Jennifer Perloff, PhD

 To describe the use of home-based services in accountable care organizations (ACOs).

 Cross-sectional analysis of 2019 ACO survey.

 We analyzed surveys completed by 151 ACOs describing the characteristics of home-based care programs serving high-need, high-cost patients. We linked survey results to publicly available information about ACO characteristics, governance, and risk model participation.

 Twenty-five percent of respondent ACOs had formal home-based care programs, 25% offered occasional home visits, and 17% were actively developing new programs. Home-based primary care was the most common program type. Half of programs were established within the past 3 years. The programs utilized multidisciplinary care teams, but two-thirds had fewer than 500 visits annually. Funding sources included direct billing for services, health system subsidies, and ACO shared savings. A majority of respondents expressed interest in expanding services but were concerned about their ability to demonstrate a return on investment (ROI), which was reported as a major or moderate challenge by three-quarters of respondents.

ACOs deliver a diverse array of home-visit services including primary care, acute medical care, palliative care, care transitions, and interventions to address social determinants of health. Many services provided are not billable, and therefore ACO leaders are hesitant to fund expansions without strong evidence of ROI. Expanding Medicare ACO home-visit waivers to all risk-bearing ACOs and covering integrated telehealth services would improve the financial viability of these programs.

Many accountable care organizations (ACOs) provide home-based care to high-need patients, including primary care, acute care, support for care transitions, and interventions to address social determinants of health. However, many services are not well reimbursed, limiting program growth.

There is no prior research describing the full range of home-based care programs in ACOs.

With Medicare’s expansion of mandatory downside risk, more ACOs are considering home-based programs.

ACO managers are hesitant to expand these programs unless they can demonstrate a return on investment.

Expanding home-visit waivers to all risk-bearing Medicare ACOs and covering telehealth for patients receiving home-based primary care would improve these programs’ financial viability.

Improving care for high-need, high-cost (HNHC) individuals with multiple chronic conditions, functional limitations, and complex social needs is an issue of growing interest for policy makers, health systems, and payers.

 These individuals account for a large proportion of Medicare spending generally and a disproportionate amount of potentially preventable spending.

 The needs of HNHC individuals are frequently not well addressed by a health care system and culture that are focused on specialized and facility-based care.

 Home-based care is increasingly recognized as an approach with potential to improve outcomes and patient experience for HNHC individuals.

There are many different home-based care models: home-based primary care (HBPC), hospital at home (HAH), community paramedicine, postdischarge transitional care, and care coordination services that employ both clinical and lay personnel. These models are distinct from certified home health agency services, which are not covered in this paper.

HBPC is well established but regularly practiced by relatively few providers. In 2013, approximately 5000 primary care providers made 1.7 million home visits to Medicare fee-for-service (FFS) beneficiaries, but almost half of the visits were delivered by just 470 providers.

 More than half of Americans live more than 30 miles from any of these high-volume providers, limiting Medicare beneficiary access to HBPC services.

Medicare reimbursement affects the availability of home-based care. Medicare pays for HBPC delivered by physicians or advanced practice clinicians (APCs), but HBPC providers see far fewer patients than office-based providers because of travel time, which limits revenue. Medicare has not historically paid for HAH, but in late 2020, CMS established a waiver covering certain HAH services during the COVID-19 pandemic.

 Transitional care management services are covered by Medicare when provided by a clinician but are typically offered in a provider’s office or telephonically.

Home-based programs rely on multidisciplinary teams, and patients may be visited by nurses, social workers, paramedics, and community health workers—none of whom can bill for home visits in most circumstances. As a result, many programs rely on financial support from a hospital, medical school, or philanthropic organization.

Although not historically well reimbursed, studies have shown that HBPC,

 and home-based programs led by registered nurses or lay health workers

 can lower spending for complex patients. These savings do not accrue to providers under traditional FFS reimbursement but generate financial benefits under models like capitation that pay a fixed per-member per-month amount for covered beneficiaries.

