Accountable care organizations participating in the Medicare Shared Savings Program have only modestly lowered the program's spending overall. They saved the program about $314 million in 2017, which is a fraction of Medicare's total spending of nearly $706 billion that year.
But certain ACOs have done better than their peers. These high-performers that have both reduced Medicare spending while still providing high-quality healthcare have a few things in common. They all work with doctors to increase their awareness of what medical services cost, while also encouraging patients — particularly those with costly chronic conditions — to get involved in their own healthcare.
Many of the top ACOs also help patients avoid unnecessary hospital visits while coordinating their transitions to a skilled-nursing facility or back home if they are hospitalized. They share data between providers and make sure to address patients' behavioral health and unmet social needs.
These strategies were outlined in HHS' Office of Inspector General's latest report released Wednesday that examined how 20 of the top ACOs managed to lower Medicare spending while improving care.
"While there isn't a one-size-fits-all solution, it shows that it's possible to adopt commonsense strategies that can help us move from a from a fee-for-service system to value-based care," Meridith Seife, the OIG's deputy regional inspector general, said of the findings.
The OIG made a number of recommendations to the CMS based on its review. They included sharing successful strategies that reduce spending and improve quality among ACOs, while also reviewing the impact of certain program changes on ACOs' ability to promote value-based care.
Late last year, the CMS overhauled the Medicare Shared Savings Program to require ACOs to take on risk sooner. Of the 561 Medicare ACOs that participated in the program last year, 82% were in an upside-only risk arrangement. Fewer ACOs joined the program for this year's July 1 start date, but more of them are taking on risk than in previous years. The CMS expects the change to lead to more savings for Medicare.
The ACOs reviewed by the OIG ranged in size, location, risk-arrangement and composition. But to some degree they all agreed that working with physicians in the ACOs was critical to their success. That's easier said than done — physicians are often unaware of what services cost and overburdened by administrative tasks.
Some high-performing ACOs responded to those challenges by recruiting physicians who had experience with an alternative payment model or showed a commitment to lowering costs and improving quality. Almost all of the ACOs provided doctors with data about their own practices and referrals to increase their awareness of the cost of services and reveal any gaps in care, according to the report. A number of them also educated physicians with unusual spending or utilization trends.
The OIG also found that the top organizations made it their mission to engage patients.
"Almost every ACO talked about the importance of annual wellness visits," Seife said.
Wellness visits help physicians build relationships with patients and get them involved in their health, the ACOs said. One ACO in the report tracked down Medicare beneficiaries who had not received a wellness visit and helped them set up appointments. That helped it increase the rate of those visits to more than 50% in 2017 from 15%, and found that those patients who had a wellness visit saw their physicians more often throughout the year.
Although many of the ACOs said they teach their patients how to manage chronic conditions, such as diabetes, most also used care coordinators to monitor the patients, help them transition from one care setting to another, and schedule needed appointments.
One ACO asked patients with certain chronic illnesses to call and report their health status to a care coordinator every day. The strategy led to 43% fewer ED visits and 47% fewer hospital readmissions in the second year of the program, according to the report.
Managing hospitalizations was another ACO priority, given that hospital care accounts for the biggest source of Medicare spending.
"ACOs were noting that it's often really hard to engage hospitals, largely because they have little incentive to lower costs," Seife said.
Often the top-performing ACOs would bring hospitals into their networks or even embed hospitalists to look after patients and ensure smooth transitions. A lot of them attempted to prevent hospitalizations by expanding office hours, staying open on the weekends or offering same-day appointments, according to the report. Similarly, ACOs embedded staff in skilled-nursing facilities or home health agencies to improve patient care.
In its report, the OIG also explained that the top ACOs understood the importance of addressing patients' behavioral health and unmet social needs. Some used telemedicine or hired behavioral health specialists to address shortages of those providers, and several integrated those needs into their primary-care services. Many of them also incorporated nonmedical staff, such as social workers, to help connect patients with community services that can help with housing, food and transportation needs.
Lastly, the OIG noted that while sharing medical information across providers is important to coordinate care, the clinicians' various electronic health records aren't always compatible. Some ACOs are getting around that obstacle by moving all of their providers to one EHR or sharing information in a different way, such as through a secure messaging system.
"These are the things happening at the ground level and they often don't know about each other, so it's important to share that information," said Judy Kellis, the report's lead author. "It has wide applicability to other providers participating in other ACOs in the commercial markets and Medicaid, as well as providers that are just trying to provide good care."