Washington, D.C. -- Accountable care organizations (ACOs) have potential to care for the nation’s seriously ill patients at lower costs and improved quality, but few are taking steps to do so, according to new research conducted by the Duke-Margolis Center for Health Policy and Leavitt Partners.
The research appears today in the June issue of Health Affairs, and is based on a national survey and interviews with 53 leaders at six diverse ACOs. It will be presented to agency officials, congressional staff, scholars, health care policy professionals and members of the news media, along with several other papers from Duke University faculty and staff, at a June 4 Health Affairs briefing on Community Care for High-Need Patients in Washington, DC.
ACOs, which care for more than 32 million patients nationwide, are groups of doctors, hospitals and other health care providers who provide coordinated high-quality care to their patients. A leading alternative to the fee-for-service payment model, these organizations are designed to improve value and quality of care through financial and other incentives.
According to the researchers, ACOs are ripe to improve the care of people living with serious illness for two reasons. First, hospitalizations and emergency room visits at the end of life are often unnecessary or harmful, and the ACO model supports the care coordination necessary to prevent these inappropriate visits. Second, the ACO model offers flexible spending of Medicare dollars to pay for important serious illness services that fee-for-service does not cover.
The national survey found that 94 percent of ACOs worked to identify their seriously ill patients. Yet only 8 to 21 percent widely implemented serious illness initiatives, such as advance care planning or home-based palliative care.
The interviews identified paths for success as well as challenges ACOs face in caring for patients confronting serious illness, defined as patients with high risk of mortality or multiple chronic diseases, heavy use of health care, and limited function.
Keys to successful programs included:
- Upfront investment: ACO infrastructure can cost up to $1 million or more, and additional infrastructure for serious illness care requires additional capital. Data infrastructure and a workforce to identify and care for the seriously ill patients were singled out as particular needs. A key element of success was building on prior infrastructure. Many ACOs were able to extend prior efforts in complex care management and value-base care redesign by developing care programs for seriously ill patients.Also important to success was the ability to connect patients to existing community resources that address social drivers of health (e.g., legal assistance, food insecurity, housing, and transportation), along with hiring social workers or community health workers.
- Business plan and organizational buy-in: The fact that many ACOs identify seriously ill patients but have few dedicated care programs suggests that the business case for serious illness care is often underdeveloped. Short-term data derived from serious illness care efforts, however, resonated with leaders and helped with organizational buy-in. Importantly, the mission to care for seriously ill patients is also a big motivator for providers, staff and many leaders: “We’re just doing it because it’s the right thing to do. Period. For the patient,” stated one interviewee.
- Data and health information technology: Capturing actionable data to identify and track seriously ill populations is still a work in progress, most interviewees noted. However, ACOs found data dashboards helpful in tracking important serious illness care metrics and helping to schedule and coordinate patient care across different settings.
- Context matters: ACOs in rural or poor urban areas had greater difficulty investing in new initiatives to care for seriously ill patients due to resource constraints.
“The untapped potential of ACOs to improve serious illness care underscores the need for a better understanding of organizations that do this well,” said lead author William Bleser, a research associate at Duke-Margolis. “We did observe that success in caring for these populations can occur in diverse settings, regardless of geography, rurality, payer, organizational size or leadership structure.”
“High serious illness performance is affected by a range of policy and regulatory issues,” said David Muhlestein, chief research officer at Leavitt Partners. “These include calculating shared savings in ways that properly assess the health status among seriously ill patients, the need for better quality measures to evaluate care for this population, and the vital importance of accessing timely, actionable data about these patients.”
The national survey, the ACO interviews and the analysis of this research were supported by a grant from the Gordon and Betty Moore Foundation.