Are ACOs Ready to Take On the Most Challenging Patients?

Are accountable care organization (ACO) leaders really ready to take on all the patients attributed to them—even the most challenging ones? The question is far from abstract. Indeed, the further that patient care organization leaders push into risk-based contracting, the clearer certain challenges become. That’s especially true as ACOs grow larger in size and inevitably take on both bigger populations and find themselves with more and more Medicare and commercial health plan members who have greater medical needs.

And into that breach has come a new study, published in the Health Affairs Blog last week. The authors of a study based on a survey of ACO leaders are finding significant but highly addressable gaps in caring for high-need, high-cost individuals in ACOs. Indeed, 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,” 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.”

And while 85 percent of the respondents to the survey executed by those researchers, are in ACOs that are actively doing something about the high-need, high-cost (HNHC) population, below that marquee headline, things are a bit more complicated. Among other challenges, the authors found that ACOs lack a common definition for HNHC individuals. Meanwhile, a wide variety of strategies are beginning to be applied to the problem: 80 percent of organizations surveyed 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. Still, the researchers found, 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).

So what does all of this mean? Clearly, an industry-wide consensus has yet to emerge; and at the same time, there is a lack of consistency here in terms of strategies, tactics, and approaches. Of course, there doesn’t have to be a single or consensus approach to addressing the HNHC population’s needs; but the fact that the approaches remain piecemeal, fragmented, and largely disconnected from overall continuum of care-based efforts, seems problematic.

Still, the accelerating pace of ACO development offers some hope. In addition, the April 1 announcement by Seema Verma that CMS (the federal Centers for Medicare & Medicaid Services) will pay for certain social determinants of health-related benefits to patients, in the context of Medicare Advantage plans, couldn’t come at a better time for providers moving forward under value-based payment. Granted, the MSSP program is completely separate from Medicare Advantage. But the April 1 announcement portends good news for ACOs in that area as well. As I wrote at the time, “This set of changes might seem minor to some who are looking at this from a distance; but the reality is that, by initiating these changes through the Medicare Advantage program, in which some of the most important innovations have been taking place, CMS may be igniting potential change far beyond the confines of Medicare Advantage, as the programmatic innovations in MA are often copied elsewhere. And this one is potentially quite important.”

And, I wrote, “The reality, as all of the leaders trying to move population health management forward already know, is that so many of the factors that impact the health status of individuals are not purely clinical—not at all. I remember writing an article more than 20 years ago for the health plan executive audience, about advances in care management on behalf of dual-eligibles—individuals eligible for both Medicare and Medicaid.” And, just as I outlined what I had reported on more than 20 years ago, all of these needs and issues are connected.

Indeed, many HNHC patients attributed to providers in the MSSP and the other ACO and comprehensive primary care programs managed by CMS have complex psychosocial needs as well, just as the dual-eligibles do. So policy and payment innovations taking place in Medicare Advantage right now should eventually help ACO developers (who most often are also participating in MA) as well.

We’ll have to see how all of this plays out. But the good news for now, at least, is that an important gap area is being identified, and increasingly addressed. Over time, more progress will inevitably be made. And data analytics and information technology will most surely be a part of the equation in terms of solving the broader problem, as well as all the practical sub-problems involved. The next few years are certainly going to be very interesting in this critical area of endeavor.