5 imperatives for achieving success in Medicare’s ACO programs

The number of accountable care organizations (ACOs) in the U.S. is increasing each year, and participation rose once again in 2018.

Today, about one-third of hospitals and one-quarter of original Medicare patients – about 10.5 million people – are participating in Medicare Shared Savings Program ACOs.

Experience shows that ACOs, on average, don’t achieve savings and quality improvements until after their first year of operation. However, ACOs shouldn’t accept the status quo. Now is the time to set your organization’s strategy and program participation goals, and define short and long-term success. Delaying will set you too far behind and compound the barriers to success. Doing the following will ensure the quickest path to meeting your objectives.

Have a plan to execute – not just a plan to plan
Most ACOs write a strategic plan at their board meetings – but in many cases, this is where strategy begins and ends. Successful ACOs focus on execution, which means dedicating resources to project planning, management and tracking above and beyond clinical staff and technology investments. Even if you’re a high-quality, high-performing organization, you might have to do something different to see results once you move into an ACO program.

Empower your nurses
Empower your nurses to drive population health outcomes. Start by building your primary care capacity by using nurses and medical assistants, when appropriate, to meet patient needs and provide additional support to providers. Medicare has recognized the value of these clinical assistants by allowing certain services to be billed under provider supervision. This might include ensuring your patients complete their Medicare annual wellness visit (AWV), receive all recommended vaccinations and are being coached to effectively manage their chronic conditions. Physicians get more time to acute patient needs, and patients benefit from more attention overall. One Caravan partner measured nurse-led prevention and found that nurses achieved ten metrics at an overall rate of 94 percent, while physicians on the same metric didn’t break 10 percent – not because they couldn’t, but because they didn’t have time.

Solidify provider relationships
Physicians and nurses responsible for patient care are a critical component to driving population health. Examine your goals and ensure your physician contracts encourage a collaborative work environment. Your success depends on the level of trust between providers and their ability to leverage each other’s strengths. Primary care practitioners (PCPs) in an ACO must also redefine their working relationships with specialists and facilities. The lines of communication must stay open so PCPs, specialists and facilities can most effectively work together, ensuring patients experience a smooth transition between providers.

Maximize the power of claims data
Claims data drawn from an ACOs’ member population can provide a wealth of insights, guide strategy and empower your physicians to take action. For example, you can analyze your population to understand prevalence of chronic illness, hospitalizations and related costs. You can then use this data to prioritize areas for improvement and identify where you need additional resources based on which population has the most clinical and financial risk.

Most health systems are relatively inexperienced in using claims data. Ingesting claims data and drawing meaningful reports takes time, so plan early for in-house and outsourced expertise. This might also mean some extra budget planning so you can invest in new population health management and analytics tools.

Keep score
Use a scorecard to keep all involved parties, such as physicians, specialists and administrators, focused on goals under the control of the care team, making sure to review and discuss regularly – in person and remotely – so there’s no ambiguity. The key to success is ensuring that those struggling are identified early so they can receive additional support. Metrics should be based largely on effort, not on outcomes that may create unnecessary strife between ACO leaders and clinicians. It is unfair to measure individual physicians on total cost or utilization for their patient panels – the variability in small numbers is too great – plus they will say the data is wrong or their patients are sicker. You can however measure the effort they put towards programmatic goals such as percent of patients receiving AWV’s or participation in monthly cohort meetings.

Get your coding in order
If you haven’t identified your strategy for ensuring you receive credit for the sicker patients you treat, you are already behind. Your benchmark cannot go up from better identification of sick patients, but it can go down. Numerous ACOs have found that inattention to HCC-coding workflows has been the differences between collecting shared savings and not beating the benchmark. Integrating coding best practices into your workflow can help you get credit for caring for sicker patients without driving your clinicians crazy.

The views, opinions and positions expressed within these guest posts are those of the author alone and do not represent those of Becker's Hospital Review/Becker's Healthcare. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them.

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