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How ACO models can improve to support patient engagement
Greater ACO success will come with more flexible beneficiary communication policies governing the models.
Better communication, benefit design and patient input could enhance patient engagement with and understanding of accountable care organizations, according to a new report from the Health Care Transformation Task Force (HCTTF) and the National Association of ACOs (NAACOS).
Improving patient engagement in ACOs would be a key step forward for the payment models, which are designed to enhance care coordination and patient access to preventive care, HCTTF and NAACOS said.
"Effective patient engagement is paramount to the success of ACOs," Jeff Micklos, HCTTF executive director, said in a press release. "These recommendations strengthen Medicare policies to ensure that beneficiaries are fully aware of and can benefit from these innovative care models."
ACOs are alternative payment models (APMs) designed to improve healthcare quality, reduce healthcare spending and improve care coordination. By emphasizing patient access to primary and preventive care, plus addressing social determinants of health, ACOs work to keep patients healthy rather than mitigate acute episodes.
Patient engagement and experience play a big role in ACO success, HCTTF and NAACOs wrote.
"By design, ACOs offer opportunities for providers to better address patients' needs that are not available in the fragmented fee-for-service (FFS) system," the report said. "ACOs also offer an important opportunity to address current health care delivery inequities, having demonstrated reducing racial and ethnic disparities in care and better serving rural and underserved communities."
Still, most patients don't even know they're in an ACO or the ways an ACO can benefit them. Limited patient awareness about ACO participation is a problem, the report argued, because the emphasis on preventive care access and care coordination can be confusing for patients who do not anticipate their providers and health plans to engage with them in that way.
NAACOS and HCTTF convened its member organizations, which included health system staff employed to represent patients, to discuss ACO improvements that could enhance patient engagement and experience. The task force landed on improvements to beneficiary communication and education, better beneficiary engagement in care delivery redesign and improved beneficiary engagement in ACO governance.
Boosting beneficiary communication, education
As noted above, most ACO beneficiaries do not know that they are in an ACO. Health plans and ACOs are often deterred from communicating with patients about their enrollment because CMS classifies such communications as marketing materials, which, until 2023, required CMS approval. This slowed efforts to disseminate information about ACO benefits, the report authors said.
This, plus a lack of templated language to improve beneficiary understanding of ACOs, has historically stymied ACO communication efforts. And even as CMS sets in place standards requiring ACOs participating in the Medicare Shared Savings Program (MSSP), the largest ACO initiative in the U.S., to notify enrolled beneficiaries, the process can be arduous, unclear and cause confusion for both ACOs and beneficiaries, HCTTF and NAACOS said.
The task force stated that current communication and education policies do not help build better engagement with ACO beneficiaries. Instead, a more tailored approach to communication that focuses on storytelling, not bureaucracy, would be more effective, they suggested.
CMS could accomplish this by aligning communication policies with those that govern Medicare Advantage. Additionally, granting more flexibility in how ACOs communicate with their beneficiaries could promote a more population-specific plan.
Engagement in care delivery redesign
ACOs are focused on improving patient access to primary and preventive care, but many of the tools they have developed to enable this are not mindful of patient needs and preferences.
Notably, limits on primary care provider access challenge patient engagement and care access. Patients don't always know the importance of having a primary care provider, and operational issues can attribute patients to ACOs where they no longer receive care.
Meanwhile, ACOs' role in healthcare's digital transformation might not always serve patients. For example, MSSP requires patients to select their primary care providers via the MyMedicare.gov website. This can limit care access for individuals with limited internet access, limited digital health literacy or who simply would rather select their provider a different way.
ACOs can see some flexibility using waivers, but waivers can vary by ACO model. For example, MSSP only has waivers for telehealth and skilled nursing facility (SNF) stays.
"Patient and consumer advocacy representatives described the current waivers and requirements as the antithesis to person-centeredness, noting that it does not seem like any beneficiaries were engaged in the design of the tools," the report authors added. "Waivers need to be implemented in a simplified way that is easy for providers and consumers to understand. Simplification and upfront beneficiary engagement in the design would promote person-centeredness."
Allowing ACOs to waive cost-sharing, improving the primary care selection and access process and ensuring ACOs know which individual clinicians beneficiaries visit will be central to boosting engagement in care delivery.
Patient input in ACO governance
Currently, ACOs are required to include at least one Medicare beneficiary served by the ACO on the ACO's governing body. However, it can be challenging for ACOs to recruit an individual for this role due to experience and time limitations.
What's more, ACOs are stymied in meeting their patient-centeredness criteria laid out by MSSP to build community partnerships with key stakeholders. Lack of guidance and resources gets in the way of forging deep community partnerships, the task force said.
Task force members said that, despite the importance of having a beneficiary on the ACO governing board, this is not enough for getting full patient feedback and perspectives. Initiatives like patient and family advisory councils offer a better arena in which patients can discuss their specific needs.
Meanwhile, community hub collaborations have proven effective in helping ACOs partner with and elicit feedback from the community.
"Part of the challenge with the existing requirements is the rigid, one-size-fits-all approach that hinders ACOs' ability to appropriately tailor to their populations," the report authors explained.
The task force recommended a more flexible approach that balances specifying existing policies while prioritizing best practices over rigid requirements.
"By adopting these recommendations, CMS can remove barriers that hinder more effective patient communication and engagement," said Aisha Pittman, senior vice president of government affairs at NAACOS. "This will pave the way for a better patient experience and improved outcomes, which are goals of value-based care."
Sara Heath has covered news related to patient engagement and health equity since 2015.
