When Worlds Collide: ACOs and Risk Adjustment

By John Nimsky & RaeAnn Grossman

As we enter the era of ACOs, we have to be aware of all the clinical and operational essentials that are needed to make the ACO a viable health care solution for members, plus the elements needed to support the ACO as an engaged and intelligent communicator with CMS. 

If you have a shared cost saving ACO you must have an accurate picture of the member’s health status at Day 1. This detailed clinical picture will help you as an ACO:

1) engage the member in appropriate care programs
2) understand their cost today and project cost for next year, and
3) calculate the risks and benefits of treatment.

In traditional Medicare, it is well substantiated that over 75% of the members may have undocumented HCCs or gaps in care.  However, as an ACO your primary concern is wellness and cost saving, and so you want to push toward 100% member evaluation completion for each calendar year.  Why? Your members really should be evaluated to ensure there is a documented, compliant health status profile of of each member who starts with your ACO, and each year thereafter.  

If you stratify the patient population within the ACO for relative health status, your plan for future treatment intervention will include identification of those members who can benefit from:

• referrals to case management;
• inclusion in disease registries;
• and other target services on a one to one basis.

Effective population stratification and risk assessment produces a complete health profile, a tool that can help  reduce:

• admits;
• re-admits;
• acute utilization;
• ER visits;
• and other avoidable costs found in today’s fragmented approach to health services delivery

Specifically, a robust risk assessment approach for a defined populations will

a) identify ACO members who will benefit from treatment but are currently missed by the system and thus are more likely to develop more serious pathologies later;
b) give physicians and members/patients quantitative information about the risks of adverse events and the benefits of treatment;
c) identify priorities for appropriate outreach programs; and
d) assist in calculating appropriate benchmarks and shared savings incentives for physicians.

An  in-office or in-home assessment  of the patient’s medical history and current health status,  when appropriately employed at the time of member assignment to an ACO, is a powerful tool that must be ready to launch Day 1 of ACO implementation.  Because members are likely to join the ACO throughout the year, the stratification for those new members must occur monthly and integration into the care pathway must be timely and seamless.   Timely integration of the member into standardized clinical treatment approaches will lessen the burden on care givers and will ensure that services are provided efficiently and in the appropriate setting.  This is not a  time for a long implementation phase, lags in data refreshes, or delays in re-stratifying members.    

One of the tools available to assist in the process of identifying member current health status and treatment planning is offered by CenseoHealth, which has ACO Advanced Evaluation modules for Medicare, Medicaid, and commercial members.  These populations’ clinical conditions differ, and so their outreach, analytics, and engagement strategies are also dissimilar.