Accountable care organizations (ACOs) are well positioned to improve care for HNHC populations. ACOs are provider groups that take responsibility for caring for a specified set of beneficiaries. They are eligible to share in savings if they manage spending below a prospective budget target. Many ACOs have data systems and processes to identify high-risk beneficiaries and establish care plans to coordinate services for complex patients.

 Prior research suggests that a majority of ACOs make home-based care transition visits, primarily conducted by nonphysician staff.

 This paper offers a more comprehensive assessment of home-based care in ACOs.

We conducted a national survey of ACOs to assess the prevalence and characteristics of home-based care programs. It targeted ACOs participating in the Medicare Shared Savings Program (MSSP) or Next Generation ACO (NGACO) model as of July 1, 2019, that remained in the program during 2020 (N = 505).

A web-based survey was sent to ACOs in September 2019. Weekly email reminders were sent to nonrespondents for the first 4 weeks, and biweekly reminders were sent over the next 4 months. Survey results were merged with information on Medicare ACO characteristics. Descriptive analysis of survey results focuses on ACOs with 1 or more home-based initiatives.

We received 151 completed surveys for a 30% response rate. Respondents were larger, were more likely to be affiliated with a health system, and had more Medicare ACO experience than nonrespondents (

). Forty-four percent of respondents were enrolled in a Medicare ACO track with downside risk compared with 40% of all Medicare ACOs.

Two-thirds of ACOs reported some home-visit activity: 25% had formal programs, 25% provided occasional home visits, and 17% were actively developing programs.

This paper focuses on the 40 ACOs with formal home-visit initiatives. Fifty-eight percent of them participated in a Medicare ACO arrangement with downside risk vs 40% for all ACOs. They were also more likely to participate in commercial and Medicare Advantage risk contracts than other respondents (Table 1). ACOs with home-visit programs were larger and had more Medicare ACO experience than other ACOs.

The 40 ACOs reported 49 distinct home-based initiatives that focused on home-based primary care (37%), care coordination (24%), care transitions support (13%), addressing social needs (13%), and acute hospital-level services (11%), as shown in 

. Respondents provided other services to supplement their program’s principal function including care coordination (70%), addressing social determinants (65%), care transition support (59%), palliative care (41%), and acute urgent care services (24%).

Half of the programs were established between 2017 and 2019, and one-third of them reported 500 or more home visits annually (Table 2). Duration of services ranged from a single home visit (24%), 30 days or less (13%), 1 to 6 months (42%), to longer than 6 months (9%).

Most home-visit programs utilized multidisciplinary teams. Key staff included physicians (48% of programs), nurse practitioners (65%), registered nurses (85%), and social workers (70%). Approximately one-third reported using pharmacists, paramedics, or community health workers (Table 2).

The sustainability of home-visit models depends on funding. Major sources of program funding included billed services (54% of programs), shared savings from value-based contracts (52%), and institutional support (46%). Fifteen percent reported grant funding, and 7% reported direct support from health plans.

Respondents were asked whether they considered 6 specific issues as major, moderate, minor, or insignificant challenges (data not shown). The most common major challenge was demonstrating return on investment (ROI) (45%), followed by engaging physicians to refer patients for home-based services (30%). The most common major or moderate challenges were finding community resources for patients with social needs (72%), demonstrating ROI (70%), physician engagement to refer patients (60%), and targeting the right patients (58%).

Our survey shows that ACOs are involved in a diverse range of home-based initiatives. ACOs’ programs differed in size, staff mix, type of care provided, duration of services, and funding sources. Half of the programs were established in the past 3 years. This may reflect increasing pressure to develop initiatives that moderate spending growth as more ACOs enter risk contracts. ACOs that reported home-based programs were more likely to participate in payment models with downside risk, suggesting that more ACOs may adopt home-based care as CMS expands mandatory risk requirements.

