Analyzing Trends in Accountable Care Organizations: A Nationwide Survey

Michael R. Page, PharmD, RPh

Accountable Care Organizations: A Growing Trend
Fisher and colleagues at Dartmouth Medical School are generally credited with stimulating the development of accountable care organizations (ACOs). These organizations are comprised of health systems that offer incentives for performance and quality improvement. Through application of the principle of payment for performance, rather than payment for discrete services, ACOs seek to improve the quality of care for patients while reducing costs. Although the proliferation of ACOs represents an important shift, these systems bring together multiple existing mechanisms of performance improvement. In fact, in their 2007 paper, Fisher and colleagues acknowledged that, in their conception of ACOs, they were building on ideas explored by other investigators over a period of more than a decade prior to that time.1

ACOs help address the quality improvement goals of the Triple Aim, which were described by Berwick and colleagues from the Institute of Healthcare Improvement. In a seminal article, Berwick and colleagues argued that reform of the US healthcare system requires simultaneous pursuit of improving the overall care experience, improving population health, and reducing the cost of care for populations on a per-capita level. This is the so-called Triple Aim concept. These authors suggest that 3 inescapable design constraints underlie effective accomplishment of the Triple Aim: 1) recognition of the unit of concern as a patient population; 2) policy constraints in a given organization, such as budgetary limitations, or a requirement for equitable treatment of all patient subgroups; and 3) existence of a single authority, or integrator, that coordinates services, enabling implementation of all 3 aspects of the Triple Aim simultaneously. One method of implementation would be establishment of a registry to track patient subgroups longitudinally, over time.2

When ACOs were first envisioned, patient registries were rare, and the precursors of the ACO in the United States were largely limited to integrated delivery networks (IDNs), including large health systems with multiple specialties, such as Kaiser Permanente, Mayo Clinic, and Geisinger Health System, as well as public bodies such as the Veterans Health Administration. Additional efforts to reform healthcare led to implementation of the Patient Protection and Affordable Care Act in 2010, which mandated implementation of ACOs and IDNs within Medicare, through the Medicare Shared Savings Program. As defined by the US Congressional Research Service, ACOs have several key characteristics, including3:

Integrating the activities of many different providers and provider types across a broad range of settings
Emphasizing optimal use of primary care services
Helping payers achieve savings through integration of care across providers
Generating savings, which are shared with providers in the form of incentives
Generating savings by the use of efficiencies, which do not reduce the quality of services provided
Acceptance that improved quality and reduced costs are ultimately the responsibility of providers
Measuring improvements in outcomes across defined populations
 
Growth of ACOs
Organizations that were early adopters of the ACO model commonly operated under either the Centers for Medicare & Medicaid Services (CMS) Medicare Shared Savings Program (MSSP) or the Pioneer ACO Program. More recently, the number of ACOs in the private market has grown substantially.4

As illustrated in Figure 1,5 the number of US ACOs has grown from 64 in early 2011 to 838 in 2016, according to a recent analysis by Muhlestein and McClellan.5 However, another study, based on proprietary data for ACO market activity between 2011 and 2012 by the Optum Institute, reported the markedly higher total of ACOs in 2012, totaling 1028, of which 594 were private and 434 were public.6 As of 2017, just the ACOs that conformed to the CMS MSSP totaled 480, with 9 million beneficiaries across the United States.7

Financial Risk Levels for Providers
The central issues with the traditional fee-for-service system for healthcare delivery and reimbursement in the United States are the lack of cost control and the lack of incentivization of care quality.8 National attempts to reform healthcare have led to the development of alternative payment models, of which the ACO is a model example. The key elements in setting up an ACO, as summarized in the first section, include the critical requirement that each provider is responsible for improving quality and reducing costs.3

There are varying degrees of financial risk for an ACO depending on its structure and contract. ACO contracts range from shared savings to full capitation models. The financial obligations in the contract correspondingly vary from upside-risk only, through varying degrees of shared risk, to a full upside and downside risk in the case of full capitation reimbursement models.8

Some of the most successful ACOs have been in defined specialties, such as orthopedic surgery, end-stage renal disease services, and comprehensive oncology care. In part, this is because institutions with fully integrated systems that can provide the necessary comprehensive services already have a good understanding of the patient population and the financial obligations in providing for their total care.

