By Andy Aroditis, NextGate
Accountable care organizations (ACOs) are playing a critical role in supporting their communities in the face of the pandemic. ACOs have diverted significant tools and resources to identify high-risk populations, expand telehealth services, and provide post-acute care management for COVID-19 positive patients.
The lynchpin of the ACO is the fact that every provider is responsible for a defined, assigned population of patients. The provider is accountable for the spending and outcomes of those members regardless of the patients’ preexisting diagnoses, their socio-economic challenges, or when and where they seek care.
This creates a very strong incentive for providers to take an active role in managing patients and redirecting individuals to the most appropriate, cost-effective facility for their needs.
While it may seem easy enough to go down the list of attributed patients and check off care management tasks one by one, the reality of the current healthcare environment makes accountable care anything but simple.
Fragmented and siloed health IT infrastructure can often prevent efficient communication within the ACO. Many providers still lack insight into clinical risks and gaps in care for their patients. And because patients are free to visit providers outside of the ACO at any time if they wish, it can be difficult to identify and control activities that take place in other settings.
In light of COVID-19, ACOs have several additional concerns: educating patients about the virus, triaging members with symptoms, identifying recently hospitalized individuals, and following up with appropriate transitional care management after hospital discharge.
To overcome these challenges, ACOs need to understand their members’ clinical status, potential health risks, and the spending patterns that go along with them.
The journey to shared savings begins by developing complete visibility into an ACO’s attributed population. A comprehensive patient identity management strategy is one of the most important components for success.
Creating Confidence In An Attributed Patient’s Identity
Even within the same provider organization, duplicate records and incomplete or outdated information are commonplace, with some healthcare systems experiencing error rates in the double digits.
COVID-19 is further complicating matters. While hospitals and frontline care workers just try to cope with the influx of patients, urgency to meet demands means that basic demographic data elements needed to track and manage COVID-19 patients effectively are not being captured. According to the Council of State and Territorial Epidemiologists (CSTE), 80 percent of coronavirus tests nationally are missing demographic information.
The ACO environment can magnify these issues dramatically. Participants may be using different EHRs and other health IT tools to manage their patients – and each of these systems may have a different way to generate medical records and share information.
Coordinated access to patient data ensures that individuals, especially ACOs’ most vulnerable populations, get the right care at the right time—avoiding unnecessary duplication of services and medical errors. The growing number of diverse data sources spread out over various providers and locations in the ACO network produces volumes of duplicate medical records and fragmented patient information. As more members join the network, the greater the risk for deterioration in the accuracy and completeness of a patient’s care history.
In any ACO, nearly half of patients are out of network, so patient identification and interoperability are difficult, but critical, components in managing populations that support value-based programs. To help its members thrive in the transition toward value, ACOs must consider patient identity management tools beyond the EHR to connect stakeholders to an enterprise-level. Investing in such tools helps ACOs to identify at-risk patients and work with their communities to proactively treat individuals before they enter a hospital or long-term care facility.
Reduction in duplicate records also allows the ACOs to feel certain about the number of patients they are serving, the health of each individual, and the spending associated with their beneficiaries. Additionally, it helps ACOs be sure that they are getting the correct credit for their clinical and financial improvements without being penalized for gaps in care that have been closed.
Collaborating Within And Across Organizational Lines
Providers must work effectively with their ACOs partners, but they also will need to communicate with an untold number of other organizations in the larger healthcare community.
“ACO leakage,” or the rate at which patients visit providers outside of the ACO, is a major problem for most groups. Up to 50 percent of patients may be out of network, contributing to higher costs per beneficiary in Medicare ACOs.
ACOs have little control over these patterns, which has been a point of contention for many years. However, ACOs tackle this problem by using an EMPI platform to accurately integrate data from external entities into the correct patient records.
In addition to preventing the duplicate record rate from rising again, this strategy helps ACOs account for trends in out-of-network utilization. Providers with visibility into healthcare utilization may be able to suggest more cost-effective care alternatives to patients, such as making an appointment with a primary care provider instead of heading to the emergency room for a lower-level complaint.
Clarity around the entire scope of patient activities also will support more effective care management. In ACOs, primary care providers (PCPs) often act as the “quarterbacks” of patient care and take on the central role in care coordination and chronic disease management.
This role is even more important during COVID-19 when patients may experience a sudden hospitalization. PCPs must be able to communicate effectively with local hospitals so they can proactively reach out to people who need transitional care management services after leaving the inpatient setting.
Providers and researchers are still developing an understanding of the aftereffects of COVID-19, which can last for weeks or months in some patients. The ability to compile a complete and accurate clinical profile on each individual will help to inform future treatment protocols while ensuring that attributed members get the right care during recovery.
ACOs that equip PCPs with patient identity management tools that present internal and external utilization data will be in a better position to manage patient wellbeing in an informed and comprehensive manner.
The result is a better opportunity to reduce avoidable spending and improve quality while enabling patients to make empowered choices about when and where to access care.
Taking The Next Steps Into Personalized, Accountable Care
The ability to track individuals confidently and consistently across multiple clinical organizations can support the next phase of value-based care: integrating socioeconomic insights into the clinical care environment.
For many patients, regular screenings and chronic disease management need to be accompanied by broader efforts to address the social determinants of health.
Social determinants, including transportation access, food and housing insecurity, and interpersonal relationships, play a significant role in a patient’s ability to follow a care plan and maintain their wellbeing. Further, COVID-19 related illness is higher in areas with greater socioeconomic challenges.
ACOs are increasingly designing targeted interventions for these issues, such as collaborating with rideshare companies to provide non-emergency medical transportation or connecting families with food banks, housing resources, and other support services.
With clear insights into members and their activities across the clinical and non-clinical environments, ACOs can allocate their limited resources most effectively to reach even more individuals in need.
Getting ahead and staying ahead of the health issues and socioeconomic circumstances that impact outcomes depends entirely on knowing as much as possible about an ACO’s attributed population on a detailed level.
As value-based care initiatives become more popular in Medicare and the commercial insurance environment, providers that wish to take advantage of these opportunities should consider starting with a foundation of reliable patient identity management.
ACOs that adopt an effective patient identity strategy will be better prepared to adapt to the challenges of COVID-19, provide proactive care, foster better outcomes for their patients, control spending – and ultimately reap financial rewards for their participation in value-based care.
About The Author
Andy Aroditis is CEO of NextGate, the global leader in healthcare enterprise identification. He can be reached at email@example.com. For more information, visit www.nextgate.com.