The Engelberg Center for Health Care Reform recently hosted “The State of Accountable Care: Evidence to Date and Next Steps” to discuss the development, challenges, and potential future for accountable care efforts across the country. Sean Cavanaugh, Deputy Administrator & Director of the Center for Medicare at CMS, kicked off the event, and highlighted progress and challenges of the Medicare ACO program and potential regulatory changes that could be included in the soon to be released Medicare Shared Savings Program (MSSP) proposed rule.
A Key Takeaway: Patient Engagement is Critical to the Success of ACOs
The need for greater patient engagement was a prevailing theme of the day for ACOs at Brookings. Patient engagement is viewed as a key to improved health outcomes and lower costs; well-designed patient engagement strategies can also improve patient experience by allowing individuals to become more active participants in their care. For example, shared decision making and patient activation are proven strategies for engaging patients at the direct care level. These approaches help providers and patients to recognize that a clinical decision is necessary, understand the evidence on best available interventions, and ensure patient preferences are built into treatment decisions and plans. A recent study by Jennifer Sweeney and colleagues highlights some successful examples.
Several examples of effective strategies for engaging patients with chronic disease were highlighted at the Brookings event. Kelly Taylor, Director of Quality Improvement at Mercy Clinics, highlighted Mercy’s chronic disease outreach program, which employs health coaches to motivate patient behavior change. The program creates actionable lists for patients due for hospital visits, helps with coordinating care transitions, and conducts pre-visit and post-visit assessments. Patients that receive these services typically score in the 90th percentile for HEDIS measures, such as control of blood pressure and blood sugar levels. A financial analysis demonstrated that for every dollar spent on the health coaching program, four dollars in revenue is received.
Morey Menacker, President and CEO of Hackensack Alliance Accountable Care Organization discussed Hackensack’s remote monitoring and care management tool that allow patients to monitor their diseases in their own homes. This program has contributed to a reduction in unnecessary hospital visits and improvement in patient self-management.
A number of organizations have also used web-based tools such as online or smartphone applications for patient engagement purposes. For example, Beth Israel Deaconess Medical Center developed patientsite.org, an interactive web-based portal decision aid giving patients access to their clinical records and the ability to check accuracy of allergy and medication lists. A recent study of 30,000 patients found that even after adjusting for health status and other factors, patients with the lowest activation scores incurred costs of 8 percent to 21 percent higher than those with the highest activation scores. Despite these encouraging innovations, more work is needed to empower patients in health systems across the country.
ACO Attribution: A Challenge for Engaging Patients
Over the next twenty years, we will see the baby boomer population inflate the number of Medicare beneficiaries by 60 percent; increasing from 50 million to 80 million. This statistic, emphasized by Cavanaugh, underscores the need to engage these patients in their care through more innovative approaches. If not, “slipping through the ACO cracks” will become all too real for too many patients.
While ACOs acknowledge they have work to do to more fully engage patients in their care, they also point out that program design issues need to address patient engagement. For example, a major fault in the MSSP patient attribution process is that some patient may not be aware they have been assigned to an ACO. In this case, they may seek care outside the ACO network of providers and in fact be assigned to a different ACO from year to year. Most importantly, there are no incentives for patients to remain loyal to an ACO when the attribution process does not reflect patient preferences.
Recent research highlights concerns with current approaches to patient attribution in ACOs. A recent study by Harvard Medical School researchers analyzed whether, over a two year period, Medicare beneficiaries would continue their care within their attributed ACO, or seek medical attention outside the network. Approximately 80 percent of beneficiaries would have chosen to remain with doctors inside their ACO. Not surprisingly, the research indicates that primary care doctors have more “sticking power” than specialists, who would have lost 66 percent of their beneficiaries to competitors outside the ACO. More worrisome, however, was the finding that most of the beneficiaries that strayed from the ACO were those with chronic conditions. ACOs need to address the fragmented system and consider why they are unable to retain so many high-risk patients.
The potential turnover of ACO-attributed patients from year to year (or patient churn) warrants attention, but little evidence exists to suggest that patient dissatisfaction is the cause. In fact, Medicare ACOs are achieving overall high performance on patient satisfaction measures to date. So far, there is no clear relationship between patient satisfaction measures (CAHPS) and turnover. However, it is not unreasonable to assume that more direct patient engagement in selecting an ACO might reduce patient turnover.
Policy and Regulatory Solutions
There are a number of structural adjustments that CMS could make to the MSSP program to more effectively engage patients through financial and other incentives.
- Provide financial incentives for beneficiaries: These incentives may include reduced co-pays or deductibles for choosing providers within the ACO network or other high-performing or high-value providers. ACOs could also provide rebates or extra benefits to patients who successfully adhere to medications or provide additional discounts to patients who meet specific outcomes, such as reduced BMI or blood pressure control. Finally, beneficiaries could potentially share in some of the savings generated by the ACO, assuming that they meet a set of patient requirements or compliance metrics. While allowing patients to share in savings would be a more complex and controversial proposition, it could transform how patients think about ACOs and their own personal behavior to improve their health.
- Implement “Welcome to ACO visits” (similar to a “Welcome to Medicare visit”): These visits could provide an opportunity for ACOs to educate patients about the benefits of being in an ACO. Patients could learn how an ACO model will affect the care they receive, and how patients can become more activated and engaged.
- Transition away from the current attribution model to allow beneficiaries to actively and directly enroll in an ACO: Active enrollment could enhance patient commitment to organization, and help them better understand the implications for their care. Potential challenges to this approach include increased opportunity for adverse selection (unhealthy patient disproportionately enrolling in the ACO, thereby disrupting the overall risk pool) and not enough beneficiaries agreeing to join the ACO. While adverse selection could be addressed through additional technical changes to the program (e.g., more frequent updates to benchmarks, etc.), without a sufficient patient population, the ACO would likely not succeed. Furthermore, it is not clear how such a model would differ significantly from current Medicare Advantage and why patients would choose to join an ACO over an MA plan. We may soon have a better idea of whether an enrollment model will work; the CMMI has launched a demonstration program with a selected number of Pioneer ACO participants to test whether and to what extent beneficiaries will elect to enroll in an ACO, and what the consequences may be on the ACOs population and performance.
Patient engagement interventions and programs highlighted during the recent Brookings event are encouraging, but much more work needs to be done. Effectively engaging patients will require ACOs to think differently about what patient engagement really means; it will also require a willingness and desire on the part of patients to become more engaged as active participants in their care. A regulatory environment that encourages provider organizations to pilot new approaches to patient engagement, including innovative financial and other incentives, could be a starting point for innovation in patient engagement. The health care system will not be transformed without the patient; moreover, the real promise of ACOs—continuous improvements in quality and reduced costs—cannot be realized over the longer term without more active involvement of patients in their care.