OIG Identifies What Makes Accountable Care Organizations Successful

July 29, 2019 - Accountable care organizations (ACOs) have reduced Medicare spending and improved care quality, but some organizations are doing it better than others, the HHS Office of the Inspector General (OIG) found in a new report.

For example, the Medicare Shared Savings Program – Medicare’s largest ACO program with 561 organizations serving 10.5 million beneficiaries in 2018 – generated gross savings of about $1.1 billion in 2017, with 60 percent of ACOs reducing costs below benchmarks, CMS reported.

However, only about one-third of MSSP ACOs earned shared savings payments that year.

OIG conducted an analysis of 20 MSSP ACOs that reduced Medicare spending while providing high-quality care to uncover what strategies helped the organizations succeed under one of the most popular alternative payment models.

The watchdog found that almost all high-performing ACOs provided their physicians with customized data on healthcare costs to inform them about their practice patterns and referrals. In fact, physician engagement was a top strategy shared by the high-performing ACOs.

The ACOs reported that physician engagement was key to lowering costs and improving care quality. Therefore, the organizations aimed to recruit physicians with a commitment to ACO goals, provide data to inform physicians about their cost and quality performance, redesign office workflows (i.e., cards to remind office staff to check that screenings are complete and regular care management team meetings), and provide administrative and clinical support.

Beneficiary engagement was also a top priority for high-performing ACOs. The organizations worked to increase the number of wellness visits and educate beneficiaries on certain, relevant topics to encourage beneficiaries to take a more active role in their healthcare.

Notably, the majority of ACOs educated beneficiaries on how to better manage chronic conditions, such as diabetes. One ACO even used care coordinators to conduct motivational interviews to encourage beneficiaries to change their behaviors, which led to higher levels of beneficiary satisfaction. Several ACOs also partnered with outside organizations, like a supermarket, to engage with their population and promote healthy behaviors.

Care coordinators were also used by many of the high-performing ACOs for chronic disease management, monitoring care transitions, scheduling appointments, and ensuring care plans are in place.

OIG also identified the following strategies shared by high-performing ACOs:

• Providing care outside of the physician’s office to improve chronic disease management and management of high-cost beneficiaries
• Managing hospitalizations by expanding primary care access, identifying frequent emergency department users, and improving care coordination within hospitals and at discharge
• Working with preferred skilled nursing facilities (SNFs) and home health agencies , as well as embedding staff in the facilities to monitor beneficiary health, using the SNF 3-day rule waiver, and conducting warm handoffs
• Addressing behavioral health needs and social determinants of health by recruiting behavioral health providers, using data to identify beneficiaries with needs, and integrating physical and behavioral health in primary care
• Using technology and data sharing to coordinate care across different providers and settings, including using one EHR system and state and regional data systems to communicate

“These strategies demonstrate important steps forward in the effort to reorient the healthcare system away from a fee-for-service model toward a model that rewards providers for greater efficiency and better quality of care,” OIG stated in the report. “These strategies are also in line with the broader goals of making providers accountable navigators of the health system and preventing disease before it occurs or progresses.”

However, the watchdog did offer several recommendations to CMS in light of recent changes to the MSSP.

CMS recently overhauled the MSSP, which increased the contract period from three to five years and required participating ACOs to take on downside financial risk by their third performance period. The overhauled program, now known as Pathways to Success, also included new incentives, such as flexible SNF and telehealth coverage options and the ability to develop beneficiary incentive programs.

However, CMS should consider the impact that changes could have on ACO success, OIG stated.

“CMS should conduct this review to determine the extent to which ACOs are participating in the program and the extent to which ACOs are reducing spending and improving quality. In addition, it should use its review to inform its decisions when making changes to other alternative payment models and when developing new models,” the watchdog stated in the report.

OIG also made a number of recommendations related to behavioral health. The watchdog encouraged CMS to identify and share information with ACOs on ways to integrate physical and behavioral health, as well as strategies for ACOs to get patients to share behavioral health data.

Other recommendations from OIG included adopting outcomes-based measures and aligning quality measures across programs, sharing information about ACO use of the SNF 3-day waiver and applying the information to Pathways to Success, and using ACO referrals to identify potential fraud, waste, and abuse.

CMS concurred with all of OIG’s recommendations. The National Association of ACOs (NAACOS) also agreed with the suggestions, particularly the recommendation regarding changes to the MSSP.

“[T]he agency should carefully monitor the slowing growth to ensure the pipeline of future, risk-taking ACOs remains strong while current ACOs don’t drop out of the program,” Clif Gaus, ScD, president and CEO of NAACOS, said in response to the OIG report.