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Organizations are often considering taking on risk as an Accountable Care Organization (ACO). This blog will attempt to encapsulate the top 10 challenges they face in doing so.
1. Overcoming SDOH Challenges (behavioral, access, stress, transportation, nutrition, etc.) Drive Outsized Impacts
Several social determinants of health (SDOH) have significant impacts on the cost of care within healthcare systems. Determinants include behavioral, access, stress, transportation, nutrition, and more. These determinants influence health outcomes and healthcare utilization patterns, ultimately affecting the overall cost of providing care.
2. Lack of Electronic Health Record (EHR)
Most ACOs use a community model, and no shared EHR exists for clinical use across all participant, preferred partners and patient and patient families.
3. Lack of Interoperability
At least 70% of US healthcare providers still exchange medical information using a fax machine, according to Bloomberg Law. Even hospitals with the latest EHR technology may still use faxes. Why? EHRs often can’t share data across systems. Even within systems, data is often siloed. Sometimes, vital patient data never makes it into the EHR, can’t be properly interpreted or isn’t fully integrated with clinical decision support tools. Clinical decision support requires greater interoperability to be successful.
4. Optimizing Clinical Workflows
Clinicians and staff need access to actionable information at the point of care. But when workflows are not optimized, providers are forced to deal with incomplete information, alert fatigue and delays.
5. Managing Care Transitions
Care transitions occur when a patient moves from one health care provider or setting to another. Nearly one in five Medicare patients discharged from a hospital — approximately 2.6 million seniors — are readmitted within 30 days, at a cost of over $26 billion every year.
6. Managing ED Utilization
According to the Centers for Disease Control and Prevention (CDC), Americans make more than 139 million visits to the emergency department (ED) each year. About half of these visits involved chronic conditions, primarily related to heart disease and diabetes many of which could have been prevented with proper condition management and ongoing care from a primary care physician (PCP).
7. Financial Sustainability
ACOs often operate under value-based care models, where reimbursement is tied to quality metrics and cost savings. Achieving financial sustainability requires effectively managing costs while maintaining or improving quality of care.
8. HCC Coding and Risk Adjustment Factor (RAF) Workflow
ACOs face challenges in accurately capturing HCC codes, leading to missed revenue opportunities and inaccurate risk adjustment. Without reliable HCC coding practices, ACOs face financial penalties and miss out on revenue optimization opportunities.
9. Point of Care Decision Support
ACOs struggle to assist point of care physicians who are currently driving healthcare costs, hindering their ability to prioritize interventions and allocate resources effectively.
10. Care Management
ACOs lack clear insights into the outcomes of intervention efforts, leading to uncertainty about the effectiveness of current care strategies and resource allocation. They also lack comprehensive data on utilization trends before and after intervention, making it challenging to assess the impact of interventions on patient outcomes and cost savings.
Author:
Jeremy Powell | CEO & Founder, Acclivity Health Solutions
