Savviest ACOs Leverage Health Plan Resources

Dawn Milstead, BSN, MBA

More than ever before, physicians and health plans have compelling reasons to work together to achieve the Triple Aim, which means improving consumers’ health outcomes, their experience of care, and the costs associated with that care. In the years since the Affordable Care Act was enacted, value-based care models that more closely align providers and health plans with the shared goals of improving healthcare quality and cost have gained traction.

As of the end of January 2016, Leavitt Partners, in partnership with the Accountable Care Learning Collaborative, identified 838 active accountable care organizations (ACO) serving 28.3 million people, a 12.6% increase during 2015. More than 1,000 partnerships are currently negotiating ACO contracts, suggesting that the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is incenting even more physicians to form ACOs.

ACOs are one of many types of value-based care models. Nearly all health plans (93%) surveyed for a Deloitte 2015 study of Medicare Advantage plans and providers said they have some type of value-based arrangement in place, such as patient-centered medical homes, global capitation, and bundled payments.

At the same time, there is increasing evidence that people with chronic diseases are the ones driving healthcare costs. The Centers for Disease Control and Prevention estimates that treating people with chronic diseases accounts for 86% of our nation’s healthcare costs.

A new study from the American Health Policy Institute (AHPI) found that high-cost claimants—those employees whose healthcare costs exceed $50,000 per year—cost, on average, $122,382 annually or 29.3 times as much as other members. They represent a disproportionate 31% of total health spending. (As expected, the percentage for Medicare beneficiaries, 44%, is notably higher.) The study also determined that 52.6% of high-cost claims are for chronic conditions such as heart disease and diabetes. Most of these conditions could benefit from care management programs. In fact, care management is one of six strategies recommended in the AHPI study.

Putting care management to work

Broadly defined, care management programs identify high-need and high-cost members who are then matched with a personalized care team that helps coordinate care; the care coordination addresses not only medical needs across care settings, but also behavioral and psychosocial needs.

Health plans have a long history of allocating significant resources to comprehensive care management. Most plans have a dedicated team of clinicians, including disease managers, case managers, health coaches, and social workers, who work directly with chronically ill and at-risk members and their providers to help them manage their own health, facilitate transitions of care, and support their navigation through the healthcare delivery system. The average regional health plan with 750,000 to 1,000,000 members has between 60 and 100 case and disease managers, all clinicians who can complement the efforts of providers to manage and improve patient health.