The core mission of an accountable care organization (ACO) is to improve the quality of care and reduce unnecessary healthcare spending for the ACO’s attributed members. ACOs are financially rewarded for their ability to succeed in these areas. For ACOs that participate in “downside risk” arrangements, failure to adequately control healthcare costs compared to a predetermined benchmark can translate to financial losses for the ACO.
With the COVID-19 global pandemic, ACOs are facing unprecedented uncertainty with regard to their performance on alternative payment arrangements. At the same time, ACOs must adapt to meet the needs of COVID-19 patients while continuing to effectively manage non-COVID patients in a largely disrupted healthcare system.
The Current State of Financial Uncertainty
The public health emergency raises many pressing questions for ACOs (and other provider organizations) that participate in value-based care reimbursement programs. For example:
- Will ACOs be held accountable for COVID-related expenditures for their members? How will these expenditures be identified?
- Will financial benchmarks and target prices for the 2020 performance year be modified appropriately?
- Will payers adjust quality measure reporting requirements and benchmarks?
- With healthy patients avoiding physician offices, how will this impact member attribution in population-based models such as the Medicare Shared Savings Program? Will ACOs be measured on a disproportionately sick population?
In early April, the National Association of ACOs (NAACOS) reached out to all Medicare Shared Savings Program (MSSP) and Next Generation ACO Model participants with a survey focusing on the effects of COVID-19. The results of this survey clearly indicated that ACOs across the nation were concerned about how the pandemic would affect their performance.
Ninety-four percent of respondents reported being very or somewhat concerned about their ACO’s performance and 90 percent reported that the pandemic will have a significant or very significant impact on their ACO’s ability to earn shared savings. Taking it a step further, over half of ACOs reported that they were likely to leave MSSP in order to avoid financial losses.
To help mitigate these fears, on April 30th, the Centers for Medicare and Medicaid Services (CMS) issued new rules to provide relief for ACOs during the COVID-19 pandemic by adjusting the performance calculations methodology to account for costs related to COVID-19. CMS is also forgoing the MSSP application cycle for 2021 and allowing ACOs to extend their agreements and maintain their current financial risk track level for another performance year.
Care Management During a Global Pandemic
In addition to financial uncertainties, ACOs are also experiencing the pandemic’s effects on their day-to-day care management efforts. With entire states shut down and residents under stay-at-home orders, care management is disrupted and delayed. ACO care teams, providers, and patients are needing to relearn how to navigate the healthcare system.
Common barriers to care, such as lack of transportation and food insecurity, are now exaggerated. Furthermore, many case managers and other ACO staff are currently doing double duty to care for COVID patients on top of their regular non-COVID patients.
Despite the stress on the health system, ACO care teams are poised to rise to the challenge.
Prior to the pandemic, ACOs have been focused on increasing access to care, improving care transitions, and reducing unnecessary hospital utilization. Now, with added urgency, ACOs are being called upon to help preserve limited hospital beds, personal protective equipment, and other resources for the most acute patients. NAACOS articulated in a press release published on May 4th:
“ACOs are uniquely positioned in crisis like this because of their years of work supporting care coordination and building an infrastructure to support their ACO work. ACOs across America are identifying vulnerable patients at high-risk for COVID-19 using their population management tools, educating patients about minimizing exposure, making sure they have enough food and medication to stay home, remotely monitoring their underlying conditions, treating cases through telemedicine, and managing post-discharge complications with integrated home health and effective relationships with post-acute providers.”
To help manage the needs of COVID and non-COVID patients, a Health Affairs article suggests that ACOs leverage and transform existing population health initiatives. Through telephonic and remote patient outreach, ACOs can triage patients with respiratory symptoms. Taking advantage of more flexible telehealth guidelines, ACOs can also proactively check on at-risk patients to ensure they are receiving the support they need in order to stay out of the hospital.
The Critical Role of Care Collaboration
In the COVID-19 setting, it is more important than ever for care teams to work together to effectively coordinate care. Designed to support real-time care collaboration, Collective Medical’s technology platform brings together ACOs, hospitals, emergency departments, skilled nursing facilities, and primary care providers around a common patient. The platform supports care team members in communicating important diagnoses and known risks, enabling more informed care planning for patients that are at high risk or positive for COVID.
ACOs using the platform also gain real-time visibility into where their patients are seeking care and why. ACOs know the moment their patients present to the ED, enabling care teams to engage ED case managers before the patient leaves the hospital and collaborate on a discharge plan that will ensure the best outcomes. For patients who require inpatient or post-acute care, ACOs can follow the patient throughout their stay and ensure a smooth transition to the next setting of care as quickly and safely as possible.
In the present pandemic, ACOs play a critical role in meeting the needs of complex and high risk patients. When the crisis subsides and we enter a new normal, ACOs will continue to help prevent patients from falling through the cracks. Care collaboration technology supports ACOs in this important work for patients and the health system as a whole.
Nikki Starrett, MS
Director of Accountable Care & Population Health