Association of Pathways to Success Launch With Quality inBeneficiaries With Traditional Medicare.

Objective: To evaluate the association between implementation of "Pathways to Success" and quality among beneficiaries cared for in Shared Savings Program accountable care organizations (ACOs).

Study setting and design: Medicare initiated "Pathways to Success" in 2019 that required upside-risk only ACOs in Shared Savings Program to transition to a two-sided risk model and prior two-sided ACOs to assume even greater financial responsibility. We examined the association between Pathways and ACO-targeted (hospitalizations for congestive heart failure [CHF] and all-cause 30-day readmissions) and nontargeted (all-cause emergency department visits without hospitalization for CHF and hospital observation stays) quality measures, using a difference-in-differences framework.

Data sources and analytic sample: Data were extracted from a 20% sample of national Medicare data from 2018 to 2020. This study included 810,070 beneficiary-quarters in 514 ACOs, and 813,855 beneficiary-quarters never attributed to an ACO (i.e., controls).

Principal findings: Implementation of Pathways was not associated with significant relative changes in the quarterly number of CHF admissions (decreasing from 97.98 to 82.04 per 1000 beneficiaries in ACOs; differential change = 3.51 quarterly CHF admissions per 1000 beneficiaries, 95% CI, -4.82 to 11.85) or the quarterly number of emergency department visits for CHF (decreasing from 110.90 to 97.50 per 1000 beneficiaries in ACOs; differential change = 6.47 quarterly CHF emergency department visits per 1000 beneficiaries, 95% CI, -3.71 to 16.64). However, quarterly rates of 30-day all-cause readmissions increased slightly by 0.61% points (95% CI, 0.23 to 0.98; unadjusted readmissions increased from 14.49% to 14.81% in ACOs) after Pathways implementation. Observation stays remained unchanged (differential change = -0.16% points, 95% CI, -0.33 to 0.02; unadjusted observation stays increased from 3.64% to 3.94% in ACOs) after the launch of Pathways.

Conclusions: Medicare's Pathways to Success, which introduced two-sided risk, was not associated with improvement in select quality measures.