It was five years ago that my colleague, Monica E. Oss wrote about the “totally accountable care organization” or “TACO” described in a Health Affairs blog (see TACOs, Anyone?). Health Affairs wrote:
Within state-run Medicaid programs, [there are now] ACOs tailored to the care needs of Medicaid’s beneficiaries, many of whom have multiple chronic health and social challenges … [TACOs] offer the potential to push accountability for Medicaid populations, including those with complex needs, to a new level … beyond just medical care (for example, mental health, substance abuse treatment and other social supports).
Roll forward five years, and there are approximately 1,000 ACOs covering 32.7 million consumers under 1,477 different contracts (see After A Slow 2017, ACOs Grow And Expand Their Contracts In 2018). But, the potential for using the ACO model to serve consumers with chronic conditions and complex support needs is still a work in progress; that according to a recent report from HealthAffairs—An Initial Assessment Of Initiatives To Improve Care For High-Need, High-Cost Individuals In Accountable Care Organizations, that stated:
ACOs are keenly aware of the need to focus targeted interventions and care management on HNHC [High-Need, High-Cost] individuals, and most have implemented strategies to do so … and consider it an area of high priority … While some ACOs reported they have effective approaches, most survey respondents are in the early stages of program development. In most cases, their interventions have not been rigorously evaluated for effectiveness or scalability across settings.
What are the challenges for ACOs to address the needs of this population? The recent survey identified six factors:
ACOs can identify HNHCs, but need better methods—ACOs rely on several claims-based and clinical-data-based methods for identifying these high-cost consumers, as well as referrals from clinical professionals and staff identification. While adequate in the short-term, many ACOs “expressed frustration with the capabilities of existing tools” and need better, more efficient, more accurate methods.
ACOs don’t rely on one initiative, so bring options—The top five service approaches ACOs rely on are traditional care management, nurse care coordinators embedded in physician offices, patient-centered medical homes, centrally-located nurse care coordinators, and post-acute/skilled nursing programs. The biggest hurdles to achieving this were limited consumer engagement, limited access to data, and difficulty scaling successful programs.
ACOs need help with social determinants of health (SDH)—While most ACOs take SDH into account when assessing the needs of consumers, few can identify HNHC consumers in need of services by identifying SDH indictors. The needed competencies are the ability to collect and/or identify SDH data, make referrals based on this data, and work with consumers to identify social service gaps.
ACOs need more community-health workers—While most ACOs have a long history of using registered nurses, social workers, and physicians, the biggest trend was the increased need for non-clinical staff, including community health workers. These positions are needed to visit consumers in the home and provide non-clinical assessments and services, including “collecting information about social determinants of health, helping individuals make medical appointments, securing transportation, helping individuals enroll in social services, addressing social isolation, or even setting up home-monitoring devices.”
ACOs need provider organizations that can operate in shared savings arrangements—Shared savings payments are a principal source of program funding for ACOs, and most use this funding mechanism for HNHC consumer populations. Because of the financial uncertainty of these contracts, ACOs are highly selective about which programs to fund. In addition, most funding of any kind is fee-for-service (FFS), which limits the amount of care coordination that is available.
ACOs need help measuring program “impact”—Even though measuring inpatient admissions, emergency department visits, re-admissions, or skilled nursing facility stays is important to most ACOs, few can identify which services have the greatest effect on spending or service use. The result is the inability to accurately gauge return-on-investment (ROI).
These six challenges are areas where analytics experts and entrepreneurial provider organization management teams can help in expanding ACO ability to successfully serve complex consumers. The first challenge—better methods for identifying HNHC consumers—is one that can be best addressed by models using big data and augmented intelligence (see Yes, There Are Organizations Using Augmented Intelligence).
The other five factors are the opening that entrepreneurial managers of clinical organizations have been waiting for—a range of programs options with demonstrated cost savings that are focused on community health and social determinants, paid on shared savings basis. Our team has written before about addressing “pain points” of payers (see From Pain Point To Revenue and Pain Points Matter) and demonstrating the ROI of new programs (see Social Services ROI Essential To Social Determinants Wave and Five Keys To ‘Partnering’ With Health Plans On Social Determinants). And there are a group of specialty provider organizations who are ready for value-based reimbursement (VBR) arrangements—our data shows that 69% of those provider organizations are already getting more than 58% of their revenue from VBR contracts (see Adapting Revenue Cycle Management For A VBR-Driven World).
For more on the ACOs, check out these resources from the OPEN MINDS Industry Library:
- 4 Lessons From ACOs For Managing Downside Financial Risk
- How To Build Successful ACO Health Plan Partnerships
- 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
- The 2018 OPEN MINDS Medicaid ACO Trend Update
- The 2018 OPEN MINDS Medicare ACO Update: A Four-Year Trends Report
- Half Of ACOs Consider Exiting MSSP Over New Downside Risk Rules
And to learn more about shared risk and value-based contracts, check out our value-based reimbursement readiness assessment—Value-Based Reimbursement Readiness Assessment—or join my colleague OPEN MINDS Senior Associate Ken Carr on June 3 in New Orleans for his executive seminar, Succeeding With Value-Based Reimbursement: An OPEN MINDS Executive Seminar On Organizational Competencies & Management Best Practices For Value-Based Contracting.