Researchers See Multiple Challenges for ACOs Tackling Serious Illness Care Management

June 12, 2019
A team of researchers has examined the broad set of issues facing the leaders of ACOs around developing comprehensive approaches to care management for seriously ill patients

Even as accountable care organizations (ACOs) move forward along a number of dimensions, one broad issue continues to pose major challenges to ACO executives and clinician leaders: caring for people living with serious illness. In an article published in the June issue of Health Affairs, a team of researchers has analyzed and identified the elements involved in this set of challenges, and determined some critical success elements, including “the need for up-front investment beyond shared savings to build serious illness infrastructure and workforce; supporting the business case for organizational buy-in; how ACO contract specifications affect savings for serious illness populations; and using data and health information technology to manage populations.”

In an article entitled “ACO Serious Illness Care: Survey And Case Studies Depict Current Challenges And Future Opportunities,” William K. Bleser, Robert S. Saunders, Lia Winfield, Mark Japinga, Nathan Smith, Brystana G. Kaufman, Hannah L. Crook, David B. Muhlestein, and Mark McClellan, note that “Care for people living with serious illness is suboptimal for many reasons, including underpayment for key services (such as care coordination and social supports) in fee-for-service reimbursement. Accountable care organizations (ACOs),” they note, “have potential to improve serious illness care because of their widespread dissemination, strong financial incentives for care coordination in downside-risk models, and flexibility in shared savings spending. Through a national survey we found that 94 percent of ACOs at least partially identify their seriously ill beneficiaries, yet only 8–21 percent have widely implemented serious illness initiatives such as advance care planning or home-based palliative care.”

As the article’s authors point out, “Accountable care organizations (ACOs) offer the potential to improve serious illness care nationwide, given that 1,011 ACOs cover almost thirty-three million people. ACOs—especially those participating in models with downside financial risk, which encourage movement away from fee-for-service reimbursement—have strong incentives to coordinate care, avoid unnecessary hospitalizations and ED visits, and develop meaningful data and analytics. Beginning July 1, 2019,” they note, “all Medicare ACOs entering new contracts will be required to participate in downside risk earlier, increasing the impetus for care redesign efforts that pay off. Organizations debating whether to invest in a palliative care workforce may consider the ACO model a potential venue to do so, given its financial flexibility that allows investment in new infrastructure.”

Among the deficits examined by the research team: while the vast majority of ACOs are in the initial stages of routinely identifying seriously ill attributed patients and developing advance care planning services for them, only about 65 percent are actively routinely identifying seriously ill Medicare beneficiaries, and fewer than 20 percent have fully implemented advance care planning services. Even fewer ACOs have created hospital- and community-based palliative care programs, though a slightly higher percentage (about 25 percent) have implemented 24/7 clinical response processes for the seriously ill.