Case Management Society of America

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Accountable Care Organizations and the Impact on Care Management

BY CONNIE PHILLIPS-JONES. RN, MSN, CCM, CPHQ

In 2011, the U.S. Department of Health and Human Services (HHS) released new rules under the Affordable Care Act (ACA), aimed at helping doctors, hospitals and other providers better coordinate care by way of accountable care organizations, or ACOs.

ACOs provide a framework for rewarding providers financially — in both the public and private sectors — for ensuring that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors.

Since then, the number of ACOs has grown dramatically.

Under the Centers for Medicare & Medicaid Services (CMS), ACOs agree to manage all the healthcare needs for a minimum of 5,000 Medicare beneficiaries for at least three years. For ACO guidelines, CMS established 33 quality measures focused on care coordination and patient safety, the appropriate use of preventive health services, strengthening care management for at-risk populations and improving the experience of care for patients and caregivers. Savings from this initiative are expected to be millions of dollars.

In the beginning, ACOs were paid bonuses for reporting on quality metrics, but in 2013 the program transitioned from pay-for-reporting to pay-for-performance. The Medicare Shared Savings Program (MSSP), designed for organizations new to risk-based reimbursement, rewards ACOs that lower growth in healthcare costs while meeting performance standards on clinical quality and patient-centered care. To date, there are more than 200 ACOs participating in the MSSP.

As CMS-sponsored plans were developed, commercial healthcare insurers also began offering risk-based contracts to providers. Most commercial risk contracts include similar combinations of quality incentives, shared savings, full capitation and small budget adjustments for medical inflation, but variety in these contracts has been identified. This variety includes partial capitation (also known as bundled payments), retainer agreements, in-kind services and subsidies provided by payers, or have limited themselves to upside-only pay-for-performance incentives.

Many ACOs simultaneously contract with both private payers and CMS. Additionally, many state Medicaid programs, offered directly through a state Medicaid office or Medicaid managed care plan, are also negotiating accountable care agreements with providers.

So, what does this mean for care managers?

There has never been a better time to be a case/care manager. Care coordination is the very hallmark of accountable care and ACOs. The change from volume to value requires care management and coordination. Care managers are the glue that keeps this complex system together. The care manager keeps the entire care team connected and often acts as communicator between care team members. It is also true that physician practice patterns require attention and transformation for improved patient engagement, but it is the professional care manager who has the knowledge, skills and abilities for a major contribution to accountable care goals.

Care managers engage both patients and providers for achieving the Triple Aim: improved quality, lower costs and improved satisfaction. Specific to the MSSP model, care managers play an important role for patient retention, evidence-based medicine, readmission avoidance and transitions of care. Communicating with the entire care team to keep all aware of patients’ care and needs helps to avoid duplication and errors. Patient empowerment starts with education for improved self-care including knowing when to anticipate and avoid health problems or worsening of condition. If the patient has this knowledge they can act proactively to avoid ER and inpatient hospitalization. Returning to the PCP when necessary is better health care than visiting an ER in crisis.

But, how is this different from traditional care management?

The two biggest differences between traditional and modern care management are the reliance on data and analytics as well as outcome reporting. Care managers are dependent on data and analytics for the identification of at-risk patients and for the implementation of appropriate level of interventions. No longer will all patients get the same level of intervention. Care management needs to be targeted for patients’ risk and needs.

Outcome reporting is also more precise. Did care management affect the rate of admissions and/or readmissions? Did care management reduce the overall cost of care? Did care management improve quality metrics (evidence-based medicine)?

In the past, there was intuitive acknowledgement that care managers made a positive difference for improved care and cost, but now, the data allows for more than intuition. With the data and analytics available today, care management is evaluated on outcomes as well as process. PMPM (per member, per month) medical costs are routinely reported and analyzed for care settings in the entire continuum of care. These, in concert with quality metric reporting as well as patient satisfaction assessments, drive case management evaluation.

The alignment of practice patterns and definition of quality is what value-based care is all about, and care management is key.

A big challenge is a lack of case manager visibility. If the care management program is centralized and not embedded at the provider location, patients often question the care manager role. When practice transformation is being addressed, this should be an explicit consideration. How can providers promote care management and care managers to their at-risk patients? Providers need to consider the care manager an integral member of the care team and encourage their patients to participate.

It is appropriate to say that accountable care and ACOs hold the care managers and case management programs accountable. The providers and the care managers are accountable. The biggest impact in case management today is the availability of data for providers to ensure that personalized, quality care is carried out, resulting in improved patient outcomes.  ■

Connie Phillips-Jones. RN, MSN, CCM, CPHQ, director of clinical programs, Orange Care Group, an ACO, is responsible for developing and executing clinical programs to drive the pursuit for the quadruple aim and to maximize success in value-based models. With extensive experience in case/care management, she is committed to all stakeholders’ involvement in clinical initiatives. Connie graduated with a bachelor’s degree in nursing from the University of Pennsylvania; she also has a master’s degree in nursing and business administration from Villanova University.

Image credit: Hilch/Shutterstock.com

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