- Creating a high-value culture, engaging in proactive population health management, and implementing an infrastructure that promotes continuous performance improvement were key characteristics of 11 successful accountable care organizations (ACOs) studied by the Health Care Transformation Task Force.
The Task Force examined the ACOs in Medicare programs and at least one commercial contract to find scalable and generally applicable strategies for ACO success with reducing costs and improving care quality.
As the value-based care model matures, the group aims to promote ACO participation, particularly among smaller organizations that do not have the resources to achieve success through trial and error initiatives.
“The greatest driver of future ACO growth will be the success of existing ACOs, as fence-sitting providers will be swayed by participants’ achievements or failure, as well as the positive evolution of the ACO model,” stated Danielle Lloyd, a member of the Health Care Task Force Executive Committee and Premier Inc.’s Vice President of Policy and Advocacy. “This study applies not only to new ACOs considering these arrangements for the first time, but also to those existing ACOs that are considering whether to renew contracts, progress to risk or expand arrangements with additional payers by providing guidance on opportunities to improve.”
The Task Force recommended that hospital leaders consider implementing the three characteristics of successful ACOs, and their sub-topics, to reduce costs while enhancing care delivery.
Developing a high-value culture
Each of the 11 successful ACOs operated under a high-value culture that prioritized excellent patient outcomes at the lowest possible cost. All levels of the organization shared the culture and mission.
However, developing a high-value culture can be ambiguous for hospital and ACO leaders, the report noted. To create a sustainable commitment to high-value across all levels of the organization, the ACOs studied participated in pre-ACO activities, engaged governance bodies and providers, and forged post-acute care partnerships.
The majority of high-performing ACOs had experience with managed risk and/or pay-for-performance programs prior to creating an ACO. The experience with other value-based reimbursement models that contained financial risk structures, benchmarking, risk adjustment, and quality measurement helped to establish a culture necessary for managing a shared savings arrangement.
ACOs built off of their existing value-based reimbursement culture and infrastructure to transition to the ACO model. The organizations used the incentive payments and savings from other models to invest in ACO capabilities, such as enhanced data analytics platforms.
Once organizations have a value-based care culture, ACOs should include governance in operations. Medicare ACO programs require organizations to create a governing body, but successful ACOs integrated the body into their broader governance structure.
“A centralized governance structure allowed for creation of common goals, alignment across various value contracts, and setting expectations at the senior leadership level to help drive an overall quality and efficiency strategy for the entire organization,” the report stated.
The successful ACOs were split regarding centralizing governance and operational structures and creating parallel structures to manage ACO versus fee-for-service line of businesses. Despite the difference, governing bodies at high-performing ACOs pinpointed improvement and investment opportunities by reviewing data from multiple sources (eg, EHR, internal claims data, and quality reports) and prioritized metrics.
But the organizations were not split on whether to add clinicians to governing bodies. Successful ACOs engaged physicians and other clinical staff with increasing ACO buy-in, boosting comprehension of specific objectives, and integrating practice improvement into daily workflows.
“There’s an inclusive and collaborative culture here that’s really crucial to getting buy-in,” an executive from a physician group-led ACO explained. “If you’re going to get frontline people to change what they’re doing, it’s so much more helpful if from the very beginning they’re involved and telling you what would probably work best. And then, of course, they’re going to help design it. They’re going to then champion it.”
Finally, successful ACOs pointed out that extending their high-value culture to the post-acute care space was crucial to realizing savings and quality improvements. Executives reported that the most meaningful partnership was with skilled nursing facilities (SNF).
The organizations applied the three-day SNF rule, which allows ACOs to admit patients directly to a SNF without a three-day hospital stay. Leaders used the waivers to admit assigned patients to a narrow network of preferred SNFs.
The SNFs in the preferred network were able to provide performance reporting on length of stay, readmission rates, and quality metrics.
Several ACOs also employed nurse care manager teams to support care transitions. The teams were either in the inpatient hospital, emergency department, or practices, or directly placed in the post-acute care facilities.
Using proactive population health management
ACOs that achieved savings and high-quality care shared three operational elements in their proactive population health management strategy.
