Medicare value-based approaches and care use among commercially insured adults

To examine whether the growth of Medicare Shared Savings Program (MSSP) accountable care organizations (ACOs) and Medicare Advantage (MA) penetration was associated with changes in health care use among commercially insured populations.

Observational study using claims data.

Using Health Care Cost Institute claims data (2015-2019), we conducted a repeated cross-sectional study of 13,041,197 enrollees aged 55 to 64 years in 50 states and the District of Columbia in employer-sponsored insurance plans of 4 national payers. Linear models estimated relationships between enrollees' health care use and county-level MSSP ACO and MA penetration, controlling for enrollee and market characteristics and county and year fixed effects. Outcomes of interest were enrollees' probability of receiving preventive care services (influenza immunization, breast cancer screening, colorectal cancer screening), having any outpatient emergency department visits, and having any inpatient hospitalization in a year.

A majority of counties (72.1%) experienced increases in penetration of MSSP ACOs and MA from 2015 to 2019. Median (IQR) MSSP ACO penetration increased from 5.9% (1.6%-16.9%) to 18.9% (9.3%-31.5%), and median (IQR) MA penetration increased from 19.5% (11.2%-29.3%) to 26.8% (15.9%-36.6%). MSSP ACO and MA penetration was not substantively associated with changes in commercial enrollees' use of preventive care, emergency department, and hospital services.

The expansion of MSSP ACOs and MA was not associated with substantive changes in health care use among commercial enrollees. The lack of spillovers from Medicare to commercial enrollees may stem from misaligned incentives from different payers, indicating the potential importance of multipayer alignment in ongoing payment reforms.