- The accountable care organization (ACO) movement has gained traction over the last year as payers and providers begin to share the same viewpoints on the benefits of value-based care.
Provider attitudes about ACOs and related value-based care models are generally positive as more providers are looking to enter into these agreements.
Payers have reported successful outcomes from value-based health plans including lower healthcare costs and improved chronic disease care.
The progression of value-based care among healthcare organizations indicates a shift towards streamlined data sharing, collaborative care models, and the potential for aligned healthcare goals between payers and providers.
Payers and providers that are entering into a new ACO, however, tend to struggle when it comes to agreeing on how to measure quality, says Jeff Hulburt, the CEO of Beth Israel Deaconess Care Organization (BIDCO) and a previous executive at Tufts Health Plan and Harvard Pilgrim.
Each individual payer organization can have its own definition of quality, which makes it hard for providers to keep track of multiple payers’ quality metrics.
“Here in Massachusetts, we have three very large and very good local commercial insurance plans. Blue Cross, Harvard Pilgrim and Tufts are the big ones, yet each organization has their own variations when defining quality and deciding the metrics that are required to meet and earn a quality incentive,” Hulburt said.
“That’s a frustration from the provider side, because providers do not want to treat or measure different patients depending on their coverage,” he added. “That’s one of the gaps that still exists out there today.”
Payers can ease the confusion for providers by identifying which quality measures are applicable for certain healthcare goals and objectives.
Because payers are largely responsible for defining the metrics they will pay for, they tend to be in a stronger position when it comes to determining what constitutes “value.”
In order to ensure clarity and collaboration with their contracted providers, payers should work with their ACOs to determine which set of measurements matches the healthcare needs of the patient population in question.
“Health plans have an information advantage,” Hulburt acknowledged. “They can be the ones to perform the data analytics that really help ACOs understand the patients and conditions they should be focusing on.”
“Health plans also have advantages to assist in the integration of clinical and financial information and claims information.”
However, payers cannot rely on their data alone. They must leverage the boots-on-the-ground knowledge and expertise of their provider partners, said Hulbert.
“Physicians and hospitals excel in direct care delivery. These organizations want to do a good job in their main goal to treat the patient,” Hulburt said. “By collaborating more effectively, the health plan can really start see what goes on on a day-to-day basis in terms of taking care of patients.”
“At the same time, the health plan has to take its talents and expertise and really begin to work with provider practices so providers themselves can learn how to perform the analytics they need to improve performance. Both organizations have to embed the use of information technology and data flow into practices and hospitals.”
Recent evidence of effective ACO collaboration, when payers take the lead with analytics and providers focus on healthcare outcomes, include collaborative care agreements between UnitedHealthcare and Phoenix Children’s and Cigna’s partnership with Catalyst Health.
UnitedHealthCare developed a data-sharing system that allows both Phoenix Children’s and the payer to identify high-risk patients, reduce ED admissions, and improve medication adherence among a beneficiary population of 50,000 individuals.
Cigna provided the Catalyst Health system with patient-specific data which led to a 7.3 percent increase in the rate of eye exams for diabetic patients, a 4.5 percent increase in the number of diabetic patients whose blood sugar was well-controlled, a 6.9 percent increase in the appropriate use of antibiotics, and a 10.9 percent increase in the appropriate use of back-pain imaging tests.
“These results show what’s possible when a health plan and health care professionals collaborate to achieve common goals: better health and a better experience for the people we jointly serve,” Fredrick Watson, MD, senior medical director for Cigna in Texas and Oklahoma said.
Depending upon the outcomes of policy debates at the federal level, Hulburt said that 2018 should be a year in which the ACO environment continues to mature, even if progress is likely to happen slowly.
“I think 2018 will be another year of growth, assuming that there’s some consistency at the federal level on the policy side. Any uncertainty that gets created from a policy perspective begins to create questions if healthcare stakeholders should go all in on ACOs,” he concluded.
“It’s incremental movement. Payers and providers are swinging the pendulum to the right side of the equation at this point, but there’s still a lot of work to do that won’t fully be wrapped up by the time 2018 ends.”