Seven Success Factors for Accountable Care Organizations

With hundreds of accountable care organizations (ACOs) now serving both Medicare beneficiaries and commercial health plan enrollees, enough critical mass exists for health services researchers to study what’s working—and not working—to improve care and reduce costs. In fact, only 37 percent of ACOs surveyed by the Premier Research Institute described themselves as “high performing.” Some 42 percent described their performance as “moderate,” with 16 percent acknowledging they’re “challenged to perform as an ACO.”

With that room for improvement in mind, here are seven ACO success factors identified in recent reports, surveys and published research articles.

1. Integrate pharmacists into primary care based ACOs

That’s the conclusion of a report in the Journal of Managed Care and Specialty Pharmacy. In the report, researchers said pharmacist-provided care “has the potential to positively affect ACO quality benchmark measures.” They identified five opportunities to do so in the primary-care setting: medication therapy management (MTM), annual wellness visits, chronic disease state management, chronic care management and transitions of care.

2. Adopt and execute a formal plan to manage ACO enrollee drug costs

Only 35 percent of ACOs have a formal strategy to manage their pharmaceutical expenditures, according to a survey of 141 ACOs by the Pharmacy Benefit Management Institute. According to the survey results, 54 percent don’t have a formal strategy in place with 11 percent saying they’re not sure. “Having a comprehensive medication management program is considered one of the most effective approaches to address the rising costs of drugs in a variety of delivery systems, including ACOs,” the report said. Some 63 percent of the surveyed ACOs employ or contract with pharmacists who provide a variety of medication services to enrollees, including MTM, polypharmacy management, patient education, dispensing medications, medication adherence, transition of care and vaccinations.

3. ACOs can reduce medical costs without increasing drug costs

That’s the conclusion of a study in the journal Medical Care. In the study, researchers compared the cost of treating more than 300,000 Medicare beneficiaries in an ACO in 2012 with that of more than 500,000 beneficiaries not in an ACO that year. The researchers looked at per person annual Medicare Part D spending, total 30-day prescription drug counts, percent of brand-name drugs used and annual Medicare Part A and Part B spending. They found that ACO enrollees incurred $345 less per person in Medicare Part A and Part B spending with no significant impact on Part D spending, total prescriptions filled or brand-name drug use. “This is encouraging because it demonstrates that ACO providers may be prioritizing their focus on beneficiaries with multiple chronic conditions,” the researchers said.

4. Use of care management can reduce ACO enrollee hospitalizations and emergency room visits

That’s according to a study in the journal Health Affairs. In the study, researchers reported the impact of using care management by one Medicare ACO on enrollee hospitalizations, visits to the hospital emergency department and overall spending. The ACO identified ACO enrollees at high risk for future spending whose risk could be mitigated by care management services. They found that the use of care management reduced the targeted enrollees’ hospitalization rate by 8 percent, emergency room visit rate by 6 percent and Medicare spending by 6 percent. “Targeting beneficiaries with modifiable high risks and shifting care away from the ED represent viable mechanism for altering spending within ACOs,” the researchers said.

5. ACOs should give physicians more tools and resources to improve the quality of care to enrollees

If ACOs are to succeed at improving clinical outcomes and lowering costs, then their participating physicians need better tools and resources to make it happen. That’s the message from a survey of about 1,400 doctors participating in three types of Medicare ACOs: Pioneer, Medicare Shared Savings Program and Advance Payment Model. Researchers reported the results of their ACO physician survey in Health Affairs. In the study, researchers asked the doctors whether four specific tools and resources improved the quality of care provided to ACO enrollees. The tools and resource were: care management tools to identify high-risk patients; care support resources like case managers to work with patients on their health behaviors; information on clinical guidelines or best practices in care delivery; and performance feedback reports that compare their treatment results with those of other physicians. When asked whether the four tools and resources improved care “a lot” or “somewhat,” care management ranked first followed by care support, information on clinical guidelines and performance feedback reports.

6. Reducing physician and beneficiary turnover can help ACOs reduce medical costs

That’s the takeaway from another study in Health Affairs. In the study, researchers documented the turnover of participating physicians at one ACO from 2012 through 2014. They found that more than half of the ACO’s doctors either joined (41 percent) or left (18 percent) over that three-year period. When doctors joined, so did most of their Medicare beneficiaries. And when they left, so did most of their patients. The churn made sustainable interventions to control costs more challenging. “These findings may help explain the muted financial impact ACOs have had overall, and they raise the possibility of future gaming on the part of ACOs to artificially control spending,” the researcher said.

7. ACOs eye telemedicine and behavioral health as services to expand access and interventions

Some 48 percent of the ACOs surveyed by the Premier Research Institute with support from the Robert Wood Johnson Foundation said they offer telemedicine or home visits to ACO enrollees. Another 33 percent said they plan to do so within the next six months. Another area ACOs will be expanded into is physical and behavioral health services. Some 43 percent said they offer them now with another 29 percent planning to do so in the next six months.

Keeping enrollees healthy and enrollees with chronic illnesses as healthy as possible is the key to clinical and financial success for ACOs. As the above seven reports, surveys and published research articles show, getting there can take a variety of paths, from employing pharmacists to aggressively applying care management to expanding behavioral health services.