- A collaborative culture, prior value-based reimbursement experience, and robust EHR use are among the top factors contributing to accountable care organization (ACO) success, according to a new report from the Patient-Centered Primary Care Collaborative and the Robert Graham Center.
The literature review conducted by the two organizations uncovered six characteristics of ACOs that reduced costs, improved patient satisfaction, and advanced population health. The characteristics fell into six categories, which were leadership and culture, prior experience, health IT, care management strategies, organizational and environmental factors, and incentive and payer alignment.
Leadership and culture
Researchers found that qualities associated with ACO leadership and culture were one of the most commonly cited characteristics for success with improving care quality and reducing healthcare costs.
“One important factor referenced throughout the literature was the involvement of physicians in leadership roles acting as ‘clinical champions,’” the report stated. “At an organizational level, a cross-sectional study of Medicare ACOs found a positive correlation between savings per beneficiary and both physician leadership within the ACO and the number of physicians acting on the governing board.”
If ACOs did not use physician champions, then having top-level leadership that is consistently involved in achieving ACO goals was key to reducing costs and improving quality. ACOs with leaders that regularly engaged with clinicians earned greater system-wide buy-in and realized performance improvement.
The literature review also found that successful ACOs created a collaborative culture in which staff, clinicians, and administration were accountable for achieving quality and cost goals. A collaborative culture specifically helped two ACOs (Cornerstone Health Care and Summit Medical Group) achieve quality goals associated with lowering blood pressure.
Prior experience with value-based reimbursement and risk-based arrangements also contributed to ACO success, researchers reported.
An analysis of Medicare Shared Savings Program (MSSP) ACO performance data from 2012 to 2014 showed that time in the program led to a higher probability of shared savings payments. Another study of Medicare ACOs found that risk-bearing contract experience was significantly associated with ACOs earning shared savings payments.
Previous value-based reimbursement and risk-based contract experience also resulted in higher care quality, the literature review uncovered. ACOs that had more contracts, risk-bearing experience, and ACO program time under their belts were more likely to score higher on quality metrics.
“These findings suggest that experience makes a difference and that, over time, ACOs are learning and improving to adjust their workflows and capabilities to provide cost-effective, high-quality managed care,” the report stated.
EHRs are an integral component of value-based care. But comprehensive use of the technology to coordinate care, identify high-risk patient groups, track patient care outside of the ACO, and create performance data feedback resulted in reduced costs and improved care quality for ACOs, researchers reported.
One study of 177 MSSP and Pioneer ACOs showed that organizations with greater EHR capabilities such as those listed above were more likely to score higher on disease prevention metrics.
“This improvement in prevention scores may be due to the fact that robust EHR capabilities can help practices identify patients who are at higher risk and manage their care accordingly,” researchers explained.
Robust EHR and health IT use also led to quality improvement, researchers found.
“Several included studies stressed the crucial role of performance data feedback for quality improvement in successful ACOs,” the report stated.
“A successful ACO studied by Shortell et al. invested in advanced IT to utilize timely, effective metric feedback for physicians to review and make care improvements,” the report continued. “Furthermore, Lustig et al. revealed that in order to achieve optimal improvements in performance, Cornerstone Health Care and Summit Medical Group fostered an environment of transparency wherein physicians were able to share quality data to learn from one another.”
Care management strategies
Care management strategies, such as care coordinators, appropriate utilization, preventative care, and high-risk patient management, also played a vital role in quality improvement and cost reductions, the literature review uncovered.
Using care coordinators was a characteristic prominent in many successful ACOs, the report highlighted.
“Care coordinators spanned a variety of professions and roles, from home health nurses to healthcare professionals who helped coordinate services,” researchers explained. “Furthermore, social workers or patient navigators served a vital patient support role in some ACOs, helping patients access important community resources to address social determinants of health (e.g., housing and welfare opportunities).”