For example, a study by Kantar Health conducted in the first quarter of 2016 explored aspects of both business models and delivery of care in the dynamic US oncology care environment. Kantar Health surveyed 150 independent community-based and 80 hospital-owned or hospital-affiliated oncology practices to examine the increasing role of IDNs in cancer care. In particular, the mode of care delivery in an IDN might differ from the mode of care delivered through independent community practice.9

The Kantar Health study found that 2 years prior to the study, 35% of independent community oncology practices reported some form of business association with another entity, with the majority of these associations being with hospitals or IDNs. The report concluded that relationships between community oncology practices and IDNs had resulted in an increasingly large share of patients with cancer receiving treatment in an IDN setting. Furthermore, Kantar predicted that this trend would continue, given economic incentives, the increasing popularity of integrated care delivery models, the growth in IDN investments in oncology technologies, and a trend toward greater oncologist receptivity to working within an IDN model of care delivery.9

With respect to the role of pharmacy services in ACOs, Colla and colleagues reported a study using data from 2 waves of the National Survey of ACOs (n = 270), completed by eligible ACOs that were established prior to July 2013. The respondents (ACO executives or director-level administrators) were asked about ACO engagement of pharmacy services, pharmacy-related health information technology capabilities, and ACO accountability for prescription drug spending. The survey’s questions regarded the distinct services included in the calculation of total cost for which the ACO is responsible, including prescription drugs.10

Health information technology capabilities necessary to manage prescription drug costs and quality were mixed, among ACOs surveyed. Almost half of ACOs (45%) reported having implemented e-prescribing systems and systems for confirmation of whether or not prescriptions were filled. Additionally, the majority (54%) maintained active medication lists within electronic health record systems for each beneficiary. It was notable, however, that just a small minority (10%) of ACOs reported having achieved, or nearly achieved, the capability of integrating inpatient and outpatient data, including information related to patient medication use. Especially challenging was the integration of data from providers practicing outside of the ACO.10

The authors noted that pharmacy benefits have important implications for managing quality of care and minimizing costs. To optimize care, and minimize prescription costs, Colla and colleagues noted that utilization of clinical pharmacists, medication coaches, and use of technologies to track adherence might further improve clinical outcomes for patients.10

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.

Survey Results
Performance-Based Contracts
Question P1: What is the approximate mix of patients your organization serves by payer type?
Findings: Median values were as follows: 40% of patients had commercial insurance; 40% had Medicare; 3% were on Medicaid. For the category “Other,” the sample size was too small for a meaningful calculation of the median.
Conclusion: Most patients have either commercial insurance or Medicare coverage.
 
Question P2: Approximately what percentages of your organization’s patient populations are reimbursed by payers under performance-based contracts (PBCs)?
Options: A (risk-sharing, shared savings, or pay-for-performance) or B (not using risk-sharing, shared savings, or pay-for-performance)?
Findings: Note: PBCs (A) versus non-PBC (B); by payer type.
The ratios of the medians, A:B (%), were as follows: Commercial insurance—50:50, Medicare—75:25, and Medicaid—10:90. For the group designated “Other,” A and B were approximately equal, but the sample was too small to obtain a valid median.

Conclusion: Most patients with Medicare fall under performance-based contracts, whereas only half the patients with commercial coverage fall under performance-based contracts.
 
P1+P2 Calculation: Combining data from the responses to questions P1 and P2, it was calculated that a majority of the organizations surveyed currently have 50% or more of their patients falling under a performance-based contract, with a sizeable segment (36.7%) having 100% of their patients governed by such a contract. The results are shown in Figure 3.
 