Forty percent of respondents reported plans to expand their home-based programs, whereas 38% percent reported they would expand only if they could demonstrate positive ROI. However, measuring ROI was identified as a major challenge by 45% of programs and a moderate challenge by 26%. This is critical because many organizations are reluctant to invest in new programs designed for cost savings rather than revenue generation.

Measuring ROI is complicated by the financial structure of shared savings models. The MSSP establishes spending targets for each ACO while paying FFS for the care provided. Even if home-visit programs generate savings, the ACOs won’t benefit unless they generate sufficient overall savings. Historically, 30% to 50% of MSSP ACOs earn shared savings in any given year. These payments aren’t made until 9 months after the performance year ends, so ACOs need to fund new programs with their own capital.

 The business case is stronger with prospective monthly payments per beneficiary, which is an option under Medicare’s new ACO Realizing Equity, Access, and Community Health (REACH) model (formerly called Direct Contracting).

During the COVID-19 pandemic, Medicare began reimbursing for a wide range of telehealth services. Continued telehealth coverage beyond the pandemic could be a game-changer for HBPC because providers could reduce travel time and see more patients through a mix of virtual and in-person care. Although frail older patients often have difficulty with telehealth technologies,

 practices can send medical assistants or paramedics to patients’ homes to set up video visits and assist in exams using remotely enabled devices.

Although physicians and APCs can bill for home-based services, personnel like paramedics and nurses cannot. Medicare has been more willing to pay for services from nonclinician staff when organizations accept financial risk for the total cost of care. The NGACO and ACO REACH models offer waivers that authorize payment for up to 9 postdischarge home visits by licensed clinical staff under the general supervision of a physician.

This study has several limitations. First, the survey response rate was low (30%). Second, respondents were larger and more likely to participate in risk contracts, so our results may not be representative of all ACOs. Finally, ACOs may have added or dropped home-visit initiatives since completing the survey because of the COVID-19 pandemic.

Home-based programs are a promising strategy to improve care for high-need patients while reducing preventable hospital and emergency care. Policy changes to strengthen the financial viability of home-based care for ACOs include expanding home-visit waivers to MSSP ACOs taking downside risk; expanding the new HAH waiver, now available only to acute care hospitals, to independent medical groups; and paying for telehealth in conjunction with HBPC services on a permanent basis. These steps could help ACOs lower rates of preventable acute care services for HNHC patients and provide more personalized care in the comfort of their homes.

This work was conducted with funding from the West Health Institute. The authors thank the 151 ACOs whose participation in the survey made this paper possible.

 Brandeis University (REM, JP), Waltham, MA; Institute for Accountable Care (REM, JP), Washington, DC; The West Health Institute (ARS, CC), La Jolla, CA.

 Mr Mechanic is a board member of Atrius Health. Dr Perloff works for the Institute for Accountable Care, where the study was conducted. The remaining authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

 Concept and design (REM, JP, ARS, CC); acquisition of data (REM, JP); analysis and interpretation of data (REM, JP, ARS, CC); drafting of the manuscript (REM, JP, ARS, CC); critical revision of the manuscript for important intellectual content (REM, JP, ARS, CC); and statistical analysis (JP).

 Robert E. Mechanic, MBA, Brandeis University, 415 South St, MS035, Waltham, MA 02454. Email: mechanic@brandeis.edu.

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Articles

Accountable care organizations (ACOs) deliver a diverse array of home-based services, but many of the services are not reimbursed. ACOs may not expand these programs without strong evidence of cost savings.

Characteristics of Home-Based Care Provided by Accountable Care Organizations

 To assess the ability of accountable care organizations (ACOs) to use electronic health record (EHR) data for quality.

Cross-sectional study of ACOs participating in the Medicare Shared Savings Program (MSSP).

 A national survey of MSSP ACOs included questions on the number of EHR systems used across all providers in the ACO and barriers to reporting EHR-based quality measures.

