Identifying 7 Best Practices of Successful ACOs

During the second plenary at the National Association of ACOs fall meeting, Meridith Seife, deputy regional inspector general, Office of Evaluation and Inspections in the HHS Office of the Inspector General, presented results from a government report identifying strategies of high-performing accountable care organizations that had improved care quality while cutting costs.

With Medicare spending expected to top $1.5 trillion every year in just a decade, it is crucial that policy makers find healthcare models that provide taxpayers better services at a lower cost. A government report implies that accountable care organizations (ACOs) might be that model.

During the second plenary at the National Association of ACOs fall meeting, held September 25-27 in Washington, DC, Meridith Seife, deputy regional inspector general, Office of Evaluation and Inspections in the HHS Office of the Inspector General (OIG), presented the results of an OIG report, published in July, that highlighted the best practices of high-performing ACOs. It was refreshing, she said, to be able to report some good news, since people often think of the OIG as the agency that highlights when things have gone wrong.

“We typically get to see the darker side of healthcare,” she admitted, and OIG’s work is often around fraud and abuse.

To create the report, OIG had interviewed 20 high-performing ACOs to identify the strategies they used to manage costly patients, reduce unnecessary hospitalizations, improve care, control costs, improve quality, and engage with patients and physicians. These ACOs were geographically diverse, represented physician-only and hospital-based ACOs, and also had taken on varying levels of risk.

“Over the last 5 years, we found that physicians have been quietly changing the way they do business,” Seife said. “We might even say there has been a quiet revolution.”

OIG identified 7 strategies that high-performing ACOs had in common.

1. Supporting physicians.

These ACOs armed their physicians with key data and support to better care for patients. Physicians practicing in a fee-for-service system are largely in the dark regarding the cost of services they provided and the care other providers were offering to their patients, Seife explained.

“This meant not just duplicated services or unnecessary services, but also fragmented and uncoordinated care,” she said. “These highly successful ACOs, they worked to close those gaps in care.”

These ACOs recruited physicians who were committed to an ACO model and gave them the data they needed to improve care and coordination. They also emphasized the need for prevention through screening and monitoring.

2. Engaging beneficiaries.

Patients who are moved involved with their healthcare have better health outcomes and lower costs. This requires building relationships between the patients and their physicians.

“Many of the successful ACOs we interviewed found the Annual Wellness Visit (AWV) the linchpin for building these relationships,” Seife said.

One ACO she highlighted had tracked down those patients who had not had a wellness visit to set up those appointments. The result was that they increased the proportion of their Medicare patients who received an AWV from 15% to 50%. Those patients who had an AWV saw their physicians more often throughout the year, resulting in better care and outcomes compared with the patients who did not have an AWV.

3. Managing high-need patients.

High-cost and complex patients account for a disproportionate share of costs and successful ACOs focused on them. They made home visits to these patients, such as sending a respiratory therapist to patients with chronic obstructive pulmonary disease.

Another ACO handed out tablets and a scale to patients with end-stage congestive heart failure. The tablets sent daily medication reminders and the scale sent information daily to a care coordinator. This way, the ACO could monitor for rapid weight gain, which is a sign of a serious medical condition for these patients. The result was a 43% reduction in emergency department (ED) visits and a 47% reduction in hospital admissions for these patients.

4. Reducing avoidable hospitalizations and improving hospital care.

Successful ACOs worked to reduce avoidable hospitalizations, but hospitals can be difficult to engage, said Seife. Almost half of successful ACOs expanded access to primary care services with extended hours, telemedicine, and other benefits so patients had an alternative instead of going to the ED.

In an example of how an ACO might tailor what it offers depending on the specific population, one ACO offered a patient a standing weekly appointment with a primary care provider, which led to a reduction in that patient’s ED visits from 30 a year to just 2.

5. Working with skilled nursing facilities and home health agencies.

Some ACOs were guarding against unnecessary services in the post-acute care setting, while others selectively recruited skilled nursing facilities (SNFs) and home health agencies and designate them as preferred providers. Other ACOs embedded staff directly in the SNFs to better monitor the health of their patients.

Most of the ACOs emphasized the importance of warm handoffs, which improved care transitions.

6. Addressing behavioral health needs and social determinants of health.

ACOs are working to address behavioral health needs, some by integrated behavioral health providers in the ACO network or bringing them into the primary care setting. Others set up relationships with behavioral health providers and if there were none in the area, they used telemedicine to improve access.

“ACOs were also encouraging their primary care physicians to become more adept at recognizing, screening, and testing for certain common behavioral health conditions, and treating certain common behavioral health conditions, like depression and anxiety,” Seife said.

They also incorporated nonmedical staff, such as social workers and case managers, into the practices to better address unmet social needs, including housing, food insecurity, transportation issues, and medication assistance.

7. Utilizing technology

Successful ACOs used technology to improve care coordination. There remain challenges with interoperability, and many ACOs found ways to work around that issue either by moving all providers into a single electronic health record system to seamlessly share data or by developing alternative systems to facilitate better communication. Some used the information from health information exchanges. One developed a mobile app to pull information from the state’s health information exchange and send real-time alerts to physicians about admissions, discharges, and transfers.

Recommending Continued Support From CMS

The OIG report also included recommendations for CMS, including expanding efforts to share information about strategies that reduce spending and improve quality among ACOs and more widely with the public; adopting outcome-based measures and better aligning measures across programs; and identifying and sharing information about strategies that integrate physical and behavioral health and address social determinants of health.

While it’s true that there are no one-size-fits-all solutions, the successes of high-performing ACOs have highlighted a path forward to improve quality of care while cutting costs significantly.

“The one message that I heard over and over again from ACOs that we spoke with was that ‘We should have always been practicing medicine this way,’” Seife said.

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