Early Effects of Pathways to Success on Utilization in Traditional Medicare

To evaluate the early effects of Pathways to Success implementation on utilization, as measured by quarterly price-standardized Medicare spending per beneficiary.

This study was a nationwide retrospective cohort analysis of Traditional Medicare beneficiaries. The primary outcome was overall utilization, as measured by adjusted quarterly price standardized spending per beneficiary. Secondary outcomes included adjusted quarterly price standardized spending by component type (inpatient, outpatient institutional, Part B, and skilled nursing facility). The primary independent variable is Pathways to Success implementation on July 1, 2019.

A 20% sample of national Medicare data from January 1, 2018, through March 31, 2020, includes Traditional Medicare beneficiaries managed in ACOs (n = 1,368,523) and outside of ACOs ("controls," n = 1,476,982) prior to Pathways implementation.

Unadjusted quarterly spending among those in ACOs and controls decreased over the study period by $13.5 (from $2614.8 before Pathways implementation to $2601.3 after Pathways implementation) and $89.8 (from $2723.1 before Pathways implementation to $2633.3 after Pathways implementation), respectively. Adjusted quarterly spending per beneficiary decreased more slowly in ACOs compared to controls (differences-in-differences estimate +$46.8 (95% CI $19.2, $74.4) in ACOs vs. controls). This difference was largely driven by a more rapid decrease in the utilization of inpatient care. Adjusted quarterly spending per beneficiary for inpatient care decreased more slowly in ACOs compared to controls (differences-in-differences estimate +$43.6 [95% CI $27.2, $60.0] in ACOs vs. controls).

After Pathways, reductions in utilization, as measured by price-standardized spending, by ACOs occurred less rapidly than for those managed outside of the Shared Savings Program. This effect was driven by a more rapid decrease in spending for inpatient care by nonparticipants.