A New Study Confirms the Link Between Value-Based Contracting and the Growth of Care Coordination

Sept. 3, 2019
A study just published in the American Journal of Managed Care speaks to the opportunities—still largely unfulfilled—of growing care coordination activities under value-based contracts

As Managing Editor Rajiv Leventhal noted in his Aug. 29 report, “A study of more than 1,600 U.S. hospitals revealed that value-based programs such as accountable care organizations (ACOs) appear to encourage the adoption and spread of care coordination activities by hospitals. For the study, researchers categorized value-based program participation as participation in either an ACO or a bundled payment program. They then assessed adoption—whether a hospital was using any of a set of 12 care coordination activities as outlined in an American Hospital Association (AHA) survey—and spread (in each hospital adopting care coordination activities, how extensively those activities were implemented throughout the hospital).”

As Leventhal noted, “Care coordination activities in the AHA survey included actions such as chronic care management processes or programs to manage high-cost patients; using predictive analytic tools to identify high-risk patients; medication reconciliation as part of an established plan of care; assignment of case managers to patients after discharge; and several more. Slightly more than 18 percent of the sample hospitals were participating in an ACO compared with 9 percent participating in a bundled payment program. Less than 5 percent of the sample hospitals were participating in both programs.”

Among the most important findings:

Overall, U.S. hospitals adopted a relatively high number of care coordination activities (nearly two-thirds, on average, of those possible) but were less interested in or effective at spreading these activities throughout the hospital.

Opportunities to improve the use of care coordination activities are not evenly distributed, with hospitals reporting extensive use of some activities and minimal use of others.

Hospital participation in value-based programs, especially accountable care organizations, may provide a catalyst to adopt and spread care coordination activities.

Those findings were documented in a study published in the August issue of the American Journal of Managed Care, in an article entitled “The Adoption and Spread of Hospital Care Coordination Activities Under Value-Based Programs,” by Larry R. Hearld, Ph.D., Nathaniel Carroll, Ph.D., and Allyson Hall, Ph.D. Writing about the design of their study, they state that it was a “cross-sectional, observational study of 1648 US hospitals using the American Hospital Association (AHA)’s 2013 Survey of Care Systems. Value-based program participation included participation in either an accountable care organization (ACO) or a bundled payment program. We assessed adoption (whether a hospital was using any of a set of 12 care coordination activities in the AHA survey) and spread (in each hospital adopting care coordination activities, how extensively those activities were implemented throughout the hospital).”

As the researchers write in their AJMC article, “Hospitals adopted nearly two-thirds of the possible care coordination activities (mean [SD] = 7.9 [4.4] of 12). Among those hospitals adopting care coordination activities, there was a relatively moderate spread of these activities (mean = 2.5; range, 1 [minimally used] to 4 [used hospitalwide]). Hospital participation in an ACO was associated with the adoption of 3.07 more care coordination activities (P <.001), on average, and 0.16 more points on the scale of spread of care coordination activities (P <.001) compared with hospitals that were not participating in an ACO. Hospital participation in a bundled payment program was associated with the adoption of 1.84 more care coordination activities (b = 1.84; P <.001) but not greater spread (b = –0.04; P = .54).” Put more simply, they write that “Value-based programs such as ACOs appear to encourage the adoption and spread of care coordination activities by hospitals.”

Now, let’s look at a few of the details of the survey and study. The researchers found that hospital participation in a bundled payment program was associated with the adoption of 1.84 more care coordination activities, but that participation in an ACO was associated with the adoption of 3.07 more care coordination, on average, and 0.16 more points on the scale of spread of care coordination activities. That seems to speak to the level of comprehensiveness of a contract driving the level of comprehensiveness of care coordination activities. After all, as terrific as bundled-payment contracts can be, they remain limited in the sense that they focus on specific care delivery bundles, most commonly total-hip and total-knee replacement surgeries and the perioperative processes and care settings surrounding those procedures.

Meanwhile, ACO contracts are far more comprehensive, and, significantly, they cover patient care organizations’ care for identified patients/plan members across time and across all conditions, especially chronic conditions.

Thus, a nearly-double rate around care coordination activities being developed, speaks to the power of ACO development for building capabilities to take care of patients comprehensively and across spans of time.

And some of those capabilities will be essential to success in the emerging value-based healthcare world going forward. As the study found, among those hospitals adopting a specific care coordination activity, the most widely spread care coordination activity was the use of hospitalists for inpatients, followed closely by medication reconciliation. The least widely spread care coordination activity was the use of predictive analytic tools to identify individual patients at high risk of poor outcomes. This was followed closely by the use of post–hospital discharge continuity of care programs and nurse case managers.

Of course, there are a few caveats here. Among the hospital executives responding to the AHA’s survey, only 18 percent were participating in an ACO; only 9 percent were participating in a bundled-payment contract; and only 5 percent were participating in both. And the fact that the use of predictive analytics to identify individual patients at high risk of poor outcomes, was the least widespread care coordination-related activity, speaks to how early the U.S. provider community is, in its collective journey into value-based care delivery and payment.

In their AJMC article, the researchers conclude, “Despite evidence of their positive effects on quality, our study demonstrates that there is room to improve the extent to which hospitals use care coordination activities. Notably, these opportunities are not evenly distributed, with hospitals reporting extensive use of some activities and minimal use of others. Value-based programs such as ACOs and bundled payment programs appear to have the potential of improving the use of care coordination activities by hospitals.” Given the statistics involved here and the current landscape around care coordination in the U.S. healthcare delivery system, that reads somehow as something like an understatement.

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