By Lynn Carroll and David Wolf

Accountable Care Organizations (ACOs) are increasing in popularity as healthcare organizations strive to improve care quality and operational efficiency. Data from the Centers for Medicare and Medicaid Services (CMS) shows that more Medicare patients than ever – nearly 13.4 million beneficiaries – are being cared for by ACOs this year. The largest ACOs serve Medicare recipient populations in the hundreds of thousands.

For ACOs and other risk-bearing providers, the emphasis on preventive care in Value-based Care (VBC) enables a healthier overall population. Preventive care is particularly impactful in the management of chronic conditions by helping to reduce claims for prolonged and expensive treatments. Chronic illnesses (including Alzheimer’s disease, cancer, diabetes, heart disease, and obesity) together account for 90% of healthcare costs in the U.S., according to data from the Centers for Disease Control and Prevention (CDC).

Critically, ACOs are financially accountable under the Medicare ACO program for the quality and cost of patient care they provide. ACOs in the Medicare Shared Savings Program (MSSP) or the Next Generation ACO Model can share savings with the government if they meet certain quality targets. MSSP saved Medicare $4.3 billion in 2022, with nearly two-thirds of the 482 ACOs in the program earning shared savings.

Medicare also offers shared-risk ACO models under which ACOs cannot only share savings with the government if they meet specified quality standards, but also would bear some financial risk should spending increase beyond a certain amount. In an industry where provider margins are thin, any risk poses a threat to an organization’s viability to sustainably deliver quality care and maintain a high standard of services.

For ACOs and other risk-bearing organizations, effective contract management in a VBC environment is imperative. Collaborative shared-savings and shared-risk organizations must be able to transmit and receive data within a scalable, multistakeholder network and facilitate payment capabilities across that network.

Indeed, transparency around payments is critical to the success of ACOs and other VBC models. It ensures a shared understanding and clarity around what is being measured, how it’s being measured, and the terms of the contract. Unfortunately, the limitations of legacy IT infrastructures long deployed by provider organizations make transparency around payments, data sharing, and collaborative care difficult and even impossible.

Actionable analytics require robust platform infrastructure
Most healthcare organizations lack the digital infrastructure necessary for VBC. “We can’t graft a new digital, platform-based healthcare system onto healthcare infrastructure designed to support traditional operations and care models,” writes Mayo Clinic President and CEO Gianrico Farrugia in an article for the World Economic Forum. “Healthcare needs transformation. And to truly transform healthcare, we must simultaneously build physical and digital frameworks to meet the evolving needs of patients worldwide.”

The good news is that healthcare organizations can implement VBC without resorting to a costly rip-and-replace strategy. Doing so requires a platform infrastructure to integrate the data layers seamlessly, then extend that data layer either as a DaaS (Data as a Service) or as a PaaS (Platform as a Service) so that partner firms and/or clients can use existing applications served up via microservices or extend/create microservices and business applications for their own needs. Such a platform should enable risk-bearing entities to collect and synthesize data (including unstructured data) from electronic health records (EHRs), pharmacy records, demographic information, and data on Social Determinants of Health (SDoH) to build a 360-degree profile of their patient populations and different cohorts, such as individuals over age 60 with three or more chronic conditions, for instance.

Generating actionable analytics helps ACOs and other risk-bearers develop targeted preventive strategies and collaborative care plans aimed at the highest-risk cohorts. By aligning primary with specialty care, ACOs can help patients with chronic illnesses better manage their conditions. Analytics alone, however, can’t ensure care alignment. Operational contract management is the crucial third element.

Integrating analytics with flexible workflow capabilities is the recipe for ACO success by enabling:

• Stratification of the attributed population and management of patient outreach to engage polychronic patients, or those with social needs – proactively deploying time and resources where high-touch engagement is needed
• Management of referral workflows to reduce leakage
• Alignment and coordination of primary and specialty care
• Assessment, automation and administration of business processes and workflows within structured programs

A many-to-many network infrastructure
While legacy infrastructures may have been capable of supporting relatively simple fee for service (FFS) contracts, they are incapable of supporting the type of complex networks with multiple stakeholders typical of an ACO or other risk-bearing entity.

To attain shared savings and avoid shared costs under a VBC contract, ACOs and other risk-bearing organizations need a scalable, cloud-based digital infrastructure that enables a many-to-many network of participants. This can include Community-based Organizations (CBOs), some of which lack adequate digital capabilities but expect frictionless reimbursement for services under the terms of an ACO agreement.

Conclusion
The operational efficiency of ACOs and other risk-bearers depends on scalable digital infrastructure that can handle the demands of a many-to-many collaborative care network. The right digital infrastructure could support a network of multiple stakeholders, including payers, hospitals and physician groups, social service agencies, and CBOs.

To be successful, risk-bearing providers need to focus their resources on improving patient and population health outcomes while controlling costs. A powerful analytics platform along with strong operational capabilities running on top of a scalable digital infrastructure can serve as the foundation for a data and networking framework that supports the success of VBC contracts.

About the author: Lynn Carroll is the chief operating officer of HSBlox and David Wolf vice president, product management at MedeAnalytics.