Question P3: Approximately what percentages of your organization’s patient populations will likely be reimbursed by payers under performance-based contracts (or not) within the next 12 to 18 months?
Findings: For commercial plans, survey respondents estimated that a minority (42.5%) of beneficiaries would receive reimbursement under performance-based contracts within the next 12 to 18 months, with the remaining 57.5% not expected to receive PBC-based reimbursement. A larger proportion of beneficiaries under Medicare plans were expected to receive PBC-based reimbursement (70%) with the remaining 30% not expected to. By contrast, a minority of beneficiaries under Medicaid plans (15%) were projected to receive PBC-based reimbursement. The numbers were too small in the “Other” category of plans to obtain a meaningful calculation.

Conclusion: Comparing the P3 response data with the P2 response data, there is projected to be a slightly smaller percentage of Medicare patients (median 70% versus 75%, currently) falling under a performance-based contract. Although these data may seem to suggest an anticipated decline in the proportion of commercially insured patients falling under a PBC to less than 50%, the small size of this survey and the speculative nature of this question may have led to caution on the part of respondents, resulting in a lower than expected final estimate.
 
Question P4: What is the likelihood that 75% of your organization’s patients will fall under a performance-based contract by 2020?
Findings and Conclusions: Somewhat in contrast to the data emerging from Question P3, most respondents thought the likelihood of 75% of patients falling under a performance-based contract by the year 2020 was very high (median score of 8). About 37% of respondents thought the likelihood was extremely high (score of 10). The data are illustrated in Figure 4.
 
Question P5: For which, if any, specialty conditions does your organization have performance-based contracts with payers?
Findings: Overall, there was a 53% response, for 1 or more conditions, versus 47% for no response. Asthma was the specialty most frequently reported (53%) as being covered by a performance-based contract, followed by rheumatoid arthritis, oncology, and hepatitis C, which were each reported by 13.3% of responders.
Conclusion: Just over half of the ACOs polled have performance-based contracts for 1 or more specialty conditions. Asthma is the most common condition managed under such contracts.
 
Question P6: How, if at all, do performance-based contracts with payers impact your organization’s management of specialty drugs/conditions?
Findings: The overall response, for 1 or more management categories, was 93%. Category frequencies were in the following order: Care Management Programs > Site of Care Selection > Prior Authorization > Adherence to Guidelines > Referrals > Route of Administration Selection.
Conclusion: Nearly all respondents agreed that performance-based contracts (PBCs) impact the management of specialty drugs/conditions in 1 or more ways. Care Management Programs were the category most frequently identified as impacted by PBCs, followed by Site of Care for infusible agents.
 
Question P7: Which, if any, specialty conditions do performance-based contracts with payers impact your organization’s management decisions?
A positive response indicated applicability to 1 or more options.
Findings: The relative frequencies were in the order of Oncology > Asthma > Rheumatoid Arthritis > Pulmonary Arterial Hypertension.
Conclusion: Most respondents agreed that PBCs did impact management decisions for specialties, and oncology was the one most frequently identified. Refer to Figure 5.
 
Question P8: For which, if any, specialty conditions does your organization want to have—but does not currently have—performance-based contracts with payers?
Findings (in order of frequency): Oncology > Multiple Sclerosis > Hepatitis C > Asthma (1 or more options selected).
Conclusion: Approximately half of the ACOs want additional PBCs for 1 or more specialty conditions and, as for P7, oncology was most frequently specified (about 24%).
 
Question P9: What are the primary barriers to your organization expanding performance-based contracts for specialty conditions?
Findings and Conclusions: Categories: Lack of Payer Interest, Demand, and Measurement/Data Challenges were the ones most commonly cited, in approximately equal measure. Provider Resistance and Capabilities were cited at lower frequency than the above challenges.
 
Questions P1-P9: Comments: From a review of the comments provided by the responders, it was concluded that variability of risk across payers and contracts will continue to challenge the management of specialty drugs/conditions by ACOs.
 