First, successful ACOs established a system for identifying high-risk patients and connecting them with the appropriate intervention. Key strategies for risk stratifying patients were:
• Developing standard risk models based on claims and clinical data
• Regularly testing and updating risk models for maximum risk predictability
• Using real-time data sources whenever possible
• Ensuring risk scores are actionable for clinicians and care managers using decision support tools
Data was key to developing and implementing risk scores. ACOs used a variety of tools to gather and use data, including home-grown analytics models, EHR modules, and standalone population health management platforms. Most ACOs also used payer claims data.
However, executives expressed concerns that their organizations lacked real-time data sources to implement proactive population health management. Successful ACOs implemented systems that used admission, discharge, transfer (ADT) feeds to ping providers in real-time if assigned ACO patients interacted with a hospital.
Second, executives at successful ACOs overwhelmingly stated that care management staff contributed the most meaningful care delivery changes that led to ACO success.
Care management staff differed from more traditional case management positions in which case managers handled care resolution, with a start and end date. Care managers, on the other hand, forged deeper, ongoing relationships with patients and their family and caregivers, as well as practices that may be hesitant to adopt ACO workflows.
Most ACOs used registered nurses as care coordinators, navigators, and health coaches. A number of the organizations also used clinical social workers.
The care management staff were part of a larger multi-disciplinary team assigned to patients. The teams supported care transitions, monitored patients at risk for readmissions, and educated caregivers.
Third, successful ACOs created chronic disease management programs in addition to general care management teams. The most frequently targeted chronic diseases were diabetes, chronic heart failure, chronic obstructive pulmonary disorder, and chronic kidney failure.
The organizations created patient rosters and registries for specific conditions that built off of the high-risk patient identification process. Identified patients then underwent evidence-based standard treatment protocols and patient self-management education.
While the successful ACOs had the three population health management components, executives expressed concerns about seeing a return on investment with the programs.
“There was a shared opinion among high-performing ACOs that organizations need to spend to save; investment in the care management model must start on day one of the contract, while savings – if achieved – will not be paid out for nearly two years,” the report stated. “This concern was punctuated by financial reality: if the organization does not achieve savings, the longevity of maintaining ACO overhead costs will come into question.”
Establishing infrastructure for continuous improvement
After ACOs improve the “low hanging fruit” opportunities, the organization should focus on establishing internal and external structures that support continuous performance improvement. Successful ACOs sustained their high-value care by implementing data analytics and performance improvement resources, tying provider compensation to quality performance, and participating in shared learning initiatives.
ACOs can continue to identify areas ripe for cost savings and care quality improvements by building data analytics and performance improvement teams. Executives named performance improvement and data analytics staff as the second most meaningful contributors to ACO success behind care management staff.
These non-patient-facing teams use available data to monitor performance, identify opportunities for improvement, implement workflow changes, and support clinicians. The teams usually included quality improvement professionals, who tended to be registered nurses, registered health information administrators, and medical technicians.
Successful ACOs also built the data analytics infrastructure needed to provide clinicians with performance data. The organizations used performance forecasts and dashboards to give providers information on their quality and cost performance.
In addition to putting data into provider hands, successful ACOs also tied physician compensation to quality, rather than volume. To sustain quality improvements, about one-half of the studied ACOs incentivized their employed physicians by offering bonuses for quality measures, utilization metrics, and/or ACO objectives.
The ACOs typically started by first incentivizing their primary care providers through value-based compensation.
Some high-performing ACOs have also started to incentivize continuous improvement among affiliated providers, such as preferred post-acute care providers.
Finally, the Task Force advised ACOs to participate in shared learning opportunities. Voluntary learning collaboratives support ACO development through best practice sharing and peer comparisons.
“Over half the sample group attributed some success to participation in a regional collaborative, and perhaps unsurprisingly, some interviewees pointed to other ACOs within the sample as generous partners in shared learning among the early model adopter cohort,” the report stated. “In one highly competitive market with a dense concentration of ACOs, the local ACO collaborative encouraged organizations to work together in ways that had not happened previously, including sharing data on utilization and quality to support regional benchmark comparison.”