Just 9% of ACOs use a single EHR system, whereas 77% use 6 or more EHR systems. The more EHR systems an ACO uses, the less likely it is to report having the infrastructure to aggregate EHR data and the more concerned it is about the short-term viability and accuracy of EHR-based quality measures.

ACOs have diverse structures that often result in the usage of multiple EHR systems. This has the potential to cause serious delays when CMS begins requiring ACOs to report their quality measures through their EHRs in 2022.

The usage of multiple electronic health record (EHR) systems is a common occurrence among accountable care organizations (ACOs). This paper summarizes the results of a survey on EHR usage within ACOs and discusses some of the issues this may present in reporting quality measures, including that:

Just 9% of surveyed ACOs use a single EHR system throughout their entire organization;

77% of surveyed ACOs use 6 or more EHR systems; and

Among the 37% of Medicare Shared Savings Program ACOs with 16 or more EHR systems, concerns about EHR-based quality measures include access to data, standardization of data elements, and cost of integrating across systems.

Electronic health records (EHRs) have been the centerpiece of modernizing the US health care delivery system, promising everything from greater efficiency to better patient engagement.

 The latest ambition is better safety and quality through the use of electronic clinical quality measures (eCQMs). These measures, which are being implemented for accountable care organizations (ACOs) beginning in 2023 as part of the 2021 Medicare Physician Fee Schedule final rule,

 draw on EHR data elements for diagnoses, services, and laboratory values

 and should be a simple extension of current EHR functionality, reducing the burden of manual abstraction and reporting.

 However, ACOs and other complex delivery systems utilize multiple EHR systems, many of which have limited functionality, making it complex and costly to benefit from this new way of reporting quality measures. This study seeks to analyze the key challenges facing ACOs as they move toward eCQMs and the added challenges for ACOs with multiple EHR systems.

There is evidence that EHRs have improved health care by improving data documentation,

 and improving ability to share information across providers.

 At the same time, EHRs are also contributing to medical errors and clinician burnout, problems either driven or exacerbated by the lack of interoperability between records.

 This lack of interoperability presents a deeper issue. Health care systems, made up of hospitals and clinician groups, are complex, and, as they develop over time, even a single corporate entity may have multiple legacy EHR systems. Although some are in a single-EHR environment, the rest need to find ways to make multiple EHR platforms interoperable to share data within their own system.

 This problem is compounded for ACOs and other groups of clinicians, as they may represent multiple health care systems, each with their own set of EHR platforms, joining together into an even larger group to provide value-based care.

eCQMs are quality measures that use data extracted from EHRs or other health information technology.

 They are currently required for acute care, critical access, and dual-eligible hospitals participating in CMS’ Promoting Interoperability Programs.

 There are reasons for this, as their virtues include being able to use clinical data to assess the outcomes of treatment, reducing the burden of manual abstraction and reporting, and working toward providing the ability to access real-time data for point-of-care quality improvement.

 However, similarly to EHRs, eCQMs also have their drawbacks. A recent study found that system-owned physician practices struggled to report cardiovascular eCQMs, taking up to 15 months to submit results.

 Another study found that the median time for a physician practice to report at least 1 of 4 eCQMs was more than 8 months, although they did find that practices in ACOs tended to be able to report more quickly.

 In addition to problems reporting results, a recent study in Kansas found that 15% of EHR-based measures were missing information when patients moved between facilities (eg, hospital to skilled nursing facility).

An ACO is a set of providers who take on risk for managing the total cost of care for a given population of patients. CMS sponsors ACO models for Medicare beneficiaries, but there are also commercial ACOs, such as the Blue Cross Blue Shield of Massachusetts Alternative Quality Contract, and Medicaid ACOs. The organizational structures of ACOs vary widely, ranging from small clinician groups with no hospitals and fewer than 100 total providers to large groups with more than a dozen hospitals and thousands of providers.

 Federally qualified health centers and rural health centers can also participate. ACOs are often formed by a number of different individual clinical practices coming together. Twenty percent of the time, those forming an ACO are part of an already existing organization, and in more than 50% of cases, the groups forming the ACO have never pursued a risk-based contract together. In these newly formed ACOs, providers share the same EHR system 20% of the time.