Section Summary: Performance-Based Contracting

From these findings, it was clear that most patients—predominantly Medicare or commercial patients—fall under performance-based contracts, with performance-based contracts being far more common in Medicare plans than in commercial plans. Although respondents were cautious about projecting the percentage of their patient population likely to be reimbursed by payers within the next 18 months, the lower percentage of ACO plan representatives reporting performance-based contracting for beneficiaries may indicate the speculative nature of this question, and does not predict a reduction in performance-based contracting. In fact, more than half of ACOs polled believe that 75% of their beneficiaries will be covered by performance-based contracts by 2020. Almost all ACO representatives agreed that performance-based contracts will be important in the management of specialty conditions, particularly in oncology.
 
Performance-Based Contracts by ACO Size
Performance-based contracts

There was no evidence of differences between small and large ACOs in demand for performance-based contracts
Performance-based contracts are more common in large ACOs than small ACOs
Performance-based contracts for growth deficiency, hemophilia, and HIV/AIDS were more common in large ACOs than small ACOs
Education importance
Patient education to better manage specialty drugs/conditions was ranked higher by small ACOs than medium-sized ACOs
Desire for site-of-care education is higher in large ACOs than smaller ACOs

Small ACOs are more open to pathway-/guideline-based care for specialty drugs/conditions provided by manufacturers than are medium-size ACOs
According to these findings, ACOs with an even mix of commercially insured patients and those on Medicare seem to be closer to reaching their goals in the area of specialty drugs/conditions than are ACOs with a predominance of either commercially insured or Medicare patients. To achieve this, they look to value-based metrics to guide them in enhancing value-based care. However, the mixed commercial and Medicare ACOs far outnumbered the other 2 categories, so it is difficult to come to a definitive conclusion on this point.

ACO Geographic Location: In terms of determining willingness for ACOs to pursue industry partnerships, such as performance-based contracts, ACOs were classified by locations, categorized as belonging to each of the following locations: Northeast (n = 5), South (n = 8), Midwest (n = 9), West (n = 5), and Multi-Region (n = 3), in which the ACOs operate in more than 1 defined region. In an unexpected finding, there were no apparent differences attributable to geographic location. However, once again there remains the caveat that the small sample sizes may have masked differences that might become evident within a particular region with a larger cell size. On the other hand, very large multi-regional ACOs may be in a position to go their own way with regard to risk arrangements with respect to the specialties.

The conclusions drawn from the subgroup analysis of ACOs by patient mix (ie, Medicare, Commercial, or both) and ACO geographical location and implications are given in Table 1.

Quality Measurement
Question Q1: What, if any, CMS measures impact your organization’s management of specialty drugs and/or therapeutic areas?
Findings and Conclusions: Nearly all respondents (about 93%) identified CMS measures that impact the management of specialty drugs and/or therapeutic areas. The vast majority of responses (about 87%) identified the ACO quality measures as the leading measure, followed by Clinical Quality Measures (53%) and Consumer Assessment of Healthcare Providers & Systems (50%). See Figure 6, below.
 
Question Q2: If possible, please provide an example of how your organization’s management of specialty drugs can impact your organization’s performance on a CMS quality measure.
Findings and Conclusions: In several ways, the management of specialty drugs can impact the performance on CMS quality measures: 1) involve patient in decisions; 2) improve patient satisfaction; 3) decrease readmissions; 4) increase prescribing of condition-specific drugs.
Question Q3: To what extent do Medicare Advantage Star ratings (eg, percentage of plan members with rheumatoid arthritis with 1 or more prescriptions for an antirheumatic drug) impact your organization’s management of specialty pharmacy products?
Findings and Conclusions: (based on a scoring scale of 0 [not at all impactful] to 10 [extremely impactful]): The median was 2.0, reflecting that the majority of responders (57%) found the ratings minimally impactful, with 33% scoring 0. However, 20% of responders recorded a score of 8.
 
