Accountable care may still be a relatively new model in some areas, but the numbers of ACOs are steadily increasing. There were approximately 660 ACOs in the U.S. in 2015. The number increased to 838 last year. Success, however, can be elusive.
Only about one-fourth of U.S. hospitals entered into value-based contracts have been able to reduce administrative and healthcare costs, and less than half have met goals for improving patient outcomes. Successful ACOs are employing innovative strategies to help patients improve their health and quality of life. The following are just a few examples.
In-house specialty pharmacy services
Specialty pharmacies are a natural complement to ACOs. Their services go beyond dispensing specialty drugs to include coordinating eligibility and reimbursement, working with patients to obtain financial assistance and promoting adherence by educating patients about their drug therapies and side effects.
UMass Memorial Accountable Care Organization is heavily reliant on its specialty pharmacy care services, which embeds pharmacy staff directly into its clinics, fully integrates them with the health system’s EMR, arms them with full data analytics capabilities and empowers them to assist patients with prior authorization, billing and drug therapy adherence.
Consequently, the ACO’s medication adherence outcomes are well above the national average for areas like hepatitis C, oncology, infectious disease and neurology, according to Eric Dickson, president and CEO of UMass Memorial Health Care.
Although pharmacists are directly involved in care at a growing number of ACOs, gaps remain. Just 35 percent of ACOs have a formal strategy for managing drug costs, according to the Pharmacy Benefit Management Institute. Challenges include limited resources for patient care and care coordination, adherence and persistence, and determining the cost effectiveness of specialty drugs.
Full clinical integration
Houston-based Memorial Hermann Accountable Care Organization, which has been the number-one Centers for Medicare & Medicaid Services Shared Savings Program (MSSP) ACO for three years, generated nearly $200 million in savings by fostering a patient-centered care delivery strategy that’s built on clinical integration, collaboration and teamwork.
A staunchly “employment-agnostic” ACO, Memorial Hermann has a clinically integrated network of 2,600 employed and independent physicians from across the community. “We’ve brought together the physicians in the community, in an employment-agnostic model, and gathered them around the ACO and the care delivery network, around some of these principles associated with total cost of care,” Chris Lloyd, Memorial Hermann CEO, said in an interview with Healthcare Informatics.
By design, clinically integrated networks can support improved outcomes and care coordination. But meaningful clinical integration is challenging. Only 27 percent of ACOs have all providers on the same EMR system—and 23 percent are still using paper charts, according to the Pharmacy Benefit Management Institute. Often standing in the way of full clinical integration are regulatory hazards with regard to FTC and DOJ regulations as well as longstanding issues of mutual distrust between physicians and healthcare organizations.
URAC’s Clinical Integration accreditation program guides organizations around these obstacles, providing a roadmap that healthcare networks can use to become clinically integrated while avoiding antitrust issues.
Expanded social services
While most ACO models focus exclusively on providing traditional health care services, some are focusing more intensely on how outcomes are impacted by patient’s behavioral, environmental and social needs. This is particularly true for dual-eligible patients whose unmet needs often include housing, food security and transportation. Studies have shown these types of nonmedical factors can impact health more than a patient’s actual medical issues.
A pioneer in this area is the Massachusetts-based Commonwealth Care Alliance (CCA), a fully integrated health plan and delivery system. Often described as the nation’s first “social ACO,” CCA appoints care managers to work with an interdisciplinary team of nurse practitioners, social services providers, behavioral health professionals, personal care attendants and others to coordinate care for its 19,000 patients and to support the primary care physician. And because care managers have the authority to approve non-medical expenses, they can mobilize quickly to provide patients with such basic needs as air conditioning, meals and wheelchair ramps.
“As a health plan, we fully integrate premium dollars into our medical, behavioral health, and social spending,” Toyin Ajayi, Chief Medical Officer, and Iyah K. Romm, VP for Clinical Operations and Transformation, wrote recently on the Health Affairs Blog. “We can just as easily use ‘medical dollars’ to pay for our members’ air conditioners to prevent asthma, or for medically tailored meals that support patients with diabetes, as for inhalers and insulin to treat their downstream symptoms.”