Accountable Care Organizations and Spending for Patients Undergoing Long-Term Dialysis

Design, setting, participants, & measurements In this retrospective cohort study, beneficiaries on long-term dialysis between 2009 and 2016 were identified using a 20% random sample of Medicare beneficiaries. Trends in alignment to an Accountable Care Organization were compared with alignment of the general Medicare population from 2012 to 2016. Using an interrupted time series approach, we examined the association between Accountable Care Organization alignment and the primary outcome of total spending for long-term dialysis beneficiaries fromprior to Accountable CareOrganization implementation (2009-2011) through implementation of the Comprehensive ESRD Care model in October 2015. We fit linear regression models with generalized estimating equations to adjust for patient characteristics. Results During the study period, 135,152 beneficiaries on long-term dialysis were identified. The percentage of long-term dialysis beneficiaries aligned to anAccountable Care Organization increased from6% to 23% from2012 to 2016. In the time series analysis, spending on Accountable Care Organization-aligned beneficiaries was $143 (95% confidence interval, $5 to $282) less per beneficiary-quarter than spending for nonaligned beneficiaries. In analyses stratified bywhether beneficiaries received care froma primary care physician, savings by Accountable Care Organization-aligned beneficiaries were limited to those with care by a primary care physician ($235; 95% confidence interval, $73 to $397). Conclusions There was a substantial increase in the percentage of long-term dialysis beneficiaries aligned to an AccountableCareOrganization from2012 to 2016. Moreover, in adjustedmodels, AccountableCareOrganization alignmentwas associated withmodest cost savings among long-termdialysis beneficiarieswith care by a primary care physician.