Question Q4: As you may know, the Medicare Access and CHIP Reauthorization Act includes the Merit-based Incentive Payment System (MIPS) to assess physician performance starting in 2017, and physician payment will be based on performance of those measures starting in 2019. To what extent will the MIPS measures impact your organization’s management of specialty pharmacy products?
Findings: (based on a scoring scale of 0 [not at all impactful] to 10 [extremely impactful]). The median score was 5.5. The data distribution was somewhat bimodal in character, with 43.4% of responders scoring between 0 and 3, and 56.7% scoring between 5 and 10. However, the limited numbers of participants and the subjective nature of the scoring does not allow for drawing definitive conclusions from the observations.
Conclusions: A majority of responders thought that the measures would be somewhat impactful.
 
Question Q5: What, if any, other future quality measurement changes are driving your organization’s development or desire to develop specialty pharmacy management changes?
Findings and Conclusions: Quality measure changes can cause the following complications: 1) creating conflict with patient needs; 2) disconnecting internal quality measures from external quality measures; 3) requiring data integration.
 
Section Summary: Quality Measurement
In terms of quality measurement, CMS quality measures have an important effect on the management of specialty therapeutic areas and specialty medications, with 93% of respondents agreeing with this finding. ACO participants believe that specialty therapeutic management through CMS quality measures can help improve patient satisfaction, decrease readmissions, and increase use of condition-specific specialty medications. For instance, a sizable minority of ACO representatives (20%) reported that Medicare Advantage Star ratings among patients with rheumatoid arthritis help improve management of specialty pharmacy medications for this condition. However, care based on quality measures must be implemented carefully, as these measures can sometimes create unforeseen conflicts between outcomes and patient needs, and create data integration challenges, as well.
 
Analyzing Willingness to Implement Quality Measures by Organization Type
In an analysis of ACOs by patient mix, whether predominantly commercial patients, Medicare patients, or a mix of these 2 categories, differences were found in willingness to implement quality measures. Regarding specialty medication prescribing, commercial ACOs were less focused on CMS quality measures than were Medicare ACOs.
Commercial and Medicare mixed ACOs were more focused on educational efforts to influence specialty pharmacy prescribing behavior than were commercial-only ACOs
Medicare ACOs were more focused on improving outcomes and coordination of care than were commercial ACOs

Commercial and Medicare mixed ACOs believe they are closer to reaching goals for specialty products and conditions than do Medicare-only ACOs, based on several criteria:

Reaching drug- and condition-related goals to improve member health
Reducing time to initiation of therapy
Reducing preventable hospital admissions and emergency department (ED) visits
Reducing readmissions
Significant differences between geographic areas were not detected

Notably, in this survey, the 3 large commercial ACOs were not overtly focused on CMS quality measures, especially those pertaining to specialty drugs/conditions. The lack of focus on CMS quality measures may relate to the large size and considerable resources of these ACOs, as well as greater sophistication and awareness of needs for specialty treatment, resulting in an attitude of independence from outside standard-setting entities. Alternatively, such ACOs may not see an obligation, financial or otherwise, to formally conform to CMS quality requirements.

Guidelines and Pathways
Question G1: To what extent do external consensus statements/clinical guidelines/pathways impact your organization’s specialty pharmacy programs?
Findings and Conclusions: (based on a scoring scale of 0 [not at all impactful] to 10 [extremely impactful]). Most respondents were of the opinion that external consensus statements, clinical guidelines, and pathways are moderately to very impactful. This is reflected by a median impact score of 6.0, which coincided with the mode score of 6 (23.3% of responders). Refer to Figure 7. The next highest score was 8 (16.7%).
 
