Show me the money: Tips for becoming a high-performance ACO

By Pranam Ben

At the National Association of Accountable Care Organizations (NAACOS) fall conference in October, there was naturally a lot of discussion among attendees about managing patient populations.

What was missing from these conversations, however, was that managing populations who follow expected behaviors isn't what keeps ACOs from attaining their clinical quality and financial goals; rather, it is the exceptions to the rule - the patients who are disengaged, not adherent or not responding to their physicians' treatment plan. Too many individuals are arriving in emergency rooms or being admitted to the hospital when it could have been avoided. These patients are what the ACO's population health management (PHM) platform needs to automatically identify and help providers intervene with before an adverse event occurs.

Managing the "exceptions to the rule" patients is essential to becoming a high-performance ACO, which was just one of the points we delivered to the NAACOS attendees during a breakfast-event presentation I delivered called "Show me the money: A platform based approach to high-performance ACOs." The following are three other tips from the presentation.

1. It's all about care coordination, not just care gaps
If an ACO is utilizing its PHM platform to just manage care gaps, they will continually be playing catch-up. Instead, the platform, such as The Garage's Bridge solution, must proactively coordinate care and engage patients before these care gaps emerge. That includes what we call "care beyond the obvious," which means coordinating the behavioral and mental healthcare, and substance abuse counseling that patients need to truly be healthy and engaged. Likewise, care coordination and patient engagement must be integrated into the PHM platform to become a High Performance ACO.

2. Reports and analytics are yesterday's news
Some of the ACO leaders at the NAACOS conference were still in the mindset of relying on their PHM platform vendor to analyze data and generate reports for them. Rather, it is the platform itself that should be automatically capturing, normalizing and presenting the data and insight-not clutter-so providers and administrators can take action. If they need to design a new report, their platform should be so intuitive and reliable that they can easily create it on their own. It is our goal at The Garage that our ACOs will never need to call us for a report because they're empowered to do it themselves.

3. Recover revenue with code optimization
Our presentation is called "Show me the money," and the tips mentioned here will certainly help ACOs do that. However, one essential piece of PHM that results in real financial dividends, which all platforms should be delivering, is code optimization. Patients enrolled in an ACO will see multiple physicians, some outside the organization's affiliation. These outside physicians may diagnose the patient with conditions that your ACO's physicians haven't yet diagnosed. Or, there may be conditions from the previous year that have not been re-verified. Either way, the ACO is leaving money on the table by not keeping diagnosis codes accurate and current. That means the PHM platform should be identifying and alerting ACOs to those codes that need attention so that revenue is not lost. For example, a small, group-practice client of ours has managed to generate an additional $50,000 a month, just with this one small, but crucial step. Imagine the new revenue generated for a clinically integrated network that did the same.

Those were just a few pieces of insight from our presentation, but there are many others, including how in the next five years artificial intelligence will transform PHM for both patients and ACOs. To learn more about how to become a High Performance ACO, please contact us today at info@thegaragein.com.