Optimize Accountable Care Organizations' (ACOs) abilities to reduce disparities
Given increasing health care costs and the importance of coordinating
care for the most at-risk patients with diabetes, how can ACOs be structured
and utilized to reduce disparities in diabetes?
Lack of care coordination is a persistent problem in our
health care system today, creating a fragmented system where clinical services
are organized around small groups of providers that function autonomously and
services are sometimes duplicated or provided unnecessarily, thereby increasing costs.
This problem is especially marked for low-income, minority populations that are
most affected by disparities.
These patients frequently seek care at emergency
departments and from other safety-net providers but often do not have primary
care providers or medical homes that can track their progress, monitor for
potential problems and ensure that plans and prescriptions given by all of
their providers fit together. As a result, low-income, minority populations
frequently receive low-quality but high-cost care.viii
challenge facing these populations is lack of consistent access to high-quality
care. This can result from multiple factors, including:
- Lack of cultural competency on the part of the
of follow-up by patients; and
- Problems with inconsistent health care coverage.
are networks of physicians and other health care providers that voluntarily
work together to coordinate care and share in the cost savings realized from
the coordination of a defined group of high-risk patients. ACOs have been
suggested as one way to help improve health care coordination and, thereby,
quality of care. The ACA establishes ACOs as a new payment model under Medicare
and fosters pilot programs to extend the model to private payers and Medicaid.ix
The Alliance Experience
Alliance’s sites have utilized a variety of ways to promote better care
coordination for people with diabetes, including ACOs.
Alliance’s Camden site was instrumental in persuading New Jersey legislators to
enact legislation in September 2011 that establishes a Medicaid ACO
demonstration project. The ACO model is presented as a mechanism that can
improve health care quality and lower the overall costs of medical care by
providing incentives to coordinate care among providers throughout a region.x
The Camden site has since worked with the state of New Jersey to draft
regulations to implement the new law and is in the process of seeking
accreditation to become the first Medicaid ACO in the nation.
Policy Questions Arising from the Alliance
can physicians, hospitals and other providers work together to forge new
provider networks? For example, under the ACA, Medicare will be allowed to
contract with ACOs to provide care to enrollees. The law also allows for
experimentation with Medicaid ACOs by creating a five-year demonstration
project where state Medicaid ACO pilot projects will be funded.
could a standardized Medicaid ACO accreditation process facilitate the creation
of ACOs that meet the needs of vulnerable diabetes patients?
- How could the New Jersey example of
recently enacted legislation and regulations to implement Medicaid ACOs serve
as a model for other states?
can performance measures for ACOs and other health service providers be created
specifically to focus on reducing disparities? For example, the National
Committee for Quality Assurance (NCQA) has established quality metrics for its
Diabetes Recognition Program,xi but if these measures (HbA1c levels,
blood pressure control or foot exams) were required to be stratified by race
and ethnicity, or if other measures such as the rates of hospitalizations for
ambulatory care-sensitive conditions in diabetes were required, attention may
shift to reducing disparities.
ACA calls for the exploration and development of new care models such as
patient-centered medical homes and models where health care teams provide
continuous care to high-need groups. How can these new models be designed to
best meet the needs of low-income, high utilizers with complex chronic disease
conditions such as diabetes?
can new federal funding available through the Health Resources Services
Administration (HRSA) for community health centers working to receive
recognition as medical homes be leveraged to increase care coordination and
reduce disparities in diabetes patients?
further/new incentives and rewards can move providers toward:
- An integrated system of
care where risk can be spread across providers;
- Elimination of a fee-for-service based system of
payment and establishment of a performance-based system;
- Team-based health care delivery (e.g. team-based
payments in lieu of individual practitioner payments with some level of legal
agreement between different entities to share revenues, etc.);
- Increased sharing of
patient data; and
- Realignment of provider payments for desirable
health outcomes rather than provision of services?