ACOs Experience Unintended Consequences of Healthcare System Safeguards

We all are aware of the promise of ACOs.  By enabling physicians to manage the health of the population, the achievement of the triple aim (i.e., better care for individuals, better health for the population and lower growth – or a reduction – in healthcare expenditures) would finally be within reach.  Payers have proven over the years that they are not in a position to be able to achieve this lofty goal on their own.  However, payers and plan sponsors are in a position to enable the ACOs to be accountable for population health and to manage the associated risk by providing them with information – administrative claims data and the like – and analytical tools, clinical decision support capabilities and workflow solutions.  The movement “to arm” the ACOs has become wide-sweeping.

So what stands in the ACO’s way of capitalizing on all of the information and tools afforded them?  Depending on how the ACO is organized and its privacy program, certain privacy standards in place to protect patients may prevent ACOs from broadly viewing the care history of their patient population.  For instance, in some cases only the physician to whom the patient is attributed can see the care history for that patient.  Other physicians of the ACO, even those in management positions that have organizational responsibility to help their constituent physicians manage care, may not have access to a non-attributed patient’s care history they might otherwise use for purposes of improving the ACO’s systems of care.  And if the patient’s care includes certain sensitive services, such as behavioral health or infectious diseases, some state laws may restrict access to the related care history.  Healthcare payers, on the other hand, have broad access to the patient data they possess for their members.

Another system safeguard in place to protect physicians requires ACO physician performance data – quality and cost – to only be shared in limited views.   A common technique ACOs use to enhance outcomes is to have a physician leader/executive from the “community” share performance results with network providers.  In practice, when this comparative performance information is shared with physicians and their peers, it has been shown to improve results for the network.  Yet for ACOs and payers an individual physician’s performance cannot be shared in an open forum until he or she is first given a chance to understand and remediate (if necessary) their data.  This delay could cost the ACO months in their efforts to bend the cost curve, somewhat negating an advantage they have over payers to deliver such comparative performance metrics – physician to physician – in an expedited fashion.

Having all care (sans emergent and certain specialty care such as transplants) provided within an ACO’s network of physicians is a measure of strong care management.  Yet today, one of the biggest problems an ACO can encounter is care delivered outside its provider network (i.e., leakage) which can threaten its performance.  Detail on historical out-of-network care is necessary for the ACO to begin to repatriate services back within the ACO.  However, the ability for the payer to identify for the ACO where the out-of-network care is being delivered, how much is paid for that care and the associated quality of the care delivered is limited by traditional safeguards meant to protect the payer.  Therefore, in practice an ACO is unable to get access to leakage information it can immediately use to improve performance.  A payer, on the other hand, has full access to all leakage information – both for care delivered outside a specific ACO but within the payer’s network, as well as for care delivered outside the payer’s provider network.

As you can see, some of the traditional healthcare system safeguards in place to protect the patient, provider and payer can hinder an ACO’s operations.  Payers, in partnership with ACOs, are addressing these barriers and developing new ways to provide the necessary information while not violating these safeguards.   As the healthcare system continues to collaborate to achieve the triple aim, all parties just need to be mindful of these safeguards and innovate ways to enable ACOs.
–Joel Hoffman

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