“Return” has become a popular word across the globe of late. Return to the office, return to travel, return to going out to eat and sporting events, return to our pre-COVID lives…the list goes on.
As our world adjusts to the new normal, the healthcare industry is moving beyond emergency triage to managing today’s top challenges, including staff shortages, supply chain and cost issues, as well as disruptions in their economic revenue models.
Accountable care organizations (ACOs) are also dealing with many critical issues post COVID-19, such as consolidation pressures, uncertainty regarding risk-sharing and risk adjustment policy changes at the Centers for Medicare and Medicaid Services (CMS), and the impact of long COVID on healthcare utilization by their members.
In this piece, I’ll highlight two areas of concern that we are currently addressing with our ACO partners using advanced analytics: assessing the impact of COVID-19 on their managed populations and benchmarking ongoing performance relative to other ACOs.
Impact of COVID-19 on ACO populations
It is well understood that patients who contracted COVID-19 and were hospitalized during the past two years had significantly higher medical costs than expected. Many of these individuals, including some who were not hospitalized initially, continue to suffer from a spectrum of new adverse health conditions commonly called "long COVID." Consequently, these members are expected to require higher healthcare utilization in the future.
Less appreciated is the impact of the pandemic on healthcare utilization by those members who avoided COVID-19 by staying at home. We have found that their primary care visits were reduced by 34% compared to 2019, and specialty care visits decreased by 30%. This reduced expenditures for the past two years, but this avoidance or delay of care is likely to have adverse health and financial consequences going forward. Progressive ACOs are carefully assessing the risk profiles of their membership population to minimize the adverse consequences of COVID-19 as well as the avoidance of care during the pandemic.
Benchmarking relative performance
CMS provides a Risk Adjustment Factor (RAF) score based on demographic information and history of chronic conditions for each ACO member to establish yearly expenditure benchmarks for MMSP ACOs. This provides an incentive to assure that annual wellness visits are conducted to identify new conditions, code them appropriately to ensure that RAF scores fully reflect current patient status and consequently increase the future cost benchmarks.
Some ACOs have become proficient in managing this process to maximize RAF scoring. However, the RAF score alone only accounts for a small fraction of the variability in actual future expenditures per member, so better benchmarking tools are needed to properly assess performance versus expected outcomes for a specific population of patients. We have pioneered the use of a “digital twinning” methodology whereby everyone in the ACO is precisely matched by a predictor of the outcome of interest and across multiple factors with other similar comparison control subjects from other ACO populations.
Relative performance on any outcome of interest (number of primary care visits, hospitalizations, overall healthcare utilization, mortality, or costs) can then be compared to a chosen benchmark to determine whether the outcomes are better or worse than would be expected for that population. The insights provided by this type of deep analytic approach can be utilized to identify best practices, priority clinical areas for improvement, and opportunities for network expansion to local practices and skilled nursing facilities demonstrating the best clinical outcomes.
While we all embrace the concept of returning to normal life post-COVID, the reality is that healthcare has changed profoundly, and these changes require new innovations rather than a business-as-usual approach. ACOs are reimagining their place in the healthcare ecosystem and are assuming a greater role in evaluating and attempting to improve the health outcomes of their members as a strategy to become top clinical and financial performers.
To accomplish this, they are adopting advanced yet practical analytical tools that provide actionable insights to answer critical questions such as "How did COVID impact the health of our members," "How do our patient outcomes compare to local and national peers?" "How can we do better at identifying high-risk individuals before they suffer a costly adverse event?"
It will be interesting to track how successful these innovative ACOs can be in the coming years.
Paul J. Manberg, Ph.D., is vice president of clinical and regulatory at the Health Data Analytics Institute.