- The National Business Group on Health (NBGH) recently identified the core competencies accountable care organizations (ACOs) should have at each stage of its development.
The two resources from NBGH on ACO competencies are meant to help employers who are considering adding an ACO to their health coverage options. The scoring guide and journey map detail where ACOs should be in terms of clinical governance, networks, care models, consumer experience, health IT and data analytics, and financial models as the organization launches, develops, and demonstrates high performance.
An ACO is considered launching for the first three years. Organizations should move to the developing stage between two and five years after establishment and should enter the high-performing phase after four to eight years.
Clinical governance for ACOs from launch to maturation
As ACOs start, clinical governance should be a priority. A launching ACO should start with achieving clinical governance by establishing clinical and operational goals and plans.
The process of setting appropriate clinical governance goals involves the founding physicians identifying practice transformation initiatives. The physicians should be part of the board and involved in ACO leadership roles.
ACO clinical leaders should also implement plans to achieve initial contract goals with health plans for quality improvement, patient experience, and healthcare cost reductions.
Developing ACOs should expand clinical governance roles to primary care providers (PCPs) and specialists in clinical, pharmacy, and behavioral health areas. Clinical leaders should review and improve patient safety, care quality, and patient experience programs across the ACO network.
At the same time, ACO leaders should create and implement plans to exceed health plan contract goals.
A high-performing ACO should demonstrate advanced clinical governance in which ACO leaders are responsible for setting and achieving care quality, patient safety, and patient experience scores in the top decile for the nation.
ACO leaders should also be exceeding goals set out in the health plan contract.
ACOs should develop PCP and hospital/specialist networks
NBGH researchers stated that ACOs should include networks for PCPs as well as hospitals and specialists.
For PCP network development, launching ACOs should start with the founding PCPs. As the organization develops, leaders should add PCPs who exhibit high care quality and cost efficiency. Existing providers should also receive assessments for care quality and cost performance.
An ACO is considered high-performing when its PCPs can meet or exceed care quality and cost performance goals and the organization retains the providers within the network.
ACO leaders should continue to add high-value PCPs to its network. But they should also exclude providers who fail to meet performance goals.
Hospital and specialist network development should follow the same pattern as the PCP network creation process, the resources added.
7 competencies for ACO care model development
The resources detailed seven care model competencies that ACOs should have as it reaches the high-performing phase. The care model capabilities include:
• Medical home implementation
• Risk stratification of patients
• Clinical guideline implementation in provider workflows
• Quality improvement initiatives that foster a culture of continuous improvement
• Care coordination competencies based on ACO resources rather than payer-provided support
• Referrals to efficient care sites
• Mediation management at the provider and pharmacist level
For most of the competencies, launching organizations should start by focusing their efforts on high-risk patients. Developing ACOs should target moderate-risk populations and high-performing ACOs should encompass patient groups from across the risk spectrum.
For example, medical home implementation should start by treating high-risk patients and include all PCPs. As the ACOs mature, the medical home should target moderate and low-risk patients, use protocols for referrals and transitions, and integrate services to enhance medical and behavioral health outcomes
A high-performing ACO should build on its medical home by expanding the services to low-risk patients and implementing quality improvement initiatives to advance medical home performance.
ACOs can identify patient risk groups by implementing risk stratification competences. The organization can pinpoint high-risk patients based on health status and efficiency improvements in employer health plans. It can identify low-risk patients based on limited or infrequent health needs for primary, preventative, and wellness services.
ACOs should emphasize consumer experience for high-performance
To be considered a high-performing ACO, an organization should demonstrate consistent patient outreach, high patient satisfaction, and patient portal use.
Researchers advised ACOs to first target high-risk patients for outreach and satisfaction improvement efforts. Developing and high-performing ACOs should work on consumer experience enhancement with moderate and low-risk patients.
A key to improving patient outreach and satisfaction is patient portal use. Launching ACOs should allow patients to view their personal health information in each provider’s EHR system and permit secure two-way email-like messaging within the portal.
Developing ACOs should build on patient portal basics by adding patient access to care plans and educational content.
The resources stated that a high-preforming ACO should manage a comprehensive patient portal that integrates personal health information, records transmissions, schedules appointments, and facilitates provider communication across channels. Advanced ACOs may have patient portal functions accessible on mobile devices.
3 health IT capabilities needed for ACO operations
ACOs should have three health IT systems in place to be considered high-performing.
First, the organization should have a complete, interoperable EHR system. ACOs may start by having providers operate with their own systems and the systems demonstrate limited data sharing as well as no clinical guidelines in the workflow.
But developing and high-performing ACOs should implement EHR systems with active health information exchange, notifications for patient admissions and discharges from inpatient and emergency care, and clinical guideline incorporation in EHR workflows.
Advanced ACOs should have EHR and population health tools integrated at the patient level and in provider workflows.
Second, ACOs should invest in predictive analytics and registries. Newly-established organizations should start with primary care registries for their medical homes and work to develop specialty care registries for their hospital and specialist networks.
High-performing ACOs should be using predictive analytics and integrated registries across all providers and facilities in the organization.
Third, data analytics competencies are critical to ACO development. Before private payer contracts are signed, launching ACOs only have access to PCP and their own EHR data. As developing ACOs add specialists and hospitals to its network, the organizations generate more clinical and claims data. The organizations should start benchmarking at this point with external sources and public reporting.
ACOs in the high-performing phase should build on their data sources by using all provider and payer information over several years for data analytics.
Financial risk and physician incentives key to ACO financial models
The ultimate goal of an ACO should encompass being at risk for the total care costs of its patients. High-performing ACOs should engage with gain- and loss-sharing structures that allow the greatest upside and downside financial risk. Claims reimbursement should be full or partial capitation payments for at least 75 percent of total costs.
ACOs that are not ready for full financial risk should begin with gain-sharing arrangements with quality and cost-based incentive payments. Developing ACOs should expand the upside-only risk model to include loss-sharing tied to quality and cost performance.
Financial models for ACOs should also include physician incentives. Launching ACOs should offer an incentive payment of 10 percent of PCP compensation. PCPs could share in the gain-sharing bonus, but they are not at risk of losing compensation.
Researchers advised developing ACOs to increase incentive payments to up to 25 percent of a physician’s compensation and offer loss-sharing risk.
High-performing ACOs should put at least 25 percent of PCP compensation at risk for possible gain-sharing bonuses or pay reduction.