ACO leaders share methods for building successful programs

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Successful accountable care organizations (ACOs) have lessons to share with their peer health systems, said five organization leaders who spoke at the spring conference of the National Association of ACOs (NAACOS).

ACOs have success stories to share, but those have come through hard work, they said. The discussion was part of the Spring Conference of NAACOS, held April 11 and 12 in Baltimore, Maryland.

Integrating ACO models involve initial startup costs, changing culture and behavior, learning to harness technology and uncertainty and delays of getting shared savings from Medicare, said Allison Brennan, an analyst researching the “NAACOS Drivers of ACO Success” white paper to be published this summer.

“We're really here to talk about the complexity of being an ACO and the complexity of that journey,” she said. “As you all know, becoming a successful ACO is not an easy road. And as we've seen the success rates for ACOs’ earnings, shared savings, improve over years, that has been a wonderful thing. But it's still a lot of hard work and initially that challenge might look different.”

Brennan discussed her findings from interviews of leaders of successful ACOs, reflecting on a decade of experience using ACO models. They identified four main drivers for success:

• High value culture. It is crucial to have buy-in from not just physicians and administrators, but at all levels of the organization, and it must be sustained over time.
• Data and tools. One ACO leader described data as “a blessing and a curse,” but incredibly powerful, Brennan said. Vendors have grown more sophisticated in their support for ACOs.
• Patient engagement. Engaging patients and their families to build trust is important, and now a big component of patient engagement is access.
• Clinical transformation. ACO leaders discuss advanced primary care, care management, improving post-acute care, avoiding hospitalizations and readmissions when possible, and using an optimal care setting to prove the right care at the right place at the right time.

Case studies

Coastal Carolina Health Care PA, and its ACO, Coastal Carolina Quality Care Inc., has more than 80 providers across 18 clinic locations in North Carolina, with more than half being primary care, said CEO Stephen Nuckolls. In April 2012, it because one of the nation’s first ACOs, and it has ranked “pretty well” in mammography, and screening colorectal cancer, diabetes, and hypertension.

Since 2011, hospitalizations have declined 39% and emergency department (ED) visits have dropped 28%, including 2020 to 2022 rates with COVID-19 hospitalizations and ED visits. Medicare Shared Savings Program percentages have increased over time to 15.2% for the second quarter this year.

“Also in our journey, we've been able to increase our shared savings,” Nuckolls said “Unfortunately, in our first contract period, we did not achieve shared savings. So for those of you who may be in that situation like us, there is still hope.”

Ochsner Health has 48 hospitals, 370 health centers and urgent care centers, 38,000 employees and had more than 1.47 million patients served in 2022. More than 600,000 lives are under some form of value-based arrangement, said Harry Reese, Ochsner Health vice president and chief financial officer. The Ochsner Accountable Care Network (OACN), begun in 2013, stretches from Texas to Alabama, with more than 70 primary care clinics, with more than 2,400 physicians and 1,200 advanced practice providers serving more than 58,000 Medicare beneficiaries. OACN had $20 million in shared savings in 2022, landing in the top 6% for national Medicare Shared Savings ACO Performance in 2022 and in the top 13% nationally for quality performance standards that year.

The keys to success for Ochsner Health were quality improvement, documentation excellence, and cost and utilization, Reese said.

UNC Health Alliance operates a clinically integrated network with has 8,260 providers, with 2,860 of those being independent, with 1,120 locations, including 13 hospitals, in 52 counties, said Stephanie Turner, RN, MSN, vice president of population management. UNC Health Alliance began ACO operation in 2016 and lost money the first year, broke even the second year, and since then has grown. Now the organization is at the tipping point to become payer agnostic and spread value-based care to all North Carolinians and beyond, Turner said.

Essentia Health has 15,800 workers at 14 hospitals, 79 clinics and other facilities spread across Minnesota, said Mary D. Strasser, MHL, Senior vice president of population Health.

Essentia Health ACO formed in 2012 as a vehicle to advance population health and value-based programs within the organization. Now it has 28,000 attributed lives to MSSP, 49,000 to MN Medicaid (IHP), and more than 160,000 lives in other value-based programs, which now account for 40% of the system’s total revenue, Stasser said. Over the last five years, Essentia Health has saved the U.S. Centers for Medicare & Medicaid Services about $60 million, she said.

Essentia Health struggles with ED utilization, but being that it serves a rural area, if Essentia Health does not have an urgent care, there are none, Strasser said.

Cultures of success

Essentia Health has three aspirational aims – zero preventable harm, engaged and inspired people, and achieving health and vitality with our communities. “Not in our communities, but with our communities, so it really is about partnership,” Strasser said.

Essentia Health and UNC Health also pursued NCQA Accreditation, which helped drive the culture of value, Strasser and Turner said.

Ochsner Health earned physician support by compiling data, showing to them and making things about improving patient care. When they see patient compliance rates for A1C or blood pressure or metrics about getting screenings, then there is more and more buy-in, Reese said.

Turner credited UNC Health’s chief value officer the vision to integrate value-based care and system leaders willing to invest $10 million to build infrastructure and create programs that were successful.

When Coastal Carolina Health Care did not achieve shared savings in its first contract period, physicians were “very, very disheartened because they knew that we had moved a lot of key measures,” Nuckolls said. They were ready to drop out, but a coalition of the willing pushed forward based on a culture of better patient care, he said.

Coastal Carolina Health Care and Ochsner Health have added value-based incentives into compensation plans, Nuckolls and Reese said. Ochsner Health also has built value-based education into a lot of its residency programs to teach new clinicians how to handle and document value-based care, Reese added.

Getting patients on board

For patient engagement, ACO leaders cited methods such as creating initiatives that were specific to certain segments of the patient population. Those could be sophisticated or simple – one mentioned hiring a translator to assist patients with follow-up care, Brennan said.

Patients serve on committees of UNC Health, though it is difficult to keep patient representatives with non-Medicare insurance due to work commitments, Turner said.

Hearing direction from a physician has been crucial to patient engagement, Reese said. Cold call outreach to eligible patients has gotten a 16% enrollment in a complex case management program; but when a doctor tells the patient to expect the call, enrollment goes to 70%, he said. Ochsner Health also is developing patient awareness of primary care teams, so a nurse, nurse practitioner or social worker could be making the call, he said.

Essentia Health has gotten to know patients by integrating social determinants of health questionnaires into electronic health records. In 150,000 visits in 2023, about 20,000 patient triggered positive for social factors such as food insecurity, housing, transportation or income, and health system staff refer patients to community health workers or community benefit organizations.

Coastal Carolina Health Care uses a “Call Us First” campaign with patients. “In other words, don’t go to the emergency room, don’t go to someone else. We are here to help,” Nuckolls said.

He also described a physician recommending a care manager making a home visit with a “curmudgeon” patient who refused to change his diet or take his medications. It worked – the patient finally believed his doctor’s advice, acted on it, and his health measures “improved dramatically,” Nuckolls said.

“I love that story around patient engagement because it's really true, when you let them know that we care, and we're going to care enough to go to your house and call you and know your name, you're much more likely to follow along with those instructions that your doctor gives you,” he said. “And when you have that team together, that makes a difference.”