As a result, ACOs may have providers using numerous different EHR systems, ranging from simple tools, such as NueMD, to more sophisticated tools supported by large companies, such as Epic and Cerner. This diversity poses challenges for data integration, quality reporting, care coordination, and other functions for which the ACO needs to extract and share information stored in an EHR.

This cross-sectional study of CMS Medicare Shared Savings Program (MSSP) ACOs used a web-based survey to gather information on the number of EHR systems currently in use across ACO networks in the spring of 2021. This question was part of a larger survey looking at the impact of a recent overhaul of the ACO quality reporting process included in the 2021 Medicare Physician Fee Schedule final rule that was due to go into effect in 2021 and 2022, with a specific focus on the effects of the change in how quality measures will be reported.

The survey was sent to all MSSP ACOs that were active in 2021, with targeted outreach to members of the National Association of ACOs (NAACOS). We received responses from a total of 163 MSSP ACOs. The point of contact for the survey was either the primary ACO contact from CMS’ list of 2021 MSSP ACOs or the primary or secondary contact from the NAACOS database.

Survey questions were developed by ACO experts at NAACOS and the Institute for Accountable Care. Specific items were pilot tested with ACO leaders on the NAACOS Quality Committee. The survey was distributed through the Alchemer platform via an introductory email in which the first question was embedded, with a response triggering the launch of the remainder of the survey. Respondents received 3 reminder emails, each of which included a link to the full survey.

The primary question of interest asks: “How many EHRs do the practices/participant Taxpayer Identification Numbers (TINs) in your ACO use?” Additional questions asked about ease of integrating EHR data and implementing eCQMs. Survey responses were linked with the 2020 MSSP Public Use File to determine the characteristics of responders vs nonresponders. ACO high revenue status was included as an indicator of size/capital reserves. CMS considers an ACO high revenue if its total Medicare Part A and Part B expenditures far exceed its expenditures on ACO beneficiaries (the threshold is 35% or more of total A+B revenue for ACO participants / total A+B expenditures for ACO’s assigned beneficiaries). ACO size is defined by the number of unique beneficiaries participating in the model.

The descriptive analysis shows characteristics of ACOs by the number of EHR systems.

Of 477 MSSP ACOs in 2021, there were 163 respondents, for a response rate of 34%. As can be seen in 

, survey respondents tend to have more attributed beneficiaries and more providers and are more likely to be considered high revenue, an indicator of significant Medicare reimbursements outside the ACO program, than the MSSP ACO population as a whole. As shown in 

, only 9% of respondents have a single EHR system, with an additional 14% using between 2 and 5 EHR systems.

Large numbers of EHR systems are common, with 40% having 6 to 15 different systems and almost 40% having 16 or more systems. ACOs with more beneficiaries and provider groups (as defined by TINs) are more likely to have multiple EHR systems, and, consequently, they need to make greater investments to integrate their data. For example, 49% of those with 16 or more EHR systems are large, with more than 25,000 beneficiaries, compared with just one-third of those with 1 EHR system. Those in the group with 16 or more EHR systems are also least likely to have software to integrate EHRs (23% compared with 48% for those with 2-5 EHR systems) and most likely to report challenges with adding needed integration infrastructure (62% compared with 30% for those with 2-5 EHR systems).

Finally, ACOs with only 1 EHR system report the fewest concerns about moving into an eCQM reporting system. Only 29% of the single-system ACOs report concerns with data access and just 21% have concerns about standardization across EHRs. This is in stark contrast to the 67% of the ACOs with 16 or more EHR systems concerned with data access and 82% concerned with standardization across EHRs.

