Accountable care organizations (ACOs) are on the forefront of the drive toward shared risk, value-based healthcare. They are also on the front lines of determining how to best deliver and prove that value.
The Centers for Medicare and Medicaid Services set a goal to have 50 percent of Medicare recipients in an ACO or other alternate payment models by 2018. Based on history, private payers will likely follow.
It’s hard to discuss today’s various ACO models without looking back to the failed health maintenance organizations of the 1980s and 1990s. Many of those plans relied on capitation, which sets a fixed amount of provider revenue per member, with little alignment on improved quality or outcomes.
This tended to reduce service levels, with a laser focus on the bottom line and little regard for each member’s clinical outcomes and experience. By the late 1990s, studies showed almost a third of HMO members weren’t satisfied with their plans’ “timeliness, professionalism or accuracy.”
Combined with a misalignment of provider incentives, capitation-based models frankly failed because of a lack of robust, near real-time data and user-friendly tools that could give providers actionable information to help determine which services were most effective. Not that it mattered, in most cases; few HMOs had the right staff to develop and utilize individualized care plans down to the member level that could achieve the critical cost-quality balance.
Thankfully, that’s changing. Today’s ACOs can have volumes of data from multiple sources at their disposal, with intuitive analytical tools that can present it in a way providers can actually use. This information down to the member level can finally help us achieve 21st century healthcare’s Holy Grail—the triple aim goal of improving clinical outcomes, cost efficiency and the consumer experience.
Significant progress in harnessing the power of big data has been made, but work remains. ACOs—typically large, diverse organizations—have even more relevant data than most. They also face more challenges to use it effectively because of the many electronic health record and other systems, even paper records, from which it comes. An ACO must agree on what data is most relevant and how to best gather and analyze it; it needs to transform that data into actionable information that fuels the actions which will have the greatest impact on each member’s health.
Unfortunately, many organizations, including some ACOs, still use data from limited sources—primarily retrospective claims and an initial assessment call focused on a member’s primary condition. Healthcare consumers don’t like this long call—providing information they’re frequently asked to repeat later—and even hang up before it’s completed, further limiting available data. Can you blame them?
Then, typically, providers pull a one-size-fits-all care plan—usually focused on the Core 5 conditions of CHF, COPD, CAD, asthma or diabetes—off the shelf, assign a care manager and begin standard interventions for that condition—not that individual.
Leading-edge ACOs and other risk-bearing organizations are learning to improve overall population health, one unique member at a time. This represents a paradigm shift in care management and starts by capturing the most salient data to maximize targeting those with the highest impact.
This transcends conditions to precision-target members who will most benefit from personalized interventions, and then matching resources to the member’s needs and personality to optimize outcomes. Whether those needs are poor adherence to their treatment plan, lack of transportation, behavioral health issues or other factors, today’s innovative care management services can help organizations overcome barriers that increase risk and obstruct the ability to effect change.
Advanced analytics, such as biometrics, symptoms, lab, pharmacy, and claims, can effectively and continually process data to create a 360-degree view of the member. This provides actionable insights and a timely focus showing where opportunity exists for sustainable health improvement, cost savings and an improved customer experience for each member.
The ACO can develop an individualized care plan and match a member to a multi-disciplinary, condition-agnostic team that has the right mix of skills and personalities to meet the member’s clinical, behavioral and environmental needs. Frequent, brief “touch points” with the member and his or her care circle by phone, email or text continuously adds to the body of knowledge; together, this enables the team to guide a member down a clear path toward optional health outcomes, which in turn lower costs and improve satisfaction. Triple aim goals: achieved.
Armed with the right actionable information and a flexible, personalized member care plan and team, accountable care organizations have an incredible power to positively impact clinical outcomes, cost and satisfaction. If implemented correctly, ACOs will play a critical role in transforming our care-delivery system and the value we derive from it.
Register or login for access to this item and much more
All Health Data Management content is archived after seven days.
Community members receive:
- All recent and archived articles
- Conference offers and updates
- A full menu of enewsletter options
- Web seminars, white papers, ebooks
Already have an account? Log In
Don't have an account? Register for Free Unlimited Access