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ACO enrollment associated with more appropriate breast, colorectal cancer screening

Enrolling in Medicare Shared Savings Program Accountable Care Organizations led to improvements in appropriateness of breast and colorectal cancer screening, according to findings published in JAMA Internal Medicine.

“Despite rapid diffusion of Accountable Care Organizations (ACOs), whether ACO enrollment results in observable changes in cancer screening remains unknown,” Matthew J. Resnick, MD, MPH, from Vanderbilt University Medical Center, and colleagues wrote.

Resnick and colleagues performed a population-based analysis of Medicare beneficiaries to examine if the appropriateness of screening for breast, colorectal and prostate cancers changed as a result of Medicare Shared Savings Program (MSSP) ACO enrollment.

The researchers evaluated changes using Medicare data from 2007 to 2014 and difference-in-differences analyses. They also assessed differences across strata of appropriateness, including age (65 to 74 years vs. 75 years and older) and predicted survival (top vs. bottom quartile) using difference-in-difference-in-differences analyses.

Medicare beneficiaries comprised 39,218,652 person-years before MSSP enrollment and 17,252,345 person-years after MSSP enrollment. Breast cancer screening declined among the ACO population from 42.7% precontract to 38.1% postcontract and non-ACO population from 37.3% precontract to 34.1% postcontract, corresponding to a 0.79% higher adjusted rate of decline among the ACO population. The decline was more substantial among elderly women than younger women (–2.1% vs. –0.26%).

Screening rates were lower for colorectal cancer than breast cancer, with the ACO population having a precontract rate of 10.1% and postcontract rate of 10.3% and the non-ACO population having a precontract rate of 9.2% and postcontract rate of 9.1%. ACO enrollment was associated with an adjusted increase in screening (0.24%). Younger beneficiaries showed the most substantial increase (0.36%).

There were statistically significant differences in ACO effect on screening by age for both breast and colorectal cancer.

Prostate cancer screening declined among the ACO population from 35.1% precontract to 28.5% postcontract and non-ACO population from 31.2% precontract to 25.7% postcontract, corresponding to a 1.2% higher adjusted rate of decline among the ACO population. There was no difference in ACO effect on prostate cancer screening based on age strata.

“Our findings provide evidence of ACO-driven small-magnitude reductions in breast cancer overscreening, improvements in appropriate colorectal cancer screening, and a reduction in prostate cancer screening in both appropriate and inappropriate candidates,” Resnick and colleagues. “While the directionality of observed changes, particularly in breast and colorectal cancer screening is promising, the magnitude of effect is modest in the early ACO experience.

“Further investigation will characterize the most meaningful levers to optimize cancer screening programs in the United States,” they added.

In an accompanying editorial, Allison Lipitz-Snyderman, PhD, from the Center for Health Policy Outcomes at Memorial Sloan Kettering Cancer Center, wrote that the study by Resnick and colleagues shows modest improvements in cancer screening with ACO enrollment.

“Up-front assignment of accountability coupled with more explicit quality measurement for cancer screening and alignment of incentives would set the Medicare ACO program up to work as intended,” she wrote. “If implemented, these elements may prove successful for improving cancer screening based on future program evaluations.”

“However, given the complex clinical reality of cancer screening decisions, they may still not be enough to fully realize the national goal of improved cancer screening,” she added. “This will likely require a comprehensive approach that also focuses on promoting shared decision making and addressing the distinct and many contributors to underscreening and overscreening at the patient, clinician, and health system levels.” – by Alaina Tedesco

Disclosure: The authors report no relevant financial disclosures.