On January 29, 2016, Health Care For All submitted detailed comments to the Health Policy Commission on their proposed certification standards for ACOs. In our comments, we wrote that
The Health Policy Commission (HPC) has an opportunity to promote approaches to payment reform that fundamentally transform the way care is delivered. ACOs should deliver high quality, high value care that treats the individual as a whole person. ACOs should ensure coordination of care, improved communication, member support and empowerment, and ready access to health care providers, services and community-based resources and supports.
You can download our full HCFA comments (31-page pdf) here. Below is an outline of the main points of our comments:
Health Care For All Summary of Recommendations for Health Policy Commission ACO Certification Program
Consumer/patient engagement at multiple levels
- Ensure consumer representation and input in ACO governance bodies and advisory councils: Patients and consumers should be formally integrated in the design and governance of ACO policies and procedures. This includes representation on the ACO’s Governance Board and the formation of ACO Patient and Family Advisory Councils to address issues like the ACO’s quality and member experience from the consumer/member perspective.
- We recommend that criterion #3 be amended so that the ACO governance board contains more than one patient, family caregiver, and/or consumer advocate representative in order to ensure sufficient representation.
- We also recommend that the HPC provide more detailed criteria on how to ensure that participation and engagement is meaningful. We support that ACOs must have a Patient and Family Advisory Council or similar committee under criterion #5 and recommend that the HPC provide more specific documentation requirements for this requirement.
- Promote patient-centered quality measures: ACOs should use quality measures that include patient-reported outcomes measures and measures that capture members’ views regarding the care they received.
- We support criterion #14, which requires ACOs to conduct an annual survey to evaluate patient and family experiences and deploy plans to improve on those results. While patient experience measures are an important first step, ACOs should also prioritize the inclusion of patient-reported outcomes measures (PROMs). These kinds of high impact quality measures, which are meaningful to both consumers and providers, will help ACOs drive quality improvement and increase value.
- Promote member engagement and activation in care: ACOs should engage members directly in their care through approaches such as using shared decision making and trained health coaches, and helping members manage their own health and health care.
- In addition to patient experience measures (criterion #14), patient engagement/activation measures should be included among the ACO’s quality indicators. Such engagement at the clinical level allows individuals and providers to be full partners in care, which studies have shown improve outcomes and lower cost.
Comprehensive data collection and risk stratification
- Comprehensive data collection: Collecting data on key sociodemographic factors is a critical first step for effectively managing the health of an ACO’s patient population, addressing risk factors that lead to poor health outcomes, and appropriately targeting intervention points and strategies.
- We strongly support criterion #31 that ACOs should assess the needs and preferences of its patient population with regard to race, ethnicity, gender identity, sexual preference, language, culture, literacy, social needs (food, transportation, housing, etc.) and other characteristics and develop plan(s) to meet those needs. We recommend, however, that this criterion be moved from the category of reporting-only to mandatory so that ACOs understand key barriers to health and how those barriers are distributed across its member population.
- Risk stratification: Outcomes and other quality indicators should be stratified by social determinants of health indicators in order to appropriately target population health interventions, uncover and address health disparities, and improve how ACOs deliver care.
- We therefore support criterion #7, which requires ACOs to have approaches for risk stratification of its patient population based on criteria that includes social determinants of health, which could include factors such as homelessness or unstable housing, age, primary language, race and ethnicity, geography, gender identity and sexual orientation. We also think it’s important to stratify data based on functional status, activities of daily living, instrumental activities of daily living, and health literacy, as specified as optional in the criteria.
- Once collected, we think this information should be made available publically. Reporting this data will allow the HPC and the public to assess how well ACOs are serving the entire spectrum of ACO members.
Public reporting and consumer outreach & education
- Promote transparency and accountability through public reporting: Public reporting can improve both health care performance and value. Providing transparent information on cost and quality performance at the individual provider level as well as the ACO level will help members to make informed decisions with respect to choice of provider and care setting, and may also help members to understand the potential benefits that an ACO can provide.
