ACO REACH organizations that are evaluating participation must be prepared to augment traditional clinical and financial processes to achieve success. Technology, and the people and processes that power it, will be a central component of that change. The key is to identify smart healthcare IT (HIT) investments that can fulfill model requirements today, and later be extended and composed to align with the broader shift to value-based care. Here are the 5 key technology essentials for participants in ACO REACH.
1. Streamlining Capitation Adjudication
Capitation is the reimbursement model used in ACO REACH. One advantage it has over traditional FFS is it creates cash flow predictability. A pre-determined amount is paid monthly for each member, regardless of actual healthcare utilization. In this dynamic, providers are incentivized to invest in infrastructure and processes that improve coordination and delivery of appropriate, evidence-based care and preventive services that keep patients healthy. When it comes to processing capitation claims, ACOs considering participation in the REACH program need to look beyond the legacy core administrative processing systems that were designed for FFS. These traditional systems are costly to implement, operate, and maintain, and can require manual workarounds to fill functionality gaps. A streamlined payment technology solution built for capitation can increase the efficiency of financial managers with automated capitation payment reconciliation and claims adjudication. It can also allocate and distribute payments to networked ACO providers, which can quickly become complicated with payments to specialists under the model’s Total Care option. As prospective participants evaluate the technology requirements needed for success, composing a HIT platform with capitation payment technology will help organizations avoid the inefficiencies and unforeseen expenses that arise when legacy systems are extended with manual processes to fill functionality gaps.
A central theme of ACO REACH is health equity. Participants must submit a health equity plan, and then execute that plan. This can be a complicated exercise because it requires disparate technologies to work in synchronicity. Data management, analytics, and care delivery must all operate in a complementary fashion, with a single source of truth driving insights and action. A strong enterprise data foundation is a requirement. Processing clinical, claims, and social data into a centralized data lake lends itself to more accurate identification of disparities to target in a health equity plan. Once social markers are analyzed alongside the Area Deprivation Index, gaps can be identified to create a health equity plan that is based on the unique characteristics of the beneficiary population. After goals are established, executing the health equity plan requires care management operations that are deeply linked to the analytic insights and underlying data. Technology can empower care teams with focused tasks that are assigned based on role and license and relate back to the objectives of a health equity plan. Establishing care delivery workflows that coordinate care teams to act on opportunities and close gaps will help align patient outreach and care delivery with the clinical and business objectives of organizations serving the ACO REACH market.
For organizations evaluating the global risk-sharing option with the Total Care Capitation payment model, opportunities can be found in the downstream agreements between ACO REACH organizations and specialists. Provider performance analytics can evaluate the quality and cost data points to identify high-performing providers. Furthermore, innovative payment models such as sub-capitation and episode-based payment agreements can be established between the ACO and its Preferred Providers that define procedure bundles and prospective pricing for common conditions and events. Both high-performing provider networks and prospective bundles are ways for ACO REACH entities to layer more predictability into their business models.
As with other CMS models, a quality withhold is applied to reimbursement. Meet the quality targets and a greater reimbursement amount is unlocked. In ACO REACH there are quality measures tied to reporting and performance. A technology-enabled approach, including analytics-driven cohort identification and aligned care team apps, can help ensure that measures are fulfilled during patient interactions, helping to maximize the value of the encounter. Alternatively, open gaps can be evaluated and addressed through a coordinated, aggregate approach designed specifically to close care gaps.
5. Investing in Modular Componentry Designed for Value-Based Care
HIT is on the precipice of change. Legacy systems designed to support FFS payment models are failing to deliver the functionality needed for value-based care. This results in organizations that are ill-equipped to realize the clinical and financial upside of new payment and care models. Modular componentry or “composable” technology, as coined by Gartner, is the concept of adding and removing functionality to a common enterprise platform that is composed to meet the current business objectives of the organization. Walled systems and proprietary application interfaces limit flexibility. Even application ecosystems built around a proprietary product provide a limited range of options, as organizations are reliant on the decisions and speed of the ecosystem host. Investing in a modular platform designed to meet the unique needs of the organization, with point solutions that work together and that can also be replaced with new solutions as requirements evolve, will grant organizations the flexibility needed to rapidly pursue new business opportunities, like ACO REACH.
ACO REACH embodies the strategic objectives and roadmap of CMS. For this reason, it is the opinion of some that ACO REACH may become the predominant care delivery model for Medicare beneficiaries. Engaging with the model early, and cultivating the technology, people, and process required to succeed can prepare organizations serving the ACO REACH market for a future dominated by value-based care and payment.
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