Care coordinators were also key players in nurse-led care management programs that focused on appropriate healthcare utilization, particularly for high-risk patients.
The staff specifically helped to reduce inappropriate emergency department and other healthcare utilization by being involved in discharge planning and follow-up after hospitalization. The use of care coordinators also enhanced care transitions, leading to fewer hospital readmissions and lower spending at ACOs.
Organizational and environment factors
Organizational factors (e.g., ACO provider and beneficiary makeup) and environmental elements (e.g., regional and market differences) impacted ACO performance in terms of quality and cost reduction.
For organizational factors, having more Medicare ACO beneficiaries per primary care provider was linked to substantially better disease prevention and annual health screening scores.
Another study found that ACO physician makeup influenced ACO performance. Studies of ACOs with a higher proportion of primary care providers (PCP) showed an association between PCP participation and better quality and cost outcomes.
“In one study, Albright et al. found that ACOs with a larger primary care workforce were more likely to perform better on quality measures related to disease prevention, while a study by Ouayogodé et al. found a positive correlation between proportion of PCPs and an ACO’s ability to earn shared savings,” the report stated.
In terms of environmental factors, rurality and overall ACO market penetration were linked to ACO success. Rurality was associated with higher quality scores, while greater market penetration was linked to an ACO’s ability to earn shared savings payments.
Incentive and payer alignment
Incorporating and aligning financial incentives within ACOs resulted in shared savings and quality improvement, the literature review revealed.
Notably, Aledade financially incentivized their providers by requiring the practices to pay a small membership fee. The national healthcare consultant intended for the fee to motivate providers to recoup their financial loss by meeting quality and cost goals that will lead to shared savings payments.
Aledade also employed a shared savings distribution methodology that gives shared savings payments to practices within their ACOs based on the size of the practice, participation and leadership, and key performance measures.
Other successful ACOs, such as the Alternative Quality Contract program by Blue Cross Blue Shield of Massachusetts and Summit Medical Group, tied provider compensation to ACO or value-based goals.
Misalignment of quality measures represented a significant barrier to quality improvement and shared savings, the report added. Varying quality measures made it difficult for ACOs to consistently improve quality and reduce costs.
“To overcome this challenge, it is important for ACOs to develop a closer relationship with payers in order to build shared aims and interests,” researchers wrote. “This effort could help ACOs and payers make more substantial progress on choosing a common set of quality and cost measures that decrease administrative burden, as well as supporting other mutual goals (e.g., building data-sharing arrangements).”
Successful ACO characteristics align with the PCMH
The six characteristics of successful ACOs closely align with the attributed of the patient-centered medical home (PCMH), suggesting an association between advanced primary care and ACO success, researchers pointed out.
Advanced primary care relies on the following factors:
- Importance of a clinical champion dedicated to transforming care
- Collaborative culture of accountability among staff
- Need to integrate an advanced EHR to identify and manage care for high-risk patients
- Emphasis on performance feedback
- Focus on decreasing costly ED visits and hospitalizations
- Value of enhanced access to PCPs
“The themes that dominated this literature, such as coordination of care through care management strategies, accessible care through EHR implementation and after-hours access, and a commitment to quality and safety through alignment of measures and incentives, mirror the Joint Principles of the Patient-Centered Medical Home and the Shared Principles of Primary Care,” researchers wrote.
“Therefore, the systems that employed advanced primary care were naturally set up for some of the care delivery changes sought by ACOs.”
Policymakers should understand the relationship between ACOs and advanced primary care models such as the PCMH, researchers concluded.
“[P]olicy makers need to be made aware of this important relationship now as they work to shape ACO federal regulations and private sector policies, including those related to encouraging PCMH formation and evolution,” they stated. “Achieving the Triple Aim in the United States involves more than simply spending less, and the synergy between the ACO payment model and the PCMH care delivery model has the potential to move us closer to the goal of containing costs while providing high-quality care and improving the patient experience.”