Healthcare Revenue Cycle Management, ICD-10, Claims Reimbursement, Medicare, Medicaid

Value-Based Care News

Characteristics of Successful Accountable Care Organizations

Researchers found that a Medicare accountable care organization that had earned shared savings used patient-centered medical homes and care coordinators.

By Jacqueline Belliveau

- As the number of accountable care organizations (ACO) continues to grow, many healthcare providers are all too familiar with the alternative payment model’s overarching goals of improving care quality, advancing population health, and reducing healthcare costs. But, many providers are still wondering how to reach an ACO’s qualitative goals while benefiting from shared savings arrangements.

One Medicare ACO earned shared savings by promoting care coordination and patient-centered care

A study in the June edition of the American Journal of Accountable Care examines a Medicare Shared Savings Program (MSSP) ACO that received shared savings for two successive years. Researchers attributed the success of the Hackensack Alliance ACO with promoting patient-centered care, increasing care coordination, using big data analytics, and accounting for regional differences.

“The MSSP’s ACOs appear to offer ample opportunity to improve the quality of care for the patient while at the same time, reduce the cost of care,” wrote the authors of the study. “Initial factors that should facilitate these changes are having physicians certified as patient-centered medical homes by NCQA [National Committee for Quality Assurance] and providing financial support for increased care coordination.”

Receiving shared savings through the MSSP ACO program proved to be challenging for most participants in the first performance year, stated the report. While approximately half of the ACOs reduced healthcare costs through the program, it was not enough to exceed the minimum savings rate. Only 24 percent of ACOs earned shared savings in the first year.

The Hackensack Alliance ACO was one of the few that benefited from shared shavings arrangements through MSSP. In its first performance year, the Medicare ACO saved over $10 million in total and received $5.2 million in shared savings.

READ MORE: Why Accountable Care Organizations Need Revenue Cycle Risk

The ACO attributed its shared saving success to the use of patient-centered medical homes, which are designed to put primary care at the center of a patient’s healthcare experience. The primary care physician is responsible for coordinating treatment and developing relationships with patients.

In its initial development, the Medicare ACO decided to select primary care practices that already received the NCQA’s certification as a patient-centered medical home.

For physicians who wished to join the ACO but were not certified, the ACO asked the practice to acquire certification within one year and obtain an EHR system. These practices also received a complimentary trainer to help the facility get the NCQA certification.

By increasing care coordination through the patient-centered medical home, the ACO was able to reduce hospital admissions, readmissions, and emergency department visits.

The Hackensack Alliance ACO also provided larger practices with a nurse care coordinator to promote patient-centered care and care coordination.

READ MORE: Why Did Experienced Accountable Care Organizations Fail?

The nurse care coordinator’s primary goal was to pinpoint high-risk patients and develop a relationship with them. Patients would feel more comfortable seeking treatment at their primary care physician rather than immediately going to the emergency department, stated the ACO.

“To minimize waste and avoid unnecessary hospitalizations, the combination of physician and nurse coordinator working in concert enabled the identification of areas of wasteful spending, creation of work plans, and provision of timely appointments to see the PCP [primary care physician] team,” explained the report.

Physicians and nurses were also informed of the 33 quality measures that were required by CMS, which helped providers understand that compliance with these measures affected the calculation of shared savings.

Another major resource for this Medicare ACO was data analytics tools and vendors. With most value-based care models, ACOs manage large volumes of data, which are used to determine their shared savings or losses at the end of the program. The ACO needed a way to digest all the data and translate it into more actionable information.

“We knew that information would be the key to success for this project,” wrote the ACO. “Consequently, we had to identify a data analytics firm to help determine which practices were and were not doing well.”

READ MORE: Why Primary Care Matters in Medicare Shared Savings Program

Understanding regional differences was also crucial for ACO success, reported the study. Regional differences needed to be examined to understand how the ACO was to reduce expenditures, especially compared to its initial benchmark.

Through its initial design, Hackensack Alliance ACO was able to improve care quality. It received an 89 percent final quality score, which amounted to a $2.8 million performance payment in the first year of the MSSP.

Despite its success, the Medicare ACO identified several areas of improvement for CMS. The ACO advised the agency to simplify the methodology for determining cost savings, consider regional differences on cost, and address competition from other alternative payment models, such as bundled payments and the Comprehensive Primary Care Initiative.

In terms of ACOs themselves, the study explained that they should better manage leakage of beneficiaries to other ACOs, conduct annual wellness visits on assigned beneficiaries, address interoperability of different EHR systems in the network, and consider appropriate big data analytics software.

In larger networks of healthcare providers, like ACOs, it can be difficult to pinpoint specific ways to achieve success with alternative payment models. While many ACOs have yet to earn shared savings in the MSSP, this case study could serve as a starting point for how to improve value-based care and benefit from the payment arrangement.

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