Question G2: What, if any, other future external consensus statements/clinical guidelines/pathways changes are driving your organization’s development or desire to develop specialty pharmacy management changes?
Findings and Conclusions: While it appears that there is continuous monitoring of external guidance, much of the impetus for specialty pharmacy management change comes from within an organization. Comments from respondents indicated that this is usually provided by a physician committee and/or the chief medical officer, or by providers.
Section Summary: Guidelines and Pathways
Guidelines and pathways were thought to be moderately important, with the greatest number of respondents rating guidelines and pathways as a 6 in importance, on a 0-to-10 scale. Notably, guidance is continually monitored, with input from physician committees and providers.
Prescribing Behavior
Question Rx1: How does your organization attempt to influence prescribing behavior for specialty pharmacy products?
Findings: A positive response was 1 or more options selected. Categories were, in order of frequency of selection (approximate percentages), as follows: education (87%); measuring/reporting performance (63%); sharing savings (50%); sharing risk (23%); providing P4P incentives (20%).
Conclusions: Nearly all respondents (93%) identified 1 or more measures as influencing specialty pharmacy prescribing behavior, and the vast majority identified education. The results are shown in Figure 8.
 
Question Rx2: How successful are your organization’s efforts to influence prescribing behavior for specialty pharmacy products?
Findings: Scoring ranged from 0 (not at all successful) to 10 (extremely successful). The median score was 4.5.
Conclusions: There appeared to be 2 segments of responders: 1 group believed their organization’s efforts to influence specialty pharmacy prescribing behavior was somewhat successful, while the other believed they are somewhat unsuccessful, in this respect.
 
Question Rx3: What other tactics or strategies does your organization need to optimize prescribing behavior for specialty pharmacy products?
Findings: The responders identified the following tactics/strategies that could help optimize specialty pharmacy prescribing behavior:

Profiling and tracking provider performance
Aligning provider incentives
Profiling and tracking high-risk patients
Providing cost data at time of ordering
Integrating order entry and electronic health records
Engaging and educating providers and pharmacists
Optimizing the formulary

Section Summary: Specialty Medication Prescribing
Specialty pharmaceutical product prescribing behavior is largely driven by physician education and performance measure reporting. However, shared risk through performance-based contracts were also thought to be important. ACO respondents differ in beliefs that organizational influence over specialty pharmacy prescribing behavior is successful: Some believe that attempts to influence specialty product prescribing have been successful, while others believe that these initiatives are not yet successful. Efforts to optimize behavior vary; they include profiling and tracking providers, aligning provider incentives, and tracking high-risk patients.

Management Initiatives for Specialty Drugs/Conditions
Question S1: What are your organization’s specialty drug/conditions goals?
Findings: Scoring ranged from 0 (not at all important) to 10 (extremely important). The results for the various categories are shown in Figure 9.
Conclusions: Several specialty drug/condition goals are viewed as being very important, including making people healthier, improving outcomes, reducing readmissions, and reducing preventable hospital admission and ED visits.
 
Question S2: To what extent is your organization reaching its specialty drug/condition goals?
Findings: The same scoring system and categories apply as used in the Figure. Values ranged from 9.3 for Make People Healthier to 6.8 for Reduce Time to Initiate Therapy.
Conclusions: Across the board, specialty drug/condition performance was reported to be falling short, and perceived performance on the most important goals reached only moderate levels of success.
 
Question S3: Which, if any, external partners/vendors support your organization’s management of specialty drug/conditions?
Findings (approximate percentages): 77% of responders selected 1 or more of the following categories: payer/managed care organization (MCO): 40%; specialty pharmacy provider (SPP): 37%; group purchasing organization (GPO): 30%; pharmacist: 7%.
Conclusions: Most respondents identify 1 or more external partners/vendors that support the management of specialty drugs/conditions, including MCOs, SPPs, and GPOs.
 
Question S4: How satisfied is your organization with specialty drug/condition related support from external partners/vendors?
Findings and Conclusions: Only moderate levels of satisfaction with external partners/vendors supporting the management of specialty drugs/conditions are achieved, and satisfaction with SPPs is perceived as relatively higher (score 5.9) than satisfaction with MCOs (score 5.2). The score is 7.0 for pharmacists.
 
Question S5: For which, if any, specialty conditions does your organization want new programs/initiatives?
Findings: Demand was greatest for oncology (about 53%), followed by rheumatoid arthritis (27%), inflammatory bowel disease, (27%), and hepatitis (23%).
 