ACOs have diverse structures that often cut across organizations or provider groups. This frequently results in multiple EHR systems within the same ACO, many of which vary in terms of sophistication and ability to export data. In addition to different data models, EHR systems may differ in terms of quality, completeness, and even which data elements are in a standard, machine-readable format (as opposed to clinician notes). This makes it administratively burdensome for these organizations to draw on EHR data for quality or other types of reporting, such as eCQMs, at this time. Furthermore, data integration is likely to come with unanticipated expenses, staff training, new data validation processes, changes in workflow for providers, and other logistical and legal considerations. It is also important to note that the accuracy of measures may be low, particularly early in the data integration process when different EHR systems may have different definitions for the same field.

There are a few limitations that should be kept in mind when interpreting these results. First, respondents tend to be larger MSSP ACOs. It is hard to know whether smaller ACOs face the same degree of EHR integration challenges as larger ACOs. On one hand, they may be singular entities with a single EHR system, although it seems plausible to assume that independent groups that come together to form an ACO also have numerous legacy health record systems. Second, the study is cross-sectional, reflecting the technology of mid-2021. ACOs may have made data integration improvements since the time of the survey. Finally, we cannot say whether the challenges described are caused by having more EHR systems in use or whether there is another confounding factor (eg, size and complexity of ACO activity) that both is the cause of the numerous EHR systems in ACOs and makes aspects of coordination, such as eCQM reporting, difficult.

To fulfill the potential of EHR technology and advance the use of eCQMs, EHR vendors have to increase the availability of data integration tools and software that allow ACOs to efficiently gather data across different platforms. There is some hope that the 21st Century Cures Act, which sets up certain criteria for certification for application program interfaces (APIs), will ultimately result in the establishment of a standard for health care quality exchange.

 APIs are software intermediaries that allow 2 programs to talk to each other.

 Thus, in theory, standardizing APIs would make it easier to connect EHRs when it comes time to report eCQMs. In practice, however, the timeline for such standardization is still unclear. HHS’ Trusted Exchange Framework and Common Agreement, billed as a nationwide on-ramp to interoperability, is not due to go live until 2022, more than 3 years after an initial draft was released.

 CMS is also behind in implementing its interoperability agenda.

 This leaves ACOs in a difficult position. They are required to begin reporting at least 1 eCQM in 2023.

With no clear idea of when interoperability among their many EHR systems will become a realistic option, many ACO leaders are worried. Specifically, concerns about the completeness and accuracy of the data they will be able to provide in this new setting are forcing many ACOs to hire vendors or additional analysts—expensive moves that they worry will hinder their ability to achieve shared savings.

 Vendors can help in the short term by precoding eCQMs into their records, allowing ACOs to export results rather than data elements. Alternatively, expanding the data dictionaries for capturing an ACO’s core measures has the potential to provide a workaround that does not rely on EHR interoperability.

Ultimately, value-based payment models require meaningful, actionable, and patient-centered quality measures to succeed. eCQMs are an example of how EHR platforms can help create a real-time quality and patient management infrastructure across the US health care delivery system. However, without timely solutions to the issues of data aggregation, any movement toward eCQMs has the potential to create more problems, in the short term, than it solves.

The authors would like to acknowledge the contributions of Jennifer Gasperini, who reviewed drafts of this paper, and the members of the NAACOS Policy Committee for their contributions to reviewing the survey tool.

 Brandeis University (JP), Waltham, MA; Institute for Accountable Care (JP, SS), Washington, DC.

 Mr Sobul has attended meetings of the National Association of ACOs with accountable care organization leaders.

 Concept and design (JP, SS); acquisition of data (SS); analysis and interpretation of data (JP, SS); drafting of the manuscript (JP, SS); critical revision of the manuscript for important intellectual content (JP, SS); and supervision (JP).

 Jennifer Perloff, PhD, Brandeis University, MS 035, Waltham, MA 02454. Email: perloff@brandeis.edu.

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A recent survey found that more than 90% of accountable care organizations (ACOs) have multiple EHRs. This could present issues as ACOs adopt electronic quality measures.

Jennifer Perloff, PhD

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