Value-Based Care News

Accountable Care Organizations Rely on Population Health Data

CMS should consider addressing the fact that accountable care organizations must both invest funds into creating a value-based care platform and manage its revenue cycle.

By Vera Gruessner

Accountable care organizations (ACOs) are slowly becoming a mainstay of the healthcare industry, as more payers and providers are partnering through these care coordination programs and negotiating value-based reimbursement contracts. However, there are certain policy changes that the Centers for Medicare & Medicaid Services (CMS) may need to consider when operating the Medicare Shared Savings Program and working with its subsequent ACOs.

Population Health Management

For example, the American College of Surgeons, the National Association of ACOs, and the American Medical Association have urged CMS to compare health outcomes of ACO beneficiaries to other fee-for-service Medicare populations instead of analyzing how other accountable care organizations are operating. In order to ensure that accountable care organizations succeed in future years, some policy revisions to the Medicare Shared Savings Program may need to come from CMS.

Jim Giordano, Director of Population Health Management and Value Based Care Services at Kurt Salmon, offered his perspective on the need to modify the Medicare Shared Savings Program so that more accountable care organizations share in their cost savings.

“The final rule did some good in terms of addressing some of the issues that were challenging,” Giordano pointed out. “I do still think though that you have at the current time about 75 percent of ACOs not producing a margin sufficient to repay providers who are participating.”

“There’s probably a number of different issues associated with that,” he continued. “To begin with, there are some rather significant investment and cash flow that ACOs have to be able to hurdle. If there was some way to manage through that for some of the smaller and less well-funded ACOs, that would be useful.”

Giordano went on to explain that CMS should consider supporting and addressing the fact that accountable care organizations must both invest funds into creating a value-based care platform as well as manage the revenue cycle of this operation.

“There’s operating cash flow impact and there’s also investment impact associated with creating a value-based care operation and care management structure,” Giordano added. “On the cash flow side, you have to weigh the significant period of time to get revenue from your efforts. On the investment side, there is a lot of cost associated with creating a value-based care enterprise.”

“I also think that we need to remember that the original intent of this program is really a transition tool to value-based care,” said Giordano. “There are some excellent examples of how this has worked for some enterprises. In fact, there are some transitions that have gone very well of creating value and others that have not. Some of this is market specific and not ACO structural.”

To ensure ACOs are able to achieve the Triple Aim of Healthcare and share in their cost savings, population health management will need to play a key role in the progress of accountable care organizations. Steve Keltie, President of Network Development and Marketing at WellHealth Quality Care, spoke with HealthPayerIntelligence.com about the importance of population health management and data sharing to running accountable care organizations.

“Coordination and data sharing is everything,” Keltie said. “You can’t accomplish accountable care and you can’t accomplish a well-run system any longer without close coordination between all of the parties involved. I don’t mean just the patient and the primary care physician, but the specialists and the network and the payer group and the healthcare advocates.”

“Having all of these coordinated and actually working together in real-time and the data that backs all that up, is critical to our success. We can’t do what we need to do without that,” continued Keltie.

“This is why years ago, our industry started implementing things that today we would call accountable care programs, but we could really just only scratch the surface. Medical stop loss facilities and TPAs and more sophisticated entities were putting narrow, high-performing, pay-for-performance type programs in place, but they were only doing it treatment type to treatment type and specialty to specialty,” he concluded. “It was difficult to do it across the board and that’s because we didn’t have the data that allowed for good, close coordination. Now we do.”

Giordano also spoke about the importance of population health management and data sharing in the midst of a coordinated, accountable care platform. Specialists and primary care physicians able to share and access data across the continuum of care are likely to bring better outcomes for their patients.

“I think the opportunity here is for provider organizations to start to think like payers and to see the data in a way that allows them to understand the disease load of their populations, where the spending is, where to focus their interventions, and how to create delivery protocols and team-based care efforts across the continuum of care to reduce spend and affect the rest of the Triple Aim,” Giordano explained.

“That’s why access to data is important and streamlining that access to data is getting increasingly important,” he continued. “If we can speed up the time limits of data delivery and start to create some integration of claims and clinical information, we can ultimately enable the development of a longitudinal record and enhance care management under value-based care constructs to assist in the management and wellness of these populations.”

Giordano also spoke about the potential he sees in Next Generation ACOs and how their experience should lead to higher quality care and cost savings.

“I’m pretty optimistic about Next Generation ACOs,” he added. “I believe that those enterprises that have been granted access to the next generation product generally have the infrastructure and the experience to take on additional risk. This is an opportunity because there’s an improvement in terms of the economic potential of engaging your network in this transition process.”

“I do believe this will result in higher quality care and more cost savings,” he explained. “What we’re really trying to accomplish is to have these instruments as part of a portfolio of contract under value-based care revolution. I do believe they will result in positive developments.”

“The thing we have to be worried about is that some of these non-performing ACOs in track 1 - what happens to that population of providers if they don’t become viable value-producing entities?” he questioned. “Where do they go? Do they drop out of the program? Do they become integrated into other successful ACO programs in their market? How we keep those providers attached is a bigger challenge.”

Finally, Giordano spoke about the future he expects for accountable care organizations and their potential for moving outside of the Medicare market and pursuing private, commercial health plans along with Medicare Advantage plans.

“The way I look at this, there are quite a number of successful value-based enterprises that have started as an MSSP ACOs. In essence, the MSSP ACOs, especially track 1, are an excellent way to build a diverse network of providers and to teach them the principles of value-based care and give them the tools to be successful. However, I don’t believe this program was ever intended to be the beginning or the end of the value-based journey,” Giordano explained.

“These networks that have developed have actually moved beyond the simple MSSP ACO into creating a portfolio of value-based contracts that they’re supporting. Often, leveraging that narrow network that has developed around an MSSP ACO into other products, whether commercial or Medicare Advantage, is the logical progression of the journey,” concluded Giordano. “Ultimately, there’s potential that the program itself could evolve to become a gateway to Medicare Advantage plans. I think as you look at track 3 ACOs, one could argue that’s where it’s starting to move."

 

Dig Deeper:

Top 3 Ways Accountable Care Organizations Could Garner Savings

Population Health, Risk-sharing Vital for Accountable Care