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What is Holding Back the Success of Accountable Care Organizations?

The concept of value-based reimbursement is by no means a new one. CMS is aggressively tying healthcare payment to value-based payments models to move away from the traditional volume-based fee-for-service model. And a key component of this transformation is the Medicare Shared Savings Program where accountable care organizations (ACOs) care for Medicare beneficiaries, save Medicare money, and if successful- keep a part of it.  

Amid this major transformation, ACOs end up balancing two very different agendas at once: one, building the competencies they need to generate enough savings under value-based payment; and two, remaining financially viable with sustained revenue growth. ACOs have successfully generated billions of dollars in savings since their inception in 2012 and across the next decade, the transformation in healthcare would keep fueling this growth.

The challenge, however, becomes apparent when we look at the numbers closely. Out of 432 ACOs participating in MSSP in 2016, only 31% of them were able to generate enough savings. The transformation in healthcare comes with a great deal of uncertainty as ACOs carve a way out for survival and success.

Key competencies for better accountable care outcomes

The distribution of savings is uneven among ACOs and there are a few apparent reasons behind it. Additionally, despite the ACOs that generated savings received a composite quality score of 94 percent on average, the ones that did not generate any savings received a score of 93 percent. Even though the goal of improving care quality and advancing population health is clear, many providers are wondering how to achieve these qualitative goals.

One key thing to notice here is that MSSP offers ample opportunity to improve the quality of care for the patient and reduce the cost. From evaluating ACOs on measures such as preventive screenings to ensuring patient-caregiver experience is smooth, there are 33 measures defining the roadmap to success for an ACO. And all of this could be realized well within the benchmark, if only ACOs had the visibility they needed.

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“Where do we go from here?”

The National Association of Accountable Care Organizations (NAACOS) estimates that setting up an ACO costs almost $1.6 million on average. After this huge investment, it would probably be the last thing on the minds of ACO leaders to stand before a dead end.

To generate sustainable outcomes in the evolving value-based healthcare, ACOs need to gain a clear understanding of where they are and where will they go. An in-depth analysis of the financial resources and the growth opportunities of the network are crucial for ACOs to learn how they can grow.

Leveraging the power of data

To learn where you are and what lies ahead of you, a good place to start looking is the data. The combination of clinical, claims, billings, and all the other kinds are easily available to ACOs, and leveraging them could be of tremendous value. The ACO leaders can meaningfully analyze the bunch of data around them to understand their patient population, areas of cost, and where significant revenue is getting lost.

Usually, one of the significant challenges ACOs face is capturing the data. Healthcare data is so disparate that before anyone even begins to make sense out of it, it has to be normalized from all the different formats and put together in a way that is understandable. A common starting point is to implement a healthcare data platform, which pieces together fragmented data from across the network and conducts meaningful analyses on the data sets.

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ACOs can learn more about the health of their patients to optimize their case mix. Additionally, ACO providers can take a look at the in- and out-of-network activities, gaps in care for patients, and drivers such as ED utilization, SNF visits, and cost-episode variations in the network on the healthcare data platform.

Analysing your own performance to unlock ‘opportunities’

A good place to start looking is the data. An even better place is to look at the data submitted to the CMS. True, the amalgamation of clinical and claims data can reveal significant insights into the network’s activities and every facility but the quality-reported data alone can kickstart your initiatives.

After all, your reported data is a reflection of your network’s performance. A robust analysis of over-the-years performance data can reveal instrumental details into what opportunities lay ahead of you and how they can be realized, and even how much impact can be created if the ACO streamlined their efforts at their maximum capacity.

The real value of analytics- for both building the competencies to generate savings and remaining financially viable- is how an ACO prioritizes its resources on the highest-impact areas. Considering what issues need to be checked off the list first and how major cost drivers have to be mitigated is the starting point on the long way to making healthcare accountable, and if ACOs kick off with this trend- others will follow.

To learn how a healthcare data platform can help you realize the gaps in the your network, get a demo.

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Sandeep Gupta

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