A Resource Published by HCTTF and NAACOS
Overview
One of the biggest challenges in advancing accountable care is successfully communicating the benefits of these models to the people they serve. Patients and their caregivers are often unaware of how their care is being coordinated or the other benefits that value-based care models provide. Effectively communicating these benefits is one strategy providers can implement to better engage patients in their care. There are many levels of patient engagement, and this paper reimagines how people should best be engaged in governance, care planning, and care delivery redesign, primarily in accountable care organizations (ACOs).
ACOs are the largest and longest-standing alternative payment model (APM), and are designed to provide high quality, cost-effective, coordinated health care that focuses on keeping people healthy through prevention and effective care management that address both social and clinical risk factors. The Medicare Shared Savings Program (MSSP) – the largest ACO initiative in the United States – now has well over a decade of experience in pursuing these goals. The Centers for Medicare and Medicaid Services (CMS) has also tested several accountable care models through the CMS Innovation Center, including the ACO Realizing Equity, Access, and Community Health (REACH) Model currently being tested. ACOs have learned much about policies, incentives, and care delivery strategies that advance patient engagement and pursue effective and efficient person-centered care.
Building on the more than a decade of success, it is critical to reexamine how ACOs are engaging beneficiaries in both care delivery and care redesign. By design, ACOs offer opportunities for providers to better address patients’ needs that are not available in the fragmented fee-for-service (FFS) system. ACOs also offer an important opportunity to address current health care delivery inequities, having demonstrated reducing racial and ethnic disparities in care and better serving rural and underserved communities. Yet, patients in ACOs or other APMs often are unaware of their inclusion in models and the benefits they provide. Additionally, the success of ACOs and APMs has overly focused on cost savings and not on improved beneficiary outcomes. Accordingly, the National Association of ACOs (NAACOS) and the Health Care Transformation Task Force (HCTTF) sought to identify opportunities to improve beneficiary engagement in ACOs.
NAACOS and HCTTF convened a cross section of their memberships – including ACO and patient and consumer representatives – for a roundtable discussion on what person-centered care means today and how policies can best support these perspectives. This roundtable produced policy recommendations focusing on what policy changes should be made to CMS accountable care models to strengthen patient engagement and advance person-centered care.
The participants noted that much of the current MSSP and ACO REACH policies around beneficiary engagement are rooted in regulation, and therefore present some unwelcome rigidity in practice. Additionally, these policies were not developed with input from beneficiaries or their advocates (patient or consumer groups, family caregivers, etc.). CMS should consider removing regulatory rigidity by making the recommended policy changes through interpretative guidance to allow for more flexibility in implementation. Additionally, CMS can amplify its communication about ACOs. Participants appreciate the Innovation Center’s recent work to tell stories of patients in ACOs and other APMs, but this information is disjointed from CMS’ ongoing and regular communication to beneficiaries.
With the goal of incorporating beneficiary engagement across all aspects of an ACO, this paper highlights several recommendations that CMS should implement to better support ACOs in patient engagement.
- Beneficiary communications must be tailored to different patient populations. Current regulations require a one-size-fits-all approach which limits educational and engagement potential to specific audiences. CMS should transition to approaches that empower ACOs to tailor the timing and information communicated to beneficiaries. As with other programs, CMS could set broader parameters for beneficiary communications and timelines and allow ACOs to customize their approaches. For example, beneficiaries are best served when communicated with in their primary language to build trust and foster the full understanding of what is being communicated to them.
- ACOs and other APMs can be improved with enhanced beneficiary engagement tools. ACOs offer freedom from regulatory burden by waiving certain Medicare FFS requirements. Many waivers tested offer a direct benefit to the patient, such as waiving cost-sharing for certain services or allowing a beneficiary to be directly discharged to a skilled nursing facility (SNF) without meeting the minimum nights of a hospital stay. These benefits facilitate improved engagement for patients with the health care they seek. However, waivers are inconsistently applied across the various ACO models. CMS should work to expand and align waivers that provide direct benefits to beneficiaries and support ACOs with understanding parameters for meeting beneficiary-related requirements.
- Meaningful input from patients, family caregivers, and communities is critical to the success of accountable care models. Effective two-way communication promotes person-centeredness and can advance population health goals. CMS should ensure ACOs and other APM participants have adequate guidance to solicit beneficiary input and feedback, establish community partnerships, and incorporate these perspectives into their work. The focus should be on co-creation of care delivery models where the patient voice is considered and acted upon throughout the care continuum.
The remainder of this resource details the background and challenges, key considerations, and recommendations in how ACO policies should be aligned with patient preferences across the following topics:
- Beneficiary communications and education
- Beneficiary engagement in care delivery redesign
- Beneficiary participation and input in ACO governance
While these perspectivesgenerally apply to all populations being served by ACOs, the specific recommendations presented here focus on policies applicable to Medicare ACOs.