As the COVID-19 pandemic continues to unfold, accountable care organizations (ACOs) are facing a financial crisis that threatens the future of the model itself. With more than 40 percent of ACOs at risk for massive COVID-related losses, the pandemic has come to represent an inflection point in the move to value-based care. On May 8, the Center for Medicare and Medicaid Services (CMS) released the Interim Final Rule with Comment Period (IFC), which removed COVID-related costs from Medicare Shared Savings Program (MSSP) performance year expenditures—a move that likely prevented a mass exodus of ACOs from the program.
While the IFC has certainly provided relief to ACOs, it did not account for some of the more indirect financial consequences of the pandemic. For example, members who previously had part-time jobs or were receiving other types of additional income. The Kaiser Family Foundation recently found that senior unemployment quadrupled between March and April alone, rising from 3.7% to 15.6%. This exponential surge in unemployment may push Medicare members who were on the verge of homelessness or food scarcity over the edge, forcing them to make tough decisions between essentials like medicine and food.
To successfully navigate risk and support increasingly vulnerable populations, ACOs must find a safe, effective way to conduct member outreach. Over the last several months, CMS has passed legislation making telehealth visits reimbursable for a much wider range of services. By leveraging telehealth, ACOs can help mitigate the blind spot created by COVID. This will allow them to gain an understanding of their members’ current status and identify those highest in need, as well as uncover the many more members who will undoubtedly become eligible for the additional benefits of dual enrollment.
In this article, we will outline the unique challenges ACOs are facing, the regulatory measures that have been taken to address them, and the four primary use cases in which ACOs can leverage telehealth to take control of their member populations.
The Downside of Risk
An ACO’s performance is measured by its ability to lower expenditures against a financial benchmark reflective of historical costs, while also meeting quality measures. The way MSSP benchmarking is calculated has evolved over the past eight years as CMS has worked towards its goal of moving all Medicare payments into alternative models by 2025. The most sweeping changes came in July 2019, when CMS began requiring ACOs participating in the MSSP ACO program to take downside risk. In this model, ACOs that meet spending targets get a share of the savings, while those that do not must pay CMS back for a share of the losses.
As the number of confirmed COVID-19 cases in the US reaches 2.6 million and rising, ACOs are predicted to spend between $7.7 and $23.1 billion combatting the virus—a six to 18 percent increase from the previous year’s total spending. Prior to the IFC ruling, such a dramatic increase would have been nothing short of catastrophic for ACOs. Under the new IFC policy, however, they will be allowed to continue in their current risk track for 2021 regardless of COVID expenditures. CMS also granted a one-year extension for ACOs with agreement periods ending in 2020, allowing them to maintain their prior benchmark. These policy changes allow ACOs to earn shared savings in 2020, reducing the potential of large losses due to COVID-related spending spikes or gains from postponed elective procedures.
While this ruling is clearly a win for ACOs, the pandemic is far from over. For the foreseeable future, they will continue to operate in an unpredictable, rapidly changing environment. ACOs, especially those with downside risk, will need to do a full reconciliation of their historical data to understand what is in their benchmark and how to exclude COVID episodes vs. regular Part A hospitalizations and Part B services. These practices will also help identify higher-to-medium risk beneficiaries which, in turn, will help providers more quickly know what gaps need to be covered. No matter how good the analytics may be, however, ACOs will have a hard time managing risk and caring for members without data, and telehealth provides a solution for both.
By increasing the use of telehealth, ACOs can quickly scale up to manage thousands of COVID and non-COVID patients alike, while effectively reducing risk of exposure and stress on the healthcare system.
There are four key use cases for telehealth that ACOs can immediately employ:
1. Manage COVID-19 Cases
While COVID-19 has proven to be deadly, ~80% of those who become infected will recover without hospitalization. For this reason, telehealth can be especially effective in triaging COVID-19, allowing providers to ask specific questions to find out whether emergency services are required. Based on this information, only those who are truly in need will be sent to the hospital, while those with minor symptoms, such as cough and body aches, can recover at home without exposing others or overburdening emergency services.
2. Follow-up and Monitoring
Health plans should also leverage telehealth to monitor and communicate with members following a diagnosis or discharge of COVID and non-COVID illness alike. This can help reduce readmissions, keep members healthy, and potentially save money while allowing members to stay in the safety of their own homes. With reports that as many as 100 healthcare workers at a single institution have had to be quarantined due to COVID-19 exposure, telehealth is also a good way to allow these providers to monitor and care for members without spreading the virus.
3. Continue Outreach for Routine Care
Outside of treating COVID-19, providers should continue outreach to members via telehealth for most regular, necessary medical care. This will allow them to manage for better outcomes and capture chronic conditions, something which is critical for benchmarking. It will be especially important for providers to leverage telehealth for higher risk members, such as the elderly and those with chronic conditions like asthma or diabetes. In this way, members will not have to choose between staying safe from COVID-19 or receiving the ongoing medical care they need.
4. Identify SDOH, be a Changemaker for Your Patient
Beyond finding out how members are doing from a clinical standpoint, providers should take the time to mentally and emotionally connect with them to gauge their psychological state. Many people are isolated right now and struggling with basic needs, especially seniors. Telehealth provides another opportunity to identify and document social determinants of health (SDOH) and refer members to programs that can help manage their needs beyond healthcare, such as food scarcity, homelessness, etc. Health plans should also look to enroll patients into dual eligible programs, as many more are likely to become eligible, or may have moved from partial dual to full dual as this public health emergency continues.
By leveraging telehealth in these key ways, ACOs can help provide care at a reduced cost to the state, the provider, and the patient. Partnering with a company that not only has great analytics and telehealth experience but also one that knows how to measure the success of a program will be key.
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