4 questions to consider when working with a payer on an ACO

First up: Is your organization ready to invest in the necessary technology?
By Daniel Finke
10:44 AM

The shift to value-based health care models is gaining speed, and providers can prepare for the transition by assessing their own readiness and unique needs. The Department of Health and Human Services set a goal to have 50 percent of traditional Medicare's $362 billion in annual payments go to providers in value-based models by 2018.

The Health Care Transformation Task Force, which brings together patients, payers, providers and purchasers, has pledged that its members will put 75 percent of their business into these models by 2020. As a member of the task force, Aetna shares this goal.

Creating a sustainable business model in the era of value-based payments and care models depends not only on transforming, but also on growth. To enable growth, providers can align the value-based care contract model with their clinical model and state of readiness. There are four questions each organization should consider to determine the best path forward.

Four key questions to inform the accountable care journey:

1. Is your organization ready to invest in the necessary technology and tools?
 To begin, calculate the financial investment needed for population health. This involves assessing your organization’s alignment of people, processes and technologies across key functions. These functions include informatics, care management and patient engagement.

You can then identify major gaps in the shift away from volume-based care. This will help you develop a financial analysis and a transformational roadmap with priorities and timing to close gaps.

2. Are you prepared to design and implement an incentive structure that rewards doctors who meet quality, efficiency and patient-satisfaction measures? 
Assisting doctors in the transition to value-based care involves:

  • Engaging them in the development of new care processes that integrate the entire care team
  • Involving them in accountable care organization leadership to promote transparent practice patterns, quality and efficiency
  • Aligning payment and incentives with performance goals
  • As part of this effort, it is essential to deliver quality and cost metrics that help doctors accurately gauge their progress toward meeting targets.

3. How will you redesign your care delivery system to focus on keeping people well instead of a focus on sick care?Population health represents a new approach to care, and clinical and financial integration will help smooth the transition. Claims analytics can reveal where care protocols are widely inconsistent. You can then identify opportunities for improving efficiency and quality improvements through care coordination.

Care managers play an important role. Whether they are based remotely or embedded in the practice, these care managers can supply more consistency and coordination. This helps make the care delivery system more proactive and patient-centered. Simple care-access measures, such as longer hours for primary care appointments, can help to reduce emergency room visits.

4. What steps will you take to support and encourage growth? 
To succeed in adding new revenue streams, take measures to:

  • Expand your network strategically
  • Grow your patient base
  • Maximize in-network care delivery

It’s important to help affiliated providers in adopting your system. Analytics can reveal where patients are going out of the network for care. You can then take actions to reduce unnecessary out-of-network care. Payers can help drive patients to the ACO with referral management and strategies that build loyalty and attract new patients.   

Getting started in collaboration
As you begin your accountable care journey, look to payers for industry knowledge and assistance in assuming risk, expanding distribution channels and improving care coordination. By joining forces, you can also benefit from a payer's:

  • Expertise in financial risk management
  • Population health management tools, technology and expertise
  • Broad distribution channels to attract members
  • Insurance operations and administrative platform

Preparing for a value-based future
Early results show that value-based models improve clinical and financial outcomes. In September 2014, Centers for Medicare & Medicaid Services reported Pioneer ACO performance year-two results. ACOs generated estimated total savings of more than $96 million. They qualified for shared savings payments of $68 million and saved Medicare Trust Funds approximately $41 million. They also improved in 28 of 33 quality measures, with a general increase of 14.8 percent.

Collaborations between payers and provider organizations are evolving to generate real savings in this changing landscape. This can happen more quickly with full commitment on both sides of the collaboration. By taking the time today to assess readiness, deploy the right technologies and align new payment models with cost, quality and patient-satisfaction goals, your organization can take on more risk and prepare for a sustainable, value-based future in the coming years and beyond.