Accountable care organizations play a critical role moving the care continuum toward value. But such complex contracting options make it challenging for ACOs to achieve success.
The passage of the Affordable Care Act sparked many innovative care delivery and payment reform models. One unique model that emerged from this trend was the accountable care organization (ACO).
In this model, groups of doctors, hospitals, and other health care providers voluntarily come together to deliver coordinated, high-quality care to patients. The organizations achieve their goals using a universal budgeting system and value-based reimbursement.
“An accountable care organization is an entity that takes responsibility for the total cost of care for the patients it serves, regardless of whether or not it directly provides that care for their patients,” explained Ed McGookin, MD, chief medical officer of Coastal Medical, an ACO based out of Providence, Rhode Island. “We’re responsible for all the costs of care incurred.”
Like many ACOs, Coastal Medical receives base funding from the Medicare Shared Savings Program. This program and the now-defunct Pioneer ACO model spring boarded the ACO movement, sprouting several offshoots including the ACO Investment Model (AIM) and the Next Generation Accountable Care Organization (NGACO) model, which allowed ACOs to take on significantly more financial risk compared to other iterations of the ACO model.
There is no standard ACO. Each model has a nuanced funding structure and value metrics they report on, and contracts vary from group to group. Some ACOs also include specialists and hospitals while others focus solely on bolstering primary care services.
Increasingly, ACOs have become interchangeable with clinically integrated networks (CINs) as ACOs move away from a legal partnership and towards care coordination.
One of the key measures of success ACOs achieve is improving quality scores, centered around delivering high-quality patient care. ACOs monitor the gaps in care for their members and based on how well the gaps are filled, providers can earn shared savings payments. These payments help fund the comprehensive services offered through the unique care delivery model.
At the core of all ACOs is the mission to deliver high-quality care for lower costs. Despite their differences, many ACOs have common strategies for earning shared savings payments and other value-based incentives, while delivering high-value patient care
EXPANDING ACCESS TO CARE
For a majority of patients, the traditional notion of care does not work.
Many primary care offices are only open between the hours of 8 a.m. and 4 p.m. and referrals to specialists for challenges that could have been handled by primary care only push patients towards costlier services and even the emergency department.
“Population health compels us to find systems or mechanisms that take care of those who don’t feel that their needs are adequately addressed by that traditional model,” McGookin emphasized.
Practicing what they preach, Coastal Medical looked to their own physician staff first to extend hours.
“We used our clinicians, doctors, and advanced practitioner who wanted to work extra hours and who might like the flexibility of working evenings or weekends if that was helping with some family’s needs,” said McGookin. “We had to create a mechanism to ensure that we have lots of access at Coastal, that patients don’t go elsewhere for services that we can provide.”
The team added after-hours services, weekends and weeknight availability, and alternatives to the emergency department like urgent care.
Similarly, Coastal Carolina Quality Care, Inc. expanded its urgent care. The organization which joined the Medicare Shared Savings Program in 2012 increased staffing and added a new unit for “extended care,” which allowed them to provide many services traditionally reserved for hospitals on site, such as IV fluids and ultrasound.
“We’ve hired emergency room physicians and hospitalists to staff this unit. So, we have the same providers that also work at the hospital. They just work for us part-time,” Stephen Nuckolls, chief executive officer Coastal Carolina Quality Care, Inc. explained. Coastal Carolina Quality Care, Inc. also has an imaging center that can perform ultrasounds typically done in a hospital and staff on call to provide care beyond the traditional hours.
The services may cost the organization a little more to operate, but the savings stemming from an avoidable ambulance ride or a trip to the hospital is worth it. By providing more care on-site, Coastal Carolina Quality Care, Inc. saves patients, resulting in more value-based revenue from its ACO contract.
While some like Coastal Medial are looking inward to reduce costs by leveraging their own physicians, others like Catholic Health Initiatives (CHI) St. Luke’s Health are looking outward to make unique partnerships that accomplish the same goal. The ACO is partnering with vendor organizations to help disseminate information like cancer screening toolkits.
Their national lab partner will donate colorectal cancer screening kits that CHI St. Luke’s can give to their patients. After completing the test at home, patients send the results to the lab partner and the ACO can follow up with any positive results.
“Having that type of partnership beyond the walls of our facility and working with a national lab partner is huge,” articulated Michael Camacho, MPA, division vice president of a clinically integrated network at CHI St. Luke’s Health.
BUILDING CARE TEAMS
Expanding available services requires ACOs to expand their care teams for more coordinated care.
“We focused on coordinating and managing care with nurse care managers so there was somebody helping patients make choices and understand their choices when they were sick or needed services. Over time it evolved to be even more sophisticated,” said McGookin.
Several of these much-needed roles, though, are not necessarily revenue-generating. An administrator or care coordinator often does not produce billable hours or services that the ACO can create a claim for.
But the care coordination work done by these team members can have long-term impacts on patient outcomes. The relationships built through effective care coordination can help ensure patients show up for their appointments, instill confidence in their treatment options, and build trust with their providers. The ACO then becomes the patient’s go-to spot for care rather than the emergency department and other care settings beyond the ACO’s network of providers
Source: RevCycle Intelligence