- We strongly recommend that ACOs be required to publicly report quality and cost information at the provider level, as well as at the ACO level.
- The HPC should further work with ACOs to report publically on the number of lives attributed to each ACO; the financial structure of ACOs and participating providers; ACO leadership structures; and provider incentives in ACOs.
- Consumer friendly education and outreach: We recommend adding criteria to ensure that all individuals receiving care, or eligible to receive care, through an ACO be fully informed about what this means for them and how to protect themselves if necessary.
- ACOs should be required to educate their enrollees on what an ACO is, the benefits of care under the ACO, and the responsibilities and rights that accompany receiving care from an ACO.
- Information on ACOs should also be provided in ways that are accessible and understandable to all individuals, which means that the information must be relevant, communicated via a set of consistent messages, and in a languages and formats accessible to individuals who have limited English proficiency or who are deaf or hard of hearing. Under criterion #31, the provision of interpretation/translation services and materials printed in languages representing the patient population should also be made mandatory as a key strategy to address health disparities and promote health equity.
- Data sharing: Individuals should have electronic access to their medical records and other health information and related clinical knowledge needed to make informed choices about their care.
- Ensure robust appeals and grievances procedures: Because an individual’s treating physician may have a direct financial relationship with the ACO and its participating providers, ACO grievance and appeals processes should be robust and designed to address this unusual context.
- The ACO grievance process should be at least as consumer-protective as current insurance appeals. Providers who stand to share in ACO savings should be required to provide members with a description of all possible treatment options and the provider’s basis for deciding on the recommended treatment. Members who are concerned about a provider’s decision should have access to a process to seek a second opinion, outside of the ACO network, that does not incur additional cost sharing.
- The HPC should work with the Office of Patient Protection (OPP) to create, a single source of information and accountability for under-service through an ombuds program model.
- OPP should publicly report on an annual basis the number and types of internal and external grievances and complaints filed with the ACO and if and how they have been resolved.
- Monitor and track underutilization: We recommend that the HPC work with ACOs and payers to monitor and track under-service and underutilization. As providers within ACOs take on increased financial risk through alternative payment methodologies, this may shift the balance of incentives and enhance the potential for ACOs to stint on necessary care.
- One way to safeguard against potential incentives to deny or limit care, especially for individuals with high risk factors or multiple health conditions, is for under-service and underutilization to be tracked and monitored through both concurrent and retrospective methodologies, including monitoring and analysis of claims data on an annual basis. This could be a separate criterion or included under criterion # 13 (analytic capacity).
- Protect member choice of providers
- Continuity of care: The criteria should include more specific requirements to ensure continuity of care and protect choice of providers, including how consumers may access providers outside of the ACO network. This could be added to criterion # 9 (collaboration with a continuum of providers and organizations) or included as separate criteria.
- Network adequacy: Members should have access to care across the continuum, which includes reasonable access to a sufficient number of primary and specialty care physicians, facilities, and other providers, as well as benefits delivered in a timely fashion within a reasonable distance. We recommend that criterion #9 be amended to require that ACOs either include in their networks, or effectively collaborate with and promote access to, the providers and organizations listed as well as additional types of providers including oral health providers and community health workers.
Access to services and care delivery
- Incorporate oral health services: Oral health should be included within the scope of ACO services in order to improve overall health and quality of life and help achieve cost savings. There should be incentives for the integration of oral health as a component of routine primary care; inclusion of oral health providers in referral networks; inclusion of oral health providers in ACO governance and quality committees; and initial standards set for data sharing and technologies enabling provider collaboration.
- Promote care coordination: Care coordination is vital to managing an individual’s care, reducing fragmentation and improving outcomes, and should be a core component of all ACOs.
