ACO Serious Illness Care: Survey And Case Studies Depict Current Challenges And Future Opportunities.

William K Bleser,Mark Mcclellan,Robert S Saunders,Lia Winfield,Hannah L Crook,Nathan Smith,Brystana G Kaufman,Mark Japinga,David B Muhlestein

doi:10.1377/hlthaff.2019.00013

Abstract

Care for people living with serious illness is suboptimal for many reasons, including underpayment for key services (such as care coordination and social supports) in fee-for-service reimbursement. Accountable care organizations (ACOs) have potential to improve serious illness care because of their widespread dissemination, strong financial incentives for care coordination in downside-risk models, and flexibility in shared savings spending. Through a national survey we found that 94percent of ACOs at least partially identify their seriously ill beneficiaries, yet only 8-21percent have widely implemented serious illness initiatives such as advance care planning or home-based palliative care. We selected six diverse ACOs with successful programs for case studies and interviewed fifty-three leaders and front-line personnel. Cross-cutting themes include the need for up-front investment beyond shared savings to build serious illness infrastructure and workforce; supporting the business case for organizational buy-in; how ACO contract specifications affect savings for serious illness populations; and using data and health information technology to manage populations. We discuss the implications of the recent Medicare ACO regulatory overhaul and other policies related to serious illness quality measures, risk adjustment, attribution methods, supporting rural ACOs, and enhancing timely data access.

Highlights

Care for people living with serious illness is suboptimal for many reasons, including underpayment for key services in fee-for-service reimbursement
Sangeeta Ahluwalia and coauthors found that only 20 percent of Accountable care organizations (ACOs) had advanced care processes and 60 percent had basic processes,[22] which is consistent with our result that 16 percent of ACOs had widely implemented advance care planning (58 percent had partially implemented it)
Julia Driessen and Turner West found that approximately 25 percent of ACOs in the Medicare Shared Savings Program had contracted with hospice or palliative care physicians,[17] which reinforces our finding that only 20 percent of ACOs widely offered hospital-based palliative care and 8 percent offered community-based palliative care.We found that 94 percent of ACOs reported having at least partially implemented efforts to identify their serious illness population, yet much smaller numbers were widely providing related initiatives

Summary

Introduction

Care for people living with serious illness is suboptimal for many reasons, including underpayment for key services (such as care coordination and social supports) in fee-for-service reimbursement. Crosscutting themes include the need for up-front investment beyond shared savings to build serious illness infrastructure and workforce; supporting the business case for organizational buy-in; how ACO contract specifications affect savings for serious illness populations; and using data and health information technology to manage populations. We discuss the implications of the recent Medicare ACO regulatory overhaul and other policies related to serious illness quality measures, risk adjustment, attribution methods, supporting rural ACOs, and enhancing timely data access. C aring for people living with serious illness remains a key challenge for US health care reform.

Results

Discussion

Conclusion