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The American Journal of Accountable Care March 2016
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Health Plan—Provider Accountable Care Partnerships: How Have They Evolved?
Aparna Higgins, MA; Kristin Stewart, MHSA; Grant Picarillo, MS; Nicole Brainard, PhD, MPH; and Kirstin Dawson, MS
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Health Plan—Provider Accountable Care Partnerships: How Have They Evolved?

Aparna Higgins, MA; Kristin Stewart, MHSA; Grant Picarillo, MS; Nicole Brainard, PhD, MPH; and Kirstin Dawson, MS
Although health plan accountable care models have evolved provider readiness, data, analytics, and the use of performance measurement are important components of plan-provider partnerships.
ABSTRACT

Objectives: To understand the expansion of health plan–provider accountable care organization (ACO) partnerships and the evolution of the characteristics of these partnerships. 

Study Design: Qualitative data collection and survey.

Methods: We used a 2-pronged data collection approach. We collected qualitative data from the 8 plans who participated in our 2011 study on health plan–provider partnerships using the same set of interview questions. In addition, we fielded a survey on alternative delivery and payment models to 105 member plans from America’s Health Insurance Plans (AHIP), including specific questions on health plan ACO implementation.

Results: Our survey showed health plan expansion of ACO implementation with increased use of shared risk and widespread provision of analytic reports and other types of technical assistance to providers. The cohort of 8 health plans reported improvements in quality of care since 2011 while evolving their program components, such as use of more readily measureable provider eligibility criteria, ongoing emphasis on health plan–provided technical assistance, and greater collaboration between health plans and their provider partners, to continually re-evaluate quality and utilization measures.

Conclusions: Our analysis shows maturation of private sector ACOs since 2011, with shared risk playing an increasing role in changes to reimbursement. We also saw continued emphasis on provider readiness to assume downside risk, expansion to smaller provider groups, and an increase in the scope and depth of technical assistance made available to providers in these contracts. Some challenges continue to exist, including alignment of quality measurement and reporting, broader inclusion of smaller practices in alternative delivery and payment models, and developing tools and materials to assist consumers in realizing the benefits of value-based care.
To help accelerate delivery and payment reform across the public sector, HHS Secretary Burwell announced the federal government’s goal to tie 30% of traditional, fee-for-service (FFS) Medicare payments to quality and value through alternative payment models (APMs) by the end of 2016, and 50% of payments by the end of 2018.1 Implementation of APMs in the private sector has been underway for the past 5 to 6 years. Examining the experience of health plans with such models can be useful to policy makers as they seek to transition the healthcare system to value-based payment through implementation of the Health Care Payment Learning and Action Network2 and Medicare Access & CHIP Reauthorization Act of 2015 (MACRA).3
 
In 2011, we published a study on key characteristics and initial lessons from 8 health plans that were early adopters of accountable care organization (ACO) models.4 Re-examining their experience with these models over the past 4 years can yield useful insights for policy makers and other healthcare stakeholders; specifically, we sought to understand how ACOs implemented by these 8 plans have evolved. We were also interested in examining the widespread adoption of ACOs in a more systematic manner. To achieve these objectives, we used a 2-pronged data collection approach. We collected qualitative data from the 8 plans who participated in the 2011 study using the same set of interview questions. In addition, we fielded a survey on alternative delivery and payment models to 105 member plans from America’s Health Insurance Plans (AHIP), including specific questions on health plan ACO implementation. In this article, we describe key findings from the second round of data collection from the original 8 plans and a total of 28 plans who responded to the survey.
 
Expansion of ACO Implementation
Findings from our member plan payment survey showed that all 28 health plans that responded to the survey had ACO contracts in effect. We also found that these ACO contracts were present in 43 states and spanned commercial, Medicaid, and Medicare Advantage product lines. In addition, several of our 8 case study plans, which cover approximately 80 million commercially enrolled lives, reported extending their partnerships beyond the largest health systems and provider groups to smaller physician groups. Some case study health plans have lowered the requirement for minimum patient panel size from 10,000 to 5000 patients. 
 
Improvements in Quality Since 2011
The cohort of 8 case study plans with several years of experience implementing ACOs reported improvements in quality and costs. Specifically, some of the observed improvements, shown as ranges experienced by the 8 case study plans, include:
  • Improved performance on clinical quality measures for specific conditions (up to 20% improvements), such as diabetes (19%-25% increase) and medication adherence (27% increase).
  • Reduced readmission rates (11%-32% improvements).
  • Increased prescribing of lower-cost medications (21%-52%) through approaches such as generic prescribing.
  • Achieved a significantly higher referral rate to high performing specialists than the market referral rate (81% higher).
  • Reduced emergency department visits (19%-50% improvements).
 
Health plans reported actively seeking to incorporate patient satisfaction measures into their ACO contracts by conducting patient satisfaction surveys. In conducting these surveys, one plan reported that patients attributed to the ACO experienced better access to urgent care, higher satisfaction with the amount of time they spend with providers, and higher satisfaction with how well their providers listened to them compared with members not attributed to the ACO. Finally, some plans reported observing “spillover effects,” where patients not attributed to the ACO experienced improvements in outcomes, and greater access to care through extended provider office hours due to re-engineering of care delivery.
 
These improvements in quality of care were also accompanied by other key changes in the design and implementation of ACOs, which are highlighted below. 
 
Provider Eligibility
As health plans have expanded their ACO contracts, provider eligibility criteria for such contracts have also evolved. Although the 8 case study plans reported using some of the same criteria as in the 2011 study, such as strong leadership and commitment to transformation, several new and more readily measurable criteria have emerged. Table 1 lists some of these criteria.
 


 
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