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dissertation.html
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<h1>Dissertation Research</h1>
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<h2 id=paper1>Soft Consolidation in Medicare ACOs: Potential for Higher Prices Without Mergers or Acquisition</h2>
<blockquote>Antitrust guidance specifies that participation in Medicare accountable care organizations (ACOs) is sufficient to meet clinical integration standards for separately owned providers to jointly negotiate with insurers. Accordingly, ACO participation may facilitate price increases through a less conventional, “softer” consolidation that would not be categorically challenged as price fixing. Using commercial claims and data on health system membership and ACO participation, <strong>we found some abrupt, large price increases for independent primary care practices that joined health system–led ACOs but were not acquired by systems</strong>. These price jumps were rare, however, increasing prices by just 4 percent, on average, among all independent practices in system-led ACOs. Additional analyses suggested minimal increases in health systems’ primary care prices or market shares from ACO contracting. Thus, <strong>the price jumps were more consistent with an extension of existing pricing power</strong> from systems to some independent practices than with a major expansion of system market power. Nevertheless, the potential for growth of these arrangements through ACOs argues for closer monitoring and evaluation.</blockquote>
<p>Published June 2021 in <a href="https://www.healthaffairs.org/doi/10.1377/hlthaff.2020.02449" target="_blank"><i>Health Affairs</i></a> with Michael Chernew and J. Michael McWilliams.</p>
<h2 id=paper2>Regionalized Benchmarking and Selection in Risk-Sharing Payment Models</h2>
<blockquote>In 2017, the Medicare Shared Savings Program (MSSP) changed how spending targets, or benchmarks, were calculated. Compared to the original benchmarking design based on historical spending, ACO participants faced new “regionalized” benchmarks that blended historical spending with average spending in each ACO’s geographic region. <strong>This change introduced new incentives for providers with lower or higher spending in their region to selectively participate in or exit the MSSP</strong>. Such selection could manifest at the ACO level or within ACOs at the practice level, potentially enabling participants to earn bonuses without achieving commensurate savings. Using variation in exposure to regionalized benchmarking over time and across different MSSP entry cohorts, <strong>I examine whether participation patterns reflect evidence of strategic selection behavior and assess the potential implications for program performance</strong>.</blockquote>
<h2 id=paper3>Patient Flows for Inpatient and Specialty Care in Medicare ACOs</h2>
<blockquote>Effective care coordination and referral management are often identified as key strategies for success in ACOs where separately owned providers share financial risk and bonuses. As a result, ACOs have received notable waivers from regulations governing conflicts of interest, specifically anti-kickback and Stark self-referral laws. However, some have also raised concerns that <strong>these broad waivers could allow provider organizations to redirect their ACO partners’ referrals to their own specialists and hospitals when other more efficient providers might exist</strong>. In this study, I investigate these concerns by examining Medicare ACOs led by provider organizations that also own specialists or hospitals. Using patient flows as a proxy for referral behavior, <strong>I evaluate differential changes in new specialty visit and elective admission patterns associated with primary care provider participation in these types of ACOs</strong>.</blockquote>
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