Downside Risk Pays Off: Four Best Practices for High ACO Performance

Downside Risk Pays Off: Four Best Practices for High ACO Performance

The Medicare Shared Savings Program (MSSP), the accountable care organization (ACO) model that served 10.6 million seniors in 2020, collectively saved Medicare $4.1 billion last year, and $1.9 billion after accounting for shared savings payments, according to the National Association of ACOs (NAACOs) and as recently published in Healthcare Finance. 513 ACOs participated in the Shared Savings Program in 2020, down from the 541 MSSP ACOs in 2019.

According to CMS, data on ACO performance shows that over time ACOs taking accountability for costs perform better than those that do not. ACOs who assumed downside financial risk earned more shared savings than those who stayed in the upside risk model.

The CMS Pathways to Success program changes may have deterred ACOs from entering the MSSP model; however, ACOs have proven their ability to provide exceptional quality care at a reduced cost and evolving away from fee-for-service (FFS) contracts will continue to generate Medicare savings. The increase in quality scores and shared savings is promising. Many ACOs navigated the COVID-19 crisis by proactively communicating to patients to keep them healthy and mitigate ER visits for routine care needs. For example, the Alliance for Integrated Care of New York, LLC (AICNY), re-engaged their beneficiaries through a telemedicine video kiosks embedded with the data from the HealthEC population health management tools to identify at-risk patients and targeted outreach.

There have been many lessons to be gleaned from this last performance year. For one, having an accurate benchmark is vital. Taking on downside risk does not directly introduce the need for new processes, but it does highlight the importance of embedding certain steps into an ACO’s operations if they are not there already. Providers find it challenging to accept downside risk if they do not have tools to enable and empower changes in care delivery. Here are four processes that are critical to ACO success.

  1. Data aggregation

    Since the ACO is responsible for the total cost of care for each attributed beneficiary, a complete medical record t
    hat incorporates medical history from every point of care is critical for data-driven decision making. As ACOs increase their alliance partners and expand their network, the complexity of EHR compatibility and integration capabilities skyrockets. In many instances ACOs bear the burden of aggregating patient data. Investing in data infrastructure to accomplish this task will be rewarding as ACOs meet their benchmarks at both, aggregated, provider panel level and individual patient to deliver care that is economically advantageous without sacrificing quality. A consistently formatted and searchable record for each beneficiary, in combination with claims data in one central repository can become the foundation to quality care plans and connected care.

  1. Population Stratification on Risk

    Once the holistic record is created, the next step is to determine which beneficiaries are considered in each of the risk categories: high, rising, and low risk.
    Algorithms and process automation to determine predicted spend, the likelihood of hospitalization over the next six months and creating a care coordination strategies around frequent emergency room visitors, high cost patients, patient with poor adherence to medication to name a few, is important. These algorithms may include factors such as chronic conditions like diabetes, hypertension, or chronic obstructive pulmonary disease, completion of immunizations, and emergency department utilization. Including social determinants of health in beneficiary risk scoring is increasingly important when taking on downside risk.
    ACOs have had success adopting social determinants of health (SDoH) strategies as part of their population health management outreach. Prince George’s County Health Department addressed SDoH through technological advances. The county was able to identify the 10 percent of its population that represented 80 percent of hospital readmissions and non-urgent emergency department visits and risk stratify the identified group to address the high rate of readmissions and ER visits. SDoH and disease-based assessment tools were used to identify barriers and expedite access to resources.
  1. Proactive patient engagement

    Beneficiary Engagement is a major change outlined in Pathways to Success. ACOs are allowed to offer new incentive payments to beneficiaries for taking steps to achieve good health, such as obtaining primary care services and necessary follow-up care. In addition, this rule requires ACOs to provide beneficiaries with a written explanation in person or via email or patient portal of what it means to be in an ACO to put patients in the driver seat.
    Proactive outreach to ACO beneficiaries for attribution, and to engage them in their preventative healthcare activities correlate to quality measures such as mammograms and prostate exams. An engaged patient base enables a higher level of provider collaboration and improved patient experiences. High satisfaction is critical to maintaining open communication between patients and providers, and can be a driving force in a patient’s decision to create self-management goals that sync with their provider’s recommended care plan.
  1. Continuous performance monitoring

    It is important for an ACO to have a mechanism to track whether it is trending toward achieving year-end financial targets with real-time data. Actual beneficiary utilization and spending are dynamic KPI’S that can change on a frequent basis. If ACO data becomes stale or the ACO relies on an information source that does not include a connected view, the reports may be misleading.Historical cost data is a simple and readily available starting point. Continuous assessment may require the use of predictive analytics or actuarial analysis. The risk scoring methodology built into the Medicare program adjusts spending targets based on the overall health status of an ACO’s attributed population. ACOs may consider an ongoing clinical documentation improvement program to identify instances where diagnosis codes or other elements may have been missed through patient chart reviews.

Care that covers the whole spectrum

ACOs should implement a formal population health strategy that includes data aggregation, population health analysi
s, actively engaging beneficiaries and frequently take the pulse of ACO performance. These best practices will enable the ACO to pinpoint their beneficiaries that may need immediate care and engage the entire population consistently.

In response to increased exposure to financial risk, an engaged alliance of providers, nursing teams, care management personnel and revenue cycle team leadership will propel the ACO to success.