The footprint of accountable care organizations (ACO) continues to change. At the start of 2018, there are approximately 1,000 ACOs covering 32.7 million consumers—approximately 11% of the U.S. insured population (294.6 million)—under 1,477 different contracts (see After A Slow 2017, ACOs Grow & Expand Their Contracts In 2018).
The coverage varies by payer. According to Leavitt Partners, about half of the 32.7 million consumers are enrolled in commercial ACOs—roughly 11% of the 186 million people enrolled in commercial insurance. As of 2018, there are eleven states with Medicaid ACO models enrolling 3.8 million individuals and representing 6.2% of total enrollment in 2018 (see The 2018 OPEN MINDS Medicaid ACO Trend Update). Finally there were 612 Medicare ACOs with more than 10.5 million beneficiaries enrolled in them, representing 17.5% of the Medicare population (see Medicare Shared Savings Program Fast Facts).
One issue for specialty provider organizations with ACOs is their “ownership.” Leavitt Partners estimates that about 65%+ ACOs are physician group-led and 25%+ are hospital group-led (see The 2017 ACO Survey: What Do Current Trends Tell Us About The Future Of Accountable Care? and ACOs & Hospitals – The Changing Landscape). But there is wide variation in who is participating in ACOs. The Centers for Medicare & Medicaid Services estimates that about 30% of Medicare ACOs are composed of physicians-only; 58% include physicians, hospitals, and other facilities; and 12% include federally qualified health centers (FQHCs) and rural health centers (see Medicare Shared Savings Program Fast Facts). Who is leading and participating in ACOs has an impact on performance—according to a new study in The New England Journal of Medicine, physician-led ACOs saved Medicare $256.4 million in 2015, while hospital-led ACOs cost money (see Medicare Spending After 3 Years Of the Medicare Shared Savings Program). For specialty provider organizations, these physicians and hospitals are the gatekeepers and will determine if specialty provider organizations have a seat at the table.
That is why I was interested to see last month that a coalition of behavioral health advocacy organizations recommended that CMS should ensure that Medicare ensure that ACOs have the capacity to address beneficiary mental health problems, addiction disorder, and suicide risk. The advocacy organization noted that Medicare ACOs have reported poor performance on the sole behavioral health beneficiary-reported performance measure, Depression Remission at 12 Months. They believe that the post-screening follow-up problems indicated by poor ACO performance on the depression readmission measure indicates that ACOs may have widespread gaps in post-screening follow-up and that these issues are likely to extend to follow-up for addiction treatment or services for those at risk of suicide (see Behavioral Health Groups Urge CMS To Help ACOs Better Address Mental Health & Addiction).
The advocacy group made recommendations focused on three items that specialty provider organizations should recognize—behavioral health capacity, data collection, and outcomes-based payments:
- Promote Behavioral Health Capacity in All ACOs—CMS should work with ACOs to ensure that each has the capacity to meaningfully address mental health and substance use in their population.
- Explore Ways to Enhance Data Collection for Patient-Reported Outcomes (PROs) in Mental Health and Substance Use— The majority of performance challenges in the Depression Remission at Twelve Months measure may be attributable to loss to follow-up – the ACO was not able to screen a second time to determine if remission was achieved.
- Offer Additional Outcomes-Based Payments in Behavioral Health—Additional investment in mental health and substance use services, supports, and infrastructure may help build new capacities and catalyze further innovation in ACOs.
Whether this focus on poor performance in behavioral health will result in new policies or regulations is unclear—but what these recommendations do highlight is a growing need to better integrate behavioral health services into the ACO model. And with more ACOs moving to higher levels of financial risk and reward, they will need to focus on behavioral health performance (see 17 Additional ACOs To Participate In The Medicare Next Generation ACO Program). And whether ACOs decide to build increased behavioral health capacity themselves, or seek out existing specialty provider organizations, this is a moment of opportunity to specialty provider organizations.
If you are looking to contract with ACOs, now is the time to build relationships with the ACOs in your community and identify how your organization can help improve their behavioral health performance through demonstrated program outcomes (see How To Build Successful ACO Health Plan Partnerships). For more, check out these resources from the OPEN MINDS Industry Library:
- Building The ‘Next Generation’ Behavioral & Social Service ACO
- New ACO Developments, Same Challenges
- 62% Of ACOs Launched In 2012 Implemented Behavioral Health Initiatives
- 61% Of ACO Contracts Only Include Upside Financial Risk
- Most ACOs Not Ready For Two-Sided Risk Model
Also, be sure to join OPEN MINDS Senior Associate and Former SVP Network Strategy, UnitedHealth Group/Optum Deb Adler at The 2018 OPEN MINDS Performance Management Institute on February 13 for The OPEN MINDS Health Plan Partnership Summit: A Guide To Developing & Negotiating Partnership Agreements With Health Plans.