The US national healthcare expenditure has grown by 7.5% to $4.9 trillion annually, the highest globally and nearly twice as high as the next succeeding country’s healthcare spending. Accountable Care Organizations (ACOs) play a critical role in addressing these rising healthcare costs by emphasizing value-based care (VBC) over volume-based care. The ACO model of care delivery that emerged as part of healthcare reforms under the ACA (Affordable Care Act) promotes outcome-driven healthcare delivery, driving the transition from fee-for-service models to value-based care. Through close collaboration with healthcare providers and hospitals, ACOs strive to reduce cost of care while improving patient outcomes. However, this transition is not without challenges. In this blog post, we will deep dive into some of the challenges that ACOs face in the current healthcare landscape and modern technology solutions that can help them in overcoming these hurdles successfully.
Key Challenges Faced by Accountable Care Organizations and Solutions
ACOs encounter numerous complexities such as financial sustainability, data management, regulatory compliance, and interoperability in their journey of transitioning from volume to value. Modern technology solutions play a critical role in addressing these roadblocks, empowering ACOs to better manage costs and care delivery. Let’s explore some of these challenges in detail while discussing the technologies to resolve them.
1. Financial Risk and Sustainability
ACOs today struggle to balance financial risk and high-quality, cost-efficient care. Incentives are tied to savings, but exceeding cost targets can lead to penalties. Managing these upward and downward risks, especially early on, requires significant investment in technology, infrastructure, and care coordination where ACOs struggle due to resource constraints.
Solution:
- Implementing a risk-adjusted payment model ensures financial targets are based on the complexity and risk of the current patient populations. AI-driven Predictive Analytics can help assess patient risk profiles and predict cost trends, allowing ACOs to optimize their financial models based on expected utilization and risk-adjusted payments.
- Also, some ACOs in the CMS program start with a shared savings model, taking on financial risk only after achieving a designated savings threshold. This gradual phased approach to risk adoption can address financial instability in the early stages. Financial analytics platforms and real-time cost tracking tools can help ACOs monitor expenditure, predict when they will meet savings benchmarks, and make data-driven decisions.
2. Data Management and Interoperability
Effective care management in ACOs depends on seamless data sharing across the healthcare ecosystem. However, interoperability remains a challenge as different providers use varying EHR systems and data standards. Managing and integrating diverse data sources such as EHRs, claims, and lab results, is crucial for tracking patient care and meeting performance metrics.
Solution:
- ACOs can invest in Health Information Exchange (HIE) platforms that facilitate seamless data sharing across providers.
- Centralized cloud data platforms enable ACOs to integrate data from multiple sources such as EHRs, claims, and lab results and create a comprehensive patient profile.
3. Quality Measurement and Performance
Solution:
- Real-time performance tracking using integrated customized dashboards enables ACOs to efficiently track quality performance metrics across the ACO network and quickly respond to any deficiencies in care quality.
4. Regulatory Compliance
Complying with the regulatory standards laid out by multiple entities, including CMS, the Affordable Care Act, and state-level health regulations, introduces a significant challenge for Accountable Care Organizations. Failure to comply can lead to financial penalties or exclusion from key reimbursement programs, impacting financial and operational stability.
Solution:
- Modern compliance management systems can track and ensure adherence to regulatory changes, improving efficiency and reducing the risk of errors.
- Automated compliance reporting streamlines data collection and saves manual effort, enabling timely and accurate reporting.
- AI-driven intelligent recommendations from analyzing historical and real-time data can offer actionable insights for data-driven reporting.
5. Provider Alignment and Engagement
For an ACO to thrive, it’s essential to align the efforts of diverse healthcare providers, such as primary care physicians, specialists, hospitals, and post-acute care providers. However, achieving this alignment is no easy task, as different providers often have varying priorities. They may be resistant to operational changes, or might hesitate to adopt value-based care due to concerns about how it could impact their reimbursement, financial stability, or increase their workload.
Solution:
- Establishing Clinically Integrated Networks (CINs) where groups of providers collaborate to improve care and share savings addresses the provider alignment issue.
- Implementing provider incentive programs that link performance to financial rewards encourages teamwork, improves patient outcomes, and reduces unnecessary treatments.
6. Patient Empowerment and Education
A central pillar of the Accountable Care Organization model is empowering patients to take control of their health and motivating them to stick to their treatment plans. Many patients, particularly those managing vulnerable or underserved communities, face barriers such as limited resources, lack of health literacy, or low motivation, making it challenging to stay engaged in their care.
Solution:
- Introducing patient engagement programs with interactive features, personalized care plans, reminders and progress tracking, can help patients manage chronic diseases like diabetes, heart disease and CKD (chronic kidney disease) more proactively.
- Digital patient education platforms enhance patients’ understanding and adherence to treatment plans through gamified learning experiences.
7. Patient Attribution
Patient attribution remains a key challenge for ACOs, stemming from how patients are assigned to an ACO based on where they receive most of their care. If a patient seeks treatment from multiple providers, the attribution may be inaccurate. When patients are misattributed, it can distort performance metrics, leading to unfair financial penalties or lost incentives.
Solution:
- An advanced patient attribution model that uses claims data and longitudinal care records can significantly improve accuracy in patient assignments and performance tracking.
- Machine-learning algorithms can refine attribution precision, ensuring that performance metrics accurately reflect the care delivered.
8. Care Coordination Across Silos
Accountable Care Organizations strive to deliver coordinated care across a broad network of providers, from primary care physicians to rehabilitation centers. Gaps in coordination can impact patient outcomes and efficiency, and non-compliance may result in financial penalties or exclusion from key reimbursement programs.
Solution:
- A centralized care coordination platform that can track patients as they move through the care continuum can alleviate this challenge.
9. Barriers to Technology Adoption and Integration
To effectively manage patient data and track care quality, ACOs must invest in advanced technologies, including data analytics platforms, health information exchanges (HIEs), electronic health record (EHR) systems and telehealth solutions. However, these technologies can be costly to adopt and maintain. Also, staff must adapt to the new systems, often facing a steep learning curve that can lead to organizational change management (OCM) challenges.
Solution:
- A phased approach to technology adoption can ensure seamless modernization. ACOs can start with modular implementations of high-impact use cases and gradually expand capabilities in AI, data analytics and other technologies.
- Comprehensive training and change management can minimize resistance to change and make adoption of new systems easier.
10. Health Disparities and Social Determinants of Health (SDOH)
Improving patient outcomes requires addressing social determinants of health (SDOH) like poverty, housing instability, food insecurity, and transportation barriers. However, these factors often fall outside the direct control of healthcare providers. Without a full view of their patient cohorts, ACOs may struggle to meet their quality and cost-saving goals, particularly when managing high-risk populations.
Solution:
- Integrating an SDOH screening tool allows ACOs to identify critical social factors that impact patient health.
- By utilizing community health workers (CHWs), ACOs can bridge the gap between medical care and social services, ensuring patients receive the support they need for improved health outcomes.
The Future of Accountable Care Organizations
Author
