Medicare ACOs Use Analytics for Care Coordination, Population Health

Most Medicare ACOs are using data analytics to improve care coordination and population health, but many struggle with data completeness and collection.

By Jessica Kent

May 29, 2019 - Although most Medicare ACOs are leveraging data analytics to inform their care coordination and population health efforts, many are also struggling with issues of data completeness and collection, revealed a report from OIG.

Care coordination is a crucial part of keeping Medicare patients well, OIG noted, and health IT can help clinicians manage patients with complex diseases.

“CMS has identified care coordination as integral to achieving better care, improved health, and lower costs,” the report said.

“Health IT has significantly enhanced providers’ opportunities to coordinate patient care across healthcare settings, and Medicare patients often have chronic medical conditions that require care from multiple providers.”

OIG interviewed administrative staff and providers at six Medicare ACOs to see how these organizations are using data analytics and health IT to coordinate care for their patients. The agency found that most ACOs are using population-level data analytics for risk stratification, grouping patient populations according to the potential severity and cost of their health conditions.

Identifying these patients can help ACOs use specialized outreach and coordination strategies to improve population health, OIG said.

“One ACO analyzes data such as claims from CMS and admissions to identify patients who have more complex needs and require a greater level of care coordination. This ACO uses analytics to begin coordinating care for patients before their initial visit to the ACO’s providers,” the report stated.

“The ACO prospectively analyzes claims and other available patient data as soon as CMS sends the list of the ACO’s patients, assessing each patient’s risk level and preemptively setting up care management strategies.”

ACOs can identify patients with certain chronic conditions, such as end-stage renal disease, and focus its efforts on these groups. Patients can consent to increased care coordination that will help them better manage their complex conditions.

While most ACOs had some risk stratification process in place for population health, few had implemented the same methods for individual patient care. OIG found that one of these ACOs had developed a registry for high-risk patients who frequently visited emergency rooms. The organization designed care plans specifically for these patients, involving coordination across multiple providers.

Despite these efforts to improve population health, all ACOs reported having issues with data quality and completeness.

“Claims and other data from outside an EHR may be untimely, incomplete, or of poor quality. As a result, an ACO may have difficulty developing a comprehensive understanding of the patient population’s needs and risks,” the report said.

Several ACOs also said they had challenges collecting patients’ social determinants of healthdata, including where and how to collect them. Those that are incorporating social determinants information into their analytics are collecting the data from the EHR or patient surveys.

“One of these ACOs has a large population that is dually eligible for Medicare and Medicaid, and its patients may face greater difficulty in accessing basic resources,” the report said.  

“This ACO incorporates data directly from EHRs on patient housing, nutrition, and access to transportation. ACO providers and staff obtain the data from patients during new patient visits, and by going onsite to various community organizations where they manually abstract records.”

ACOs are also accessing health information exchanges (HIEs) to improve their care coordination efforts. OIG found that some ACOs have access to HIEs that provide useful patient data, but that most ACOs interviewed had access to HIEs with little or incomplete data. A lack of access to reliable, high-quality can make care coordination difficult, especially when patients see providers outside the ACOs' networks.

“Some ACOs we visited faced challenges when sharing data with providers who are outside the ACO network and do not participate in an HIE,” the report said.

“For example, one ACO told us about a situation in which an oncology patient had been hospitalized and the hospital physician was unable to retrieve records from the patient’s oncologist. Some ACOs receive data from outside providers via non-searchable PDF files or other types of files that are not easily searchable, which means that providers need extra time to find the information they need at the point of care.”

To resolve these issues, one ACO interviewed uses a web portal to capture data from providers outside the network. The portal includes a feed of admissions, discharges, and transfers that automatically alert providers at the ACO when patients use emergency services.

Overall, OIG found that although ACOs are leveraging data analytics and health IT tools to boost their care coordination and population health efforts, many still have progress to make.

“The six Medicare ACOs we visited have used health IT to better coordinate care for their patients in a variety of ways. However, the full potential of health IT has not yet been realized. ACOs differ as to the extent to which they can rely on health IT tools, in some cases because those tools are not sufficiently robust,” the report concluded.

“HHS has invested heavily in promoting the use of health IT tools because of the promise they hold to help patients achieve better outcomes at lower costs. This work showcases some of the advances that ACOs have made as well as remaining challenges to fulfilling that promise.”

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