Rich Morino

Posted on: May 21, 2019

The greatest risk doesn’t always yield the greatest reward, or does it? A recent study in the Health Affairs revealed that just over half of accountable care organizations (ACOs) said they would consider leaving the Medicare Shared Savings Program (MSSP) if required to take on more downside risk. Thirty-two percent of ACOs said they are extremely or very likely to leave. Nineteen percent believe they are moderately likely to leave.

In 2018, there were more than 600 ACOs managing care for nearly 12 million Medicare beneficiaries, the researchers said. So, what’s next? Who is strong enough to survive? The question lies not just in the financial gain and risk but in putting the patient at the center of care.

Next Generation ACOs

Those in the Next Generation model receive financial incentives for meeting quality expectations and spending less than pre-determined target amounts. However, Next Generation ACOs have the potential to earn a higher rate of savings than their counterparts in commercial models as well as those in the Pioneer ACO Model and the Medicare Shared Savings Program. One disadvantage? They’re also subject to greater financial losses should they fail to meet spending and quality targets.

The good news is that ACOs are already ahead of the game because they possess a strong foundation of collaboration and progressive care management strategies. As patient-centered organizations in which physicians, hospitals and other healthcare providers and suppliers render low-cost, high-quality healthcare services, they are a textbook definition of value-based care. This is a strength on which ACOs use to improve outcomes and still survive.

Social Determinants of Health Insights and Utilization

Additional sources of data, like social determinants of health (SDOH), provides critical insight into healthcare utilization and spending. Social Determinants of Health data can even show the risk of hospital readmissions that could impact Medicare reimbursement rates and Star ratings.

Social Determinants of Health data can also help ACOs prepare for important changes to the CMS Quality Payment Program (QPP) in 2019, particularly an increase in the weighting of the MIPS cost category to 15 percent (up from 10 percent in 2018).

They can also correlate utilization data (e.g., ED visits and acute care hospital days per 1,000 beneficiaries) with Social Determinants of Health data to understand why certain patients access high-cost services and steer these patients toward lower-cost settings.

Consider these three examples:

  1. An ACO notices an uptick in spending for patients with heart disease. SDOH data (e.g., relatives, associates and zip code) helps the ACO identify patients who may be socially isolated so it can proactively connect these individuals with community resources to provide social support.
  1. An ACO sees an increase in its ED visits for diabetic patients. Social Determinants of Health data (e.g., income and education level) helps the ACO identify patients who may benefit from care coordinators who provide ongoing education and support to ensure these individuals take their insulin properly.
  1. An ACO decides to target obesity in an effort to improve health outcomes. SDOH data (e.g., income, crime index and address) helps the ACO identify patients who may benefit from nutritional counseling and access to healthy food options.

Of course, none of these interventions would be possible without having accurate patient contact information, including address, phone number and email address.

Accurate contact information also enables ACOs to remind patients of preventive services (e.g., annual wellness visits) that can ultimately drive down costs and improve outcomes.

The questions remains, who will stay and who will go? The strongest to survive will be the ACOs taking on the most risk and succeeding in improving outcomes and care management with new and innovative data sources.

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