What the Most Successful ACOs Know

The numbers for 2014 are in, and accountable care organizations (ACOs) are improving the quality of care for an ever-growing number of Medicare beneficiaries, while generating financial savings, according to the Centers for Medicare & Medicaid Services (CMS). With a goal of providing more person-centered care, ACOs are groups of doctors, hospitals and other healthcare providers who voluntarily come together to provide coordinated care, particularly to the chronically ill.

“These results show that accountable care organizations as a group are on the path towards transforming how care is provided,” said CMS Acting Administrator Andy Slavitt in a press release. “Many of these ACOs are demonstrating that they can deliver a higher level of coordinated care that leads to healthier people and smarter spending.”

Which means these 353 ACOs get to share in the $411 million in savings they’ve generated for CMS. If you do the math, there’s a big chunk of change that could be yours, if you join or develop a successful ACO. Here are three things the best ACOs know, and you should, too.

1. How to generate savings

According to the CMS report, ACOs with more experience in the program were more likely to generate shared savings. Among ACOs that entered the program in 2012, 37% generated shared savings, compared to 27% of those that entered in 2013, and 19% of those that entered in 2014. Ensuring patients receive the right care, at the right time, without duplication is critical to achieving these kinds of savings.

For example, they set up “care centers” — which don’t have to be physically in one place but, rather, are protocols for care and pathways for referral that ensure healthcare providers are pulling in the same direction, and that patients don’t fall through the cracks. The Rio Grande Valley ACO has developed a diabetes program that accounts for the multidisciplinary nature of care for the systemic effects of this chronic illness and seeks to prevent expensive interventions that may be required as the disease progresses. To encourage ongoing management, the RGV ACO approach emphasizes blood pressure, lipids, glucose, aspirin use and tobacco avoidance.

The challenge is made more difficult by the fact that, if a patient is not compliant with one measure, the ACO ‘fails’ in all five measures for that patient. The RGV ACO responded by creating a diabetes learning center, with health coaches to promote self-management and regular follow-up communication to remind patients to take their prescribed medications. EHR was used to provide reminders to the appropriate providers across the ACO, to track key patient factors including HbA1c, low-density lipoprotein cholesterol, blood pressure, smoking status and the use of anti-platelet therapy. The RGV ACO reports “75–90% of patients are on target on individual DM QMs, and 48% of patients are compliant with all DM clinical measures at once.”

2. How to improve quality

ACOs that reported in both 2013 and 2014 improved on 27 of 33 quality measures. Quality improvement was shown in such measures as patients’ ratings of clinicians’ communication, beneficiaries’ rating of their doctor, screening for tobacco use and cessation, screening for high blood pressure, and EHR use.

To achieve these kinds of improvements in quality measures, it is important to “establish a performance-measurement program that allows you to continually evaluate outcomes and costs,” writes one expert. “The worst time to collect performance data is at reporting time, because the data are subject to the arbitrary results of the patient sample, and you can’t do anything about the results. The main purpose for performance measurement is not just to benchmark your providers and patient results, but also to identify patients and providers for focused interventions.”

Determine these metrics from the outset, and gather benchmark data before pursuing “improvements” in quality. Once the benchmarks are clear, you can define them— just what does “good doctor communication” mean, for example? — risk-adjust your population and set appropriate targets for continuous improvement across the ACO. With a focus on primary care, your ACO can focus on prevention and management of chronic illness — which not only is in line with CMS’s push towards population health management, but also lets you “evaluate the cost and quality of specialists before you direct patients to them, as a best practice for establishing a referral network that will deliver both good outcomes and lower cost.”

Remember that quality improvement isn’t a destination, it’s a process, and building a strong foundation will make it easier to test interventions and redesign the processes of care to further minimize costs and maximize outcomes.

3. How to perform in group practice reporting

ACOs achieved higher average performance rates on 18 of the 22 Group Practice Reporting Option (GPRO) Web Interface measures reported by other Medicare providers reporting through this system.

To gain an extra advantage with GPRO, be sure you’ve agreed upon your nine relevant metrics across the ACO, as well as how they will be tracked, assessed and reported. Because the group composite scores are, to some extent, based on patient volumes, missing out on good scores because they were reported into a different metric can drag down the group.

Whatever reporting mechanism you use — registry, EHR-direct or web interface — you should choose the one that gives you the greatest control over meeting the quality composite score. EHR-direct can pose difficulties if ACO members have different systems; registries require paying to partner (which comes with the advantage of advice); and CMS is promoting web interface as a good, centralized way to ensure that data reporting is standardized for each ACO (although this comes with the disadvantage of extra data input). It’s also important to get and maintain buy-in from all eligible providers, as more than 50% must be reporting to avoid group penalties.