

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Dr. Kelly Stahl, surgical resident and lead author of the study published in the Annals of Surgical Oncology, said that previous studies evaluating surgical interventions for metastatic breast cancer had conflicting results which has led to a lack of consensus among clinicians and researchers."Results from previous trials evaluating surgical benefit in metastatic breast cancer patients have been questioned because of the small number of participants or the fact that patients weren't also receiving chemotherapy or other systemic therapies," Stahl said. "We felt another key factor missing from those studies was whether the biologic subtype of breast cancer affected the survival rates in relation to surgical intervention."Stahl worked with Dr. Daleela Dodge and Chan Shen to identify 12,838 stage four breast cancer patients from the National Cancer Database from 2010-2015 and whether these patients' cancer cells had a growth-promoting protein called HER2 and hormone receptors for estrogen and progesterone, which can fuel cancer growth.

The researchers said knowing these characteristics of a cancer's biological subtype can help determine which treatment plans may be effective.Stahl studied patients who either had systemic therapy alone, had systemic therapy and surgery, or had systemic therapy, surgery and radiation. She and her coauthors then evaluated whether certain biologic subtypes and timing of chemotherapy were associated with survival advantages."We evaluated whether the hormone status had an influence on surgical benefit in these treatment-responsive breast cancer patients," said Dodge, an associate professor of surgery and humanities. "Some types of breast cancer, especially like triple negative, where the cancer is hormone receptor and HER2 negative, are not very responsive to treatment. So our goal was to see if surgery made a difference in metastatic breast cancers that were responsive to treatment."The researchers excluded patients who died within six months of their diagnoses, in order to ensure that treatment-responsive cancers were being studied.

They found that patients with a surgical intervention tended to have a longer length of survival compared to patients with other treatment plans. Patients whose cancers were HER2 positive especially saw prolonged survival when their treatment plan included surgery.Stahl and her coauthors further analyzed the patients who received surgery to see whether receiving chemotherapy before or after surgery had an impact on their length of survival. They found that regardless of hormone receptor or HER2 status, patients who received systemic therapy -- including chemotherapy and targeted treatments -- before surgery tended to live longer than those who had surgery before systemic treatment."Not only did we find that surgery may be beneficial for treatment-responsive metastatic breast cancer patients, we also uncovered that getting chemotherapy before that surgery had the greatest survival advantage in patients with positive HER2 and estrogen and progesterone receptor status," said Shen, associate professor of surgery.The researchers said that randomized, controlled trials evaluating the role of surgery after systemic therapy in a younger demographic with minimally metastatic cancers could be used to confirm their results, but said that patient resistance to randomization in trials like this have resulted in poor study recruitment. Therefore, they encourage clinicians to evaluate real-world evidence, including their study, to choose optimal treatment for metastatic breast cancer patients."Stage four breast cancer patients who are responsive to systemic therapy may be able to benefit from the addition of surgery regardless of their biologic subtype," Stahl said.

Story Source. Materials provided by Penn State. Original written by Zachary Sweger. Note.

Content may be edited for style and length..