A More Robust Map to the New World of ACO Success?

Oct. 3, 2019
A discussion at the NAACOS annual meeting last month in Washington, D.C., and the federal report that inspired that panel discussion, speak to the more detailed map of ACO success that’s beginning to emerge now

As Senior Editor David Raths reported in an article published on September 29, “At last week’s meeting of the National Association of ACOs (NAACOS) in Washington, D.C., a panel was convened to respond to the recent report from the U.S. Department of Health and Human Services (HHS) Office of Inspector General on lessons learned from the Medicare Shared Savings Program.” That report, entitled “ACOs’ Strategies for Transitioning to Value-Based Care: Lessons From the Medicare Shared Savings Program,” had been published on July 19.

As Raths noted, Meredith Seife, deputy regional inspector general for the Office of Evaluation and Inspections at OIG, opened the panel at the NAACOS annual conference by describing some of the report’s findings. “The good news is that physicians are quietly changing the way they do business,” she said. The report evaluated the first three years of the shared savings program and found some high-performing ACOs that led off by describing some of the report’s findings. “The good news is that physicians are quietly changing the way they do business,” she said. The report evaluated the first three years of the MSSP and found commonalities among successful accountable care organizations (ACOs).

Here are the seven strategies that the Office of Evaluation and Inspections’ report found to be common among successful ACOs:

1.     They have focused on better supporting physicians.

2.      They’ve improved patient relationships, including increasing the number of annual wellness visits.

3.      They’re doing a better job of managing beneficiaries with costly or complex care needs. This includes using care coordinators and providing care outside the physician office through services such as remote patient monitoring.

4.      They’re managing hospitalizations, working to reduce avoidable hospitalizations, and finding alternatives to the emergency department, such as extended hours, same-day appointments, and telemedicine. In addition, there is an increased focus on improving care coordination at hospital discharge to ensure smooth transitions between settings.

5.      Managing relationships with skilled nursing facilities (SNFs) and home health by creating lists of preferred providers and doing warm handoffs into and out of post-acute care.

6.      Successful ACOs are working to address behavioral health needs and the social determinants of health.

7.      They are using technology to improve care coordination and overcome interoperability issues. Some ACOs are moving all the providers onto a single electronic health record (EHR) system, so that they can seamlessly share data.

The report recommended, among other things, that CMS should adopt more outcomes-based measures, and better align measures across programs.

It must be very gratifying for the leaders of the more successful ACOs to hear about that report, for a number of reasons. It is affirming and validating so much of what they’ve been doing. It also speaks to broader issues around ACO success.

Every one of the seven elements above is one that we at Healthcare Innovation have been reporting on very extensively for some time now; let’s walk through them.

First, while the idea of better supporting physicians is one of those “baseball, Mom, and apple pie” concepts that no one would reasonably object to, actually accomplishing that is far from automatic; indeed, we continue to hear many reports that physicians, who often are participating in multiple ACOs, are still feeling burdened by many aspects of ACO participation, especially the more (to them, at least) bureaucratic ones. So no, finding ways to make physicians feel more supported is not automatic or easy.

Second, patient engagement is another one of those elements that everyone supports in theory, but that is much harder to achieve than it sounds.

As for items 3 through 6 above, all are connected to core functions that are helping ACOs to achieve success. The leaders of those ACOs are doing data analytics, are risk-stratifying the populations they’ve been contracted to care-manage, are then placing the highest-risk and next-highest-risk patients into rigorous and well-constructed care management programs, and are incorporating in their initiatives key efforts such as reducing hospitalizations and rehospitalizations, and are incorporating behavioral healthcare and social determinants of health issues into their care management work; and, per item 7, they are strategically leveraging information technology and other forms of technology to help them do optimal work in all those areas.

And yes, all of that is a lot. It just is. Yet the leaders of the ACOs that have been achieving success are plunging in and getting the work done. And I have no doubt, based on our interviewing and reporting, that those leaders have also been working hard, and persistently, at changing their cultures, in order to move their organizations forward. And in a certain sense, that’s the biggest lift of all, as it requires the reengineering of culture, which as we all know is a very significant challenge in any patient care organization.

And all of this speaks to the frame that the OEI-OIG report published in July, put on all of this. The reported that “Medicare Shared Savings Program ACOs have developed a number of strategies to reduce Medicare spending and improve quality of care. Among those they cited were “working to increase cost awareness in ACO physicians, engaging beneficiaries to improve their own health, and managing beneficiaries with costly or complex care needs to improve their health outcomes. Other strategies that ACOs found successful involve reducing avoidable hospitalizations, controlling costs and improving quality in skilled nursing and home healthcare, addressing behavioral health needs and social determinants of health, and using technology to increase information sharing among providers. ACOs also reported challenges in each of these areas and describe ways they overcame them.” The report’s authors note that “CMS recently made changes to the Shared Savings Program. As CMS carries out this and other ACO programs and develops new alternative payment models, it should support the use of these strategies and other successful strategies that emerge. These strategies can apply not only to ACOs but also to other providers committed to transforming the healthcare system toward value.”

And, the report’s authors state, “On the basis of the experiences of the selected ACOs, we recommend that CMS take the following actions to support efforts to reduce unnecessary spending and improve quality of care for patients: (1) review the impact of programmatic changes on ACOs' ability to promote value-based care; (2) expand efforts to share information about strategies that reduce spending and improve quality among ACOs and more widely with the public; (3) adopt outcome-based measures and better align measures across programs; (4) assess and share information about ACOs' use of the skilled nursing facility 3-day rule waiver and apply these results when making changes to the Shared Savings Program or other programs; (5) identify and share information about strategies that integrate physical and behavioral health services and address social determinants of health; (6) identify and share information about strategies that encourage patients to share behavioral health data; and (7) prioritize ACO referrals of potential fraud, waste, and abuse. CMS concurred with all of our recommendations.”

Those are some rather specific recommendations—and, to this observer, important ones. It remains to be seen the extent to which Administrator Seema Verma and her fellow senior officials at CMS show themselves to be willing to seriously consider them, even as the leaders of the so-far-successful ACOs continue to find success along the dimensions mentioned above. Clearly, there are a lot of moving parts to all of this; but the way forward is looking clearer than it was, and one can anticipate that it will look even clearer in the next two years.

So, as an industry, we are beginning to move out of the fog of first steps, into a landscape in which successful case studies, and indeed, sets of case studies, are emerging. All of this evidentiary documentation will be exceptionally important moving forward. And associations like NAACOS and others are helping to further incubate change, through their conferences, publications, and other forms of sharing. Certainly, we in the professional healthcare press are all in now in terms of helping to bring forward these case studies. And reports like the OEI-OIG report only help move all of this forward.

In other words, this train has left the station. And the real pioneers in the industry are already on it.

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