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Analyzing Trends in Accountable Care Organizations: A Nationwide Survey
Michael R. Page, PharmD, RPh

Analyzing Trends in Accountable Care Organizations: A Nationwide Survey

Michael R. Page, PharmD, RPh
Performance-Based Contracts
In 2017, CMS measures quality of care using 31 nationally recognized quality measures in 4 key domains11:

Patient and caregiver experience (8 measures)
Care continuation and patient safety (10 measures)
Clinical care for at-risk populations (5 measures)
Preventive health (8 measures)

In addition to standards set by CMS, various official bodies are responsible for development of other quality standards that are also used by CMS. These official bodies include the Agency for Healthcare Research and Quality, with or without input from CMS; the National Committee on Quality Assurance; medical professional organizations, such as the American Medical Association and the American Heart Association; and others, such as consumer and community entities in the healthcare arena.11 Through these organizations, and others, quality measures continue to be developed for execution of performance-based contracts.

In an effort to quantify the perspectives of ACOs and to better understand the transition from a focus in general medicine to include specialty diseases in the Triple Aim, this nationwide survey evaluates methods that ACOs use to track quality measures and to implement programs to improve those quality measures. This survey also takes measure of the characteristics of ACOs throughout the United States, and to the attitudes of these organizations to niche disease state management and quality assurance, most specifically to address the need for the increasing importance of ACO management in specialty care settings.

Increasingly, specialty management is extending beyond common disease states to encompass management of niche disease states. Specialty pharmaceuticals are expected to be increasingly managed in the future by ACOs, with some of the first attempts being made in specialty oncology products. For example, an ACO was formed between Florida Blue Cross/Shield (insurance), Baptist Health South Florida (hospital), and Advanced Medical Specialties (oncology). Among these groups, 226 patients with cancer were enrolled in a disease state management program, with an estimated total spending of $23 million per year. After 1 year, the ACO successfully saved the hospital and the oncology group 2% of these expenses, equal to $250,000.12 The success of the ACO model in oncology validates its expansion beyond management of other more general medical disease states, such as diabetes and cardiovascular disease. As shown by this successful case, we are beginning to see ACO disease state management models spread beyond general disease states to include many different niche disease states, not only to reduce the cost of care, but also to improve the quality of patient care.
Survey Objectives and Methodology
The primary objectives of this project were to explore trends related to specialty medical conditions and specialty pharmacy, including:

Performance-based contracts
Quality measurement
Guidelines and pathways
Prescribing behavior
Management initiatives

It was also designed to explore the types of organizations with which ACOs are partnering, to accomplish population management and the Triple Aim in specialty therapeutic areas.
Between December 2016 and February 2017, 30 respondents completed an online survey consisting of closed- and open-ended questions. The respondents represented ACOs of variable sizes and geographical locations; they included a mix of senior personnel including:

10 chief executive officers
 8 vice presidents/executive directors
3 chief medical officers
6 directors/managers
2 chief operating officers
1 chief information officer

Survey questions were categorized under headings corresponding to the 5 primary survey objectives listed above, namely: performance-based contracts (10 questions); quality measurement (5 questions); guidelines and pathways (2 questions); prescribing behavior (3 questions); and management initiatives (9 questions). Each respondent was also invited to make a closing comment on the future management of specialty drugs and specialty conditions. Quantitative data were analyzed and charted, and the qualitative data were coded.

This diverse set of ACOs had the following characteristics:

Geographic mix: Northeast (n = 5); South (n = 8); Midwest (n = 9);
West (n = 5); and Multi-Region (n = 3), defined as an ACO that  operates in more than 1 defined region (Figure 2).
Range of ACO size: small (n = 18; <100,000 lives); medium (n = 9;
100,000-499,000 lives); and large (n = 2)/extra-large (n = 1)
(total n = 3; 500,000+ lives).

Different combinations of active contracts or developing contracts with CMS and/or commercial payers.

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