Thriving Under the New ACO Program: How Technology Can Pave the Path to Risk

In our first blog on Pathways to Success, posted right after CMS released the final rule in December, we discussed the challenges around the program’s accelerated path to risk and how to assess an organization’s appetite for risk when weighing the decision to participate. We also laid out a high-level strategy to prepare less experienced ACOs for the higher-risk/higher-reward program. With the first agreement period for Pathways fast approaching, many ACOs are now scrambling to get the appropriate infrastructure in place. To help them prepare, in this blog we’ll take a more in-depth look at one component of our suggested strategy for managing more lives and ramping up on risk more quickly: investing in care coordination technology powered by real-time data.

A Brief Review of the Program’s Goals and Structure
The reason CMS has taken a more aggressive stance with Pathways than with its predecessor, the MSSP, is that value-based payment models seem to be most successful at reducing healthcare costs when providers have skin in the game—that is when they take on downside risk. The new rule limits the time frame ACOs are permitted to take upside-only risk from six to two years (with some exceptions). Tracks 1, 2, and 3 have been replaced with the BASIC and ENHANCED tracks, and all ACOs are expected to eventually transition to the ENHANCED track that has the highest level of risk and potential reward. CMS projects that Pathways will bring in an overall Medicare savings of $2.9 billion over 10 years.

In addition to cost reduction, another primary goal of Pathways is to enhance the quality of care available to Medicare patients. To this end, CMS has included a set of waivers and incentives in the program that are designed to allow organizations that take on downside risk to be more innovative in their approaches to care. These include the 3-day SNF waiver, the telehealth waiver, and the beneficiary incentive program (learn more in our previous blog).

Technology’s Role in Preparing to Ramp up Risk
With so much more on the line under Pathways, it’s imperative that participating ACOs be able to closely monitor every life they’ve taken responsibility for. Care coordinators need to be armed with tools that give them visibility into all care settings across the continuum—so that they are aware of what’s happening with patients in real time and intervene as needed to redirect care and improve outcomes. Ideally, all provider organizations that are a part of an ACO would be using the same care coordination platform to facilitate easy data sharing across settings, clear communication between providers, and seamless care transitions for the entire patient population. Along with these overarching goals, next-generation care coordination technology can also help ACOs meet and exceed specific benchmarks on key metrics such as readmission rates and length of stay.

Reducing Hospital Readmissions and Decreasing Length of Stay
Medical readmissions are extremely common for Medicare’s high-risk patient populations, but most come with a penalty, so ACOs entering Pathways need to find new strategies to intervene and prevent those that are unnecessary. Avoiding readmissions starts with getting patients to the highest quality providers post-discharge. Today, care coordinators primarily track and follow up on patients by phone and fax, which is both time-consuming and inefficient. The delay in receiving information is truly problematic, because once a patient has been admitted to the hospital from the ED, it’s too late to impact the course of care, even if a post-acute facility or home care would be more appropriate. To effectively reduce these preventable readmissions, care coordinators need access to real-time data, and they also need tools that help them leverage that data. It should be organized in an easily digestible way and presented contextually through a user-friendly interface. Products like CarePort Guide are the starting point – an easy-to-use search engine for finding the highest quality and most clinically appropriate providers. CarePort Connect is specifically designed to support busy care coordinators and case managers who need to be able to understand the story the data is telling at first glance. Rather than being shown in isolation, an event like a readmission is shown alongside other recent patient events to paint a complete picture of health.

Length of stay (LOS) is another key metric for ACOs under Pathways. When patients are discharged from the hospital and transition to post-acute facilities, which is quite common among Medicare patients, case managers need to keep an eye on LOS to control costs. Connect allows case managers to look at individual patients and automatically issues real-time alerts when LOS is exceeding the expected time based on the patient’s discharge disposition. Such alerts are truly valuable to these busy professionals. CarePort Insight provides a population-level view of LOS and other metrics with easily generated custom reports that can be filtered by whatever is important to the ACO—provider, patient type, condition, or some other characteristic. Unlike claims data, which is typically six months old, or provider self-reporting, which comes with its own set of issues, these reports are completely objective are accessible without any lag time.

Sharing Data and Best Practices Across a Network
Beyond its daily value for individual patients, technology powered by real-time data is also helpful when it comes to identifying gaps in care and managing an ACO’s population. These organizations need to aggregate patient data over time and review it within the context of critical benchmarks to improve care quality while decreasing costs. Population-level data is the best indicator of which areas require improvement within the organization, as well as where in the system resources are most needed. It’s vital that this data be shared in real time and across the entire care continuum, so that problems are identified quickly and providers can collaborate to solve them. The ability to discern and respond to patterns in specific clinical cohorts (e.g., patients managing complex clinical conditions like COPD or diabetes) will be especially valuable to ACOs as they take on more risk under Pathways. Population-level data can also help ACOs manage their post-acute networks and identify post-acute providers offering the highest quality of care.

Steering ACOs toward two-sided risk is part of a larger dynamic to promote accountability, improve the quality of healthcare, and transition to a more competitive marketplace. While this puts more pressure on ACOs, it also gives them more opportunities to share in savings.

Learn more about CarePort’s suite of data-driven tools to support ACOs transitioning to Pathways.