Study: ACO Leaders Are Behind in Addressing High-Need, High-Cost Patients’ Needs

April 18, 2019
A new study published in the Health Affairs Blog points to huge, but highly addressable, gaps in caring for high-need, high-cost individuals in accountable care organizations

A new study published in the Health Affairs Blog points to huge, but highly addressable, gaps in caring for high-need, high-cost individuals in accountable care organizations (ACOs). Indeed, write Janet Niles, Teresa Litton, and Robert Mechanic, in their article, “An Initial Assessment of Initiatives to Improve Care For High-Need, High-Cost Individuals In Accountable Care Organizations,” published on April 11, point to a range of possible strategies in this area.

The authors state that “Accountable care organizations (ACOs) are well positioned to serve the HNHC [high-need, high-cost] population more effectively and have financial incentives to do so. ACO payment models incorporate annual global budget targets for defined beneficiary populations. ACOs can earn shared savings payments by controlling spending below their target budget. Although the ACO model is relatively new, ACOs already care for more than 32 million covered lives across all payer types. ACOs have a strong interest in improving care for this population and are required by regulation to provide person-centered care.”

What’s more, the researchers note, with regard to the survey on which they based their study findings, “The vast majority of the survey respondents (85 percent) reported implementing some type of program to address the needs of HNHC individuals, describing more than 40 unique interventions. Focus group discussions and individual interviews suggest that many ACOs deploy multiple initiatives and believe that a combination of approaches is needed to produce positive outcomes for this population.”

Among the challenges: “ACOs do not have a common definition for HNHC individuals. Interview and focus group participants frequently cited programs that target high-risk patients defined as individuals with high risk adjustment factor (RAF) or Hierarchical Condition Categories (HCC) scores. Most participants consider high-risk patients as a large subset of HNHC individuals. Programs also frequently target individuals with high service usage or health spending. One way to think about the differences among these classification options is that high risk represents potential future spending, while high cost represents past or current spending.”

That said, “The vast majority of ACO respondents (80 percent) have deployed transitional care management programs to facilitate the movement of patients between care settings, such as from inpatient to skilled nursing facilities. Most (77 percent) have nurse care coordination programs, either embedded in physician practices or centrally located within the ACO structure,” the authors note. “The top five services implemented by the survey respondents are shown in Exhibit 1. Some initiatives, such as patient-centered medical homes (PCMH), are common ACO strategies that affect a broad range of patients but that typically focus attention and resources on patients with complex needs.”

Meanwhile, among those ACOs that are addressing high-need, high-cost patients, 80 percent are deploying “traditional care management” to address their needs; 73 percent are using nurse care coordinators embedded in physician practices; 58 percent are involved in patient-centered medical home (PCMH) initiatives; 57 percent are making use of centrally located nurse care coordinators; and 50 percent are leverage post-acute and SNF (skilled nursing facility) programs. But, they note, only 39 percent of ACOs respondents to the researchers’ survey reported that they’ve fully implemented their initiatives targeting HNHC individuals.

The impediments that ACO leaders cited, for the survey? Funding (65 percent); patient engagement (65 percent); actionable data (40 percent); physician resistance (36.5 percent); geographic challenges (35 percent); measuring effectiveness (35 percent); ability to scale (35 percent); IT resources (33 percent); staff recruitment (32 percent); and prioritization (30 percent).