As we move into a new year, it's interesting to see the flood of articles and reports about healthcare trends. While it's great to have all these different perspectives, it's also important to focus on what's practically achievable for Accountable Care Organizations (ACOs) and Clinically Integrated Networks (CINs).
In our decades of experience, we’ve noticed that the foundation of every successful business is based on acquiring and using high-quality, accurate data to inform both strategic and operational decision-making.
For ACOs, leveraging data-driven insights is crucial to consistently improve the quality of care, and achieve cost savings. Success is measured by different metrics within your payers' managed care agreements and ultimately translates into financial success or failure during the measurement period.
With ongoing margin pressures, labor challenges, payer mix, patient community needs, and revenue goals to consider, ACO executives must navigate an increasingly complex environment.
To manage all these variables effectively, value-based care (VBC) leaders must ensure they have a robust tool set with a foundation of highly accurate data.
In this article, we share observations on three critical challenges ACOs and CINs will face in 2024. These challenges will ultimately shape their success or failure. We hope these practical insights help VBC leaders navigate the ever-changing healthcare system.
As the healthcare system continues to evolve, one of the biggest challenges faced by ACO and CIN leaders is gaining access to a patient's complete medical history. With multiple Electronic Health Records(EHRs) and out-of-network provider entities involved in the patient’s care, it becomes difficult to get a comprehensive picture of the patient's healthcare journey.
To address this issue, ACO and CIN leaders must demand a population health analytics platform that can provide accurate data aggregation from numerous sources and present a 360-degree view of the patient’s care and their network.
While a single EHR for the entire network may not be feasible due to cost and time constraints, it is crucial to have unwavering confidence in the data extraction capabilities of your vendor. Initiating discussions with your network’s EHR vendors and Information Technology (IT) teams can help you understand the available options and build a reliable data foundation.
It is also essential to identify gaps in data sources and measure their potential impact on your total strategy to improve the quality of care and achieve cost savings. Claims, clinical, pharmacy, and lab data, hospital ADT feeds, and Determinants of Health (DoH) data are some of the sources that should be included.
Selecting a population health analytics platform that can quickly and accurately provide aggregated data from these varied sources is key to the long-term success of every managed care program, no matter the ACO model.
And more importantly, the leader's credibility within their provider network. Each program, Medicare Shared Savings Program, Medicare Advantage, or commercial ACO plan, has unique performance measures.
ACO and CIN leaders need the ability to see all their data in a single population health analytics platform that integrates financial and clinical data for their members regardless of service location. Leaders need the ability to dig deeply into the data when challenged by a provider to build trust and gain consensus on the path forward to improve performance gaps, risk profiles, quality of care, or payment inaccuracies.
With a reliable data foundation in place, ACO and CIN leaders can lead change initiatives based on complete and accurate data, improving patient outcomes, and achieving cost savings.
It's important to keep up with the changing healthcare regulatory landscape.
For example, in 2024, there will be a migration from HCC v24 to v28, which will have a direct impact on value-based care Medicare reimbursement. To prepare for these changes, it's crucial to have access to detailed data and use data-informed strategies for actionable decision-making to determine effective provider initiatives.
One of the changes introduced by HCC v28 is new mapping to ICD 10 codes, which will affect risk scores and Medicare reimbursement. Organizations should educate providers to ensure accurate documentation of each patient's clinical risk, and an analytics platform can help identify providers who need additional coaching and monitoring to optimize financial performance.
Quality measures reporting changes, including the sunsetting of the current web interface reporting option in 2025, require careful consideration and testing of different reporting options before the cutoff date.
A population health platform with modeling capabilities can show the impact of these changes and help leaders navigate a smooth transition to new quality measures reporting formats with minimal financial disruption, including drilling deeper to see the service line impact.
In 2024, healthcare providers such as ACOs and CINs will face significant challenges in managing population health.
It's essential to prioritize risk factors and determine which cohorts to focus on for each payer’s unique contract. Employing flexible approaches to build care coordination programs that deliver measurable results is also crucial to ensure successful patient outcomes.
One way to enhance patient engagement and gain insights into hidden patterns across the community's Medicare, Medicaid, and commercial populations is by capturing new DoH data.
Choosing a capable population health analytics platform can help explore the nuances of each population and identify potential outreach opportunities to deliver meaningful engagement, lower costs, and improve outcomes is paramount.
Accurate and timely scorecards can aid in optimizing network performance, combating fraud, waste, and abuse, and delivering high-value care.
A reliable platform allows drilling into opportunity areas, understanding what needs to change, and using data to engage providers in managing the care delivery initiative. These insights can help improve the quality of the network by addressing the unique needs of patient populations within the community.
In conclusion, the challenge for ACOs and CINs in 2024 is tied to their ability to manage an array of patient care variables that frequently change against a risk-based contract for a subset of patients. Accurate data aggregation across all populations is critical to sustained financial success and quality of care improvements.
Embracing a proven population health analytics platform built on a foundation of data accuracy and transparency is a non-negotiable requirement to enable data-informed strategies and position ACOs and CINs for success in each ACO contract and the overall value-based care strategy.
DT Nguyen is the CEO and Founder of Koan Health. As a long-time healthcare industry leader, DT’s passion is to empower ACO leaders and providers with the tools and data-driven insights needed to deliver better outcomes and lower costs across each population.