- We recommend that the care coordination criteria (#23-26) be amended to add a criterion that ACOs must also demonstrate an ability to coordinate care for high risk and complex patients and to provide outreach services to hard-to-reach populations, such as through utilizing community health workers. ACOs should further educate members on care coordination and care planning, including group visits and chronic disease self-management programs. The care coordination criteria should additionally be moved from reporting-only to mandatory.
- Promote the integration of behavioral health services: ACOs should integrate mental health and substance use disorder services with primary care, which can include co-located models, formal partnerships with community-based behavioral health providers, and/or the federal Health Homes opportunity. ACOs should also emphasize prevention and early interventions with children and their families.
- We fully support the inclusion of criterion #27 addressing peer support programs and recommend that this criterion be made mandatory in order to ensure access to services that help individuals manage their conditions successfully.
- Ensure adequate access to and appropriate standards for pediatric services: ACOs should establish access and quality standards specific to pediatric primary care, behavioral health, oral health, and specialty providers. ACO design should include pediatric-specific approaches including payment frameworks and quality standards.
- Provide culturally and linguistically appropriate care: ACOs should be required to train their providers on cultural competence and make efforts to reduce implicit bias among caregivers.
Population health and prevention
- Promote linkages with community-based organizations and active coordination with community resources: Given that many populations face significant social, economic, and environmental barriers beyond their immediate health concerns, it is critical that ACOs provide education and assistance with accessing the community resources in their area and coordinate with those resources to exchange member information.
- We support the requirement in criterion #9 that ACOs must demonstrate and assess effectiveness of ongoing collaborations with and referrals to community/social service organizations as well as other specified providers.
- We recommend that the criteria specify that ACOs should first assess community assets and challenges to better understand community needs and target partnerships/interventions. ACOs should also partner with community resources (with member permission) to exchange member information.
- In addition to the providers and organizations listed under criterion #9, we recommend adding that ACOs should utilize community health workers both through partnerships and within care teams to provide care coordination, wrap-around services and outreach to high risk patients, and engage in population health interventions.
- Targeted population health programs: Population health programs should address specific risk factors and social determinants of health identified through screening and data collection.
- We strongly support criterion #8, which requires ACOs to target programs at improving health outcomes for its patient population addressing mental health, addiction, and/or social determinants of health. As part of this criterion, ACOs should describe how the programs address the specific identified needs of social determinants of health for their population. The standards should also require the program to be of sufficient size to address the documented needs.
- Support and invest in community-level changes in conditions that drive health outcomes: Population health should include measuring and analyzing health indicators to address community-based drivers of poor health. By focusing on the underlying social determinants of health at the community-wide or geographic level, ACOs have an opportunity to work towards truly improving health outcomes and advancing health equity.
- We strongly support criterion #15, which requires that the ACO advance or invest in the population health of one or more communities where it has at least 100 enrollees that accounts for the social determinants of health.
- In order to effectively impact health and costs, we suggest, however, that ACOs should address population health via these initiatives – either directly or through partnerships – in all communities where the ACO serves significant numbers of individuals that suffer from poor health outcomes/with documented health needs.
Financial incentives and payment methodologies
- Incentive payments: The HPC should work with payers to encourage quality and cost-based payment incentives for ACOs that prioritize patient quality outcomes as the leading component of payment incentives, so that cost savings are not the sole motivation of provider payment reforms.
- Risk adjustment should take into account socioeconomic status and social determinants: In order to reduce incentives to deny or limit medically necessary care, the HPC should encourage payer contracts with ACOs to use risk adjustment measures under alternative payment arrangements that include adjustments for social, cultural, and economic factors, so that resources are available to provide culturally and linguistically appropriate services for people who are lower income, homeless, have difficulties with English, are from ethnic and/or minority populations, and for persons with physical, mental, intellectual or sensory impairments.
- Flexibility in spending: Payers should be encouraged and incentivized to pay for coordination, wellness and prevention services that are not traditionally reimbursed.