Question S6
: To help your organization more effectively manage specialty drugs/conditions, what types of programs, services, tools, or information would be helpful?
Findings and Conclusions: All responders desired additional help in managing specialty drugs/conditions. The vast majority (about 83%) identified pathways/guidelines, and most identified provider education (73%) and risk profiling/stratification (73%). Refer to Figure 10.
 
Question S7: What, if any, types of programs, services, tools, or information would your organization be open to receiving from a drug manufacturer to more effectively manage specialty drugs/conditions?
Findings and Conclusions: Nearly all respondents (97%) welcome support from drug manufacturers and, specifically, support with pathways/guidelines (57%) and provider education (57%), which were the categories most frequently identified. Cost models and patient education were also high on the list.
 
Question S8: Which, if any, programs, services, tools, or information is your organization currently receiving from drug manufacturers to more effectively manage specialty drugs/conditions?
Findings and Conclusions: Most respondents (70%) report receiving support from drug manufacturers to manage specialty drugs/conditions, and this support most commonly comes in the form of patient and provider education (57%). Provider education is also commonly provided by drug manufacturers (53%).
 
Question S9: How satisfied is your organization with the following programs, services, tools, or information it is currently receiving from drug manufacturers to more effectively manage specialty drugs/conditions?
Findings and Conclusions: Only moderate levels of satisfaction are achieved for pharma-sponsored pathways/guidelines (score 5.8), provider education (score 5.7), and risk profiling/stratification (score 5.0), which are the most commonly desired types of support from drug manufacturers for the management of specialty drugs/conditions.

Taken together, the closing comments expressed by the respondents suggest that change is in the air. While there is likely to be increasing reliance on data, pathways, and education, the exact ways in which specialty drugs and conditions will be managed differently in the future remains unclear.
Table 2, above, summarizes the findings of the survey and their implications for future planning.
 
Section Summary: Specialty Partnership

ACO respondents believed that use of specialty medications should be guided by improving health outcomes and reducing preventable hospital admissions and readmissions. Although external partners are recruited to manage specialty medications, there is a perception that performance on use of specialty medications falls short for ACOs attempting to improve outcomes in specialty medication use. Unsurprisingly, respondents report only moderate levels of satisfaction with external partners and vendors. Demand for new programs and initiatives is greatest in oncology, followed by the areas of rheumatology, inflammatory bowel disease, asthma, and hepatitis. Tools that ACO respondents believed might be important in management of specialty condition include greater use of pathways and guidelines, as well as better provider education, with a component of patient risk profiling for specialized conditions. Almost all (97%) of respondents welcomed support from specialty medication manufacturers in these areas.

Overall Conclusions
Accountable care organizations are focused on improving outcomes for patients by aligning financial incentives and outcomes to optimize health for patients, with some of this improvement expected to occur through industry partnership and shared risks. In fact, more than half of ACOs polled believe that 75% of their beneficiaries will be covered by performance-based contracts by 2020, with the greatest impact of these contracts predicted to occur in oncology. At the same time, broader use of quality measures are thought to be an important factor in improving management of specialty disease states, with 93% agreeing with this statement. Moreover, many ACO respondents believe that quality measures have the potential to help improve outcomes in specialty disease states, such as rheumatoid arthritis. Although ACO respondents rely on guidelines and pathways, it is notable that guidance is constantly readjusted and contextualized by internal medical teams. By partnering with specialty medication manufacturers, 97% of respondents believed that it would be possible to improve outcomes for beneficiaries.

Through partnership with pharmaceutical manufacturers, ACOs have an opportunity to improve the selection of patients who might qualify for use of specialty medications, many of which represent important breakthroughs in several areas of medicine. Use of these specialty products can be optimized through performance-based contracts that reimburse based on outcomes achieved with medications. As these contracts grow in importance, with up to 75% of beneficiaries of ACO plans expected to fall under performance-based contracts by 2020, these novel models of care will have an important influence on the future of healthcare provision throughout the United States.
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