Alliance to Reduce Disparities in Diabetes

Optimize Accountable Care Organizations' (ACOs) abilities to reduce disparities

Policy Consideration:
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?

The Problem

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

Another 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 physician;
  • Lack of follow-up by patients; and
  • Problems with inconsistent health care coverage.

ACOs 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

The Alliance’s sites have utilized a variety of ways to promote better care coordination for people with diabetes, including ACOs.

  • The 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 Experience:

  • How 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.
  • How 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?
  • How 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.
  • The 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?
  • How 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?
  • What 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?