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ACOs: What we know, where we stand and what’s next

5 min read


This post is sponsored by Orion.

Accountable care is one of the biggest, most rapidly evolving areas of health care innovation right now. For an update and a look ahead, Accountable Care SmartBrief interviewed two experts in the field, Aparna Higgins, Senior Vice President of Private Market Innovations and Director of the Center for Policy and Research, and Kirstin Dawson, Senior Director of Private Market Innovations with AHIP.

Question: This was a big year for collaborations between insurers and providers. What have we learned as these collaborations have developed?

Answer: The partnerships between insurers and providers have highlighted the importance of the providers’ need for timely data that supports health care decisions and interventions. Claims data and the analytic reports generated from that data help identify gaps in care and opportunities for improvement. This type of meaningful data exchange is essential for providers and health plans to be successful in coordinating care and achieving positive outcomes for patients.

An increased emphasis on data is important from a consumer perspective as well.  Consumer use of information through health insurer transparency tools and shared decision-making platforms helps inform their treatment decisions and choice of providers.

Q: Are there still some universal barriers to advancing value-based care, and if so, what are they?

A: The health care system has made great progress in advancing value-based care. However, some challenges still remain to achieving a complete transition to a value-based health care system. For example, there are still significant opportunities to improve health information exchange and the interoperability of health information technology to facilitate the two-way flow of information necessary to support decision-making and care coordination. Alternative care models such as accountable care and patient-centered medical homes need data analytics capabilities and access to patient registry tools and evidence-based guidelines to more effectively manage population health, but each of these systems are designed without the other in mind, which can lead to costly IT patches and additional administrative costs to transfer data across settings and providers.

In addition, measurement gaps exist in a number of areas, including patient-reported outcomes, certain areas of specialty care, cost of care, resource use, and shared accountability and decision-making across the care continuum. It is essential to advance efforts to develop metrics in these areas to provide a more robust platform for value-based care.

Q: Can you provide a little insight into some of the most innovative experiments in care delivery you’ve seen?

A: The variety and depth of care delivery reforms being implemented by our member plans is truly impressive. Their efforts cut across various models such as accountable care, patient-centered medical homes and bundled payment strategies. These strategies are built on a collaborative, provider-health plan partnership, and they are flexible enough to be customized to meet providers’ level of readiness to participate in these models. Noteworthy elements of some of these collaborations include the use of virtual provider networks, where a group of physicians agree to “virtually connect” to provide patients with increased access to timely care and better care coordination; targeting of high-cost specialty care by utilizing evidence-based clinical pathways to improve clinical outcomes for cancer and cardiology care; and integration of prevention, behavioral health and long-term care to ensure a more patient-centered approach.

Q: What policy measures are needed to advance innovations in health care delivery?

A: Given the success of value-based care models in the commercial population, flexibility at a federal level is necessary to test and implement innovative strategies that can further enhance value and better align practices and quality standards among the commercial, Medicare and Medicaid populations. These could include:

  • Allowance for the use of remote access technologies, especially in rural areas.
  • Better integration of long-term services and supports as well as behavioral health into Medicaid health plan benefits.
  • Greater flexibility within existing federal program criteria to allow for increased beneficiary engagement in innovative models.

Q: Health insurers, policymakers and providers are all working to shift the conversation in health care to preserving wellness rather treating disease as part of a more sustainable model. How are stakeholders engaging patients in this conversation?

A: Health plans engage patients in a variety of ways through the utilization of wellness programs, which tie health risk assessments to specific wellness interventions such as education, health coaching and tools to help members achieve fitness and nutrition goals. For patients diagnosed with chronic illnesses, health plans provide care management to assist in managing the clinical condition, prevent secondary conditions and improve quality of care for the patient. Additionally, health plans increase patient access to care through the coverage and reimbursement of retail clinic visits, use of remote monitoring and alternative physician access points such as email and video.

While these tools are intended to assess and meet the needs of the patients in order to improve their quality of life, limitations of wellness programs still exist. A 2013 study commissioned by the U.S. Department of Labor found that while almost half of U.S. employers offer wellness promotion initiatives, the effect is generally small. The study found that less than one-half of employees obtain screenings or complete a health risk assessment and one-fifth or less of at-risk employees actually engage in the available wellness tools.

More research is needed to understand wellness program limitations and patient engagement.