Accountable care organizations are responsible for managing the quality and cost of patients. However, a small share of patients make up a large share of health care cost. How can ACOs improve the care and reduce the cost of these patients?
First, ACOs need to understand the needs of high-cost patients. A perspective by Powers and Chaguturu (2016) examine the complexity of these high-cost patients:
The costliest 1% of Medicare patients had an average of eight co-occurring chronic conditions. Most had cardiovascular risk factors, and more than half had end-stage sequelae of ischemic heart disease, congestive heart failure, or chronic kidney disease…In the Medicaid population, high-cost patients also had several co-occurring chronic conditions (an average of five) but there was a striking prevalence of mental health disorders. A quarter of the patients had been diagnosed with depression, another quarter with anxiety, and almost one fifth with bipolar disorder…Drivers of high costs [for the commercially insured population]…included catastrophic injuries, neurologic events, and need for specialty pharmaceuticals — particularly antineoplastics, but also biologics for multiple sclerosis or rheumatoid arthritis.
How can ACOs reduce the cost of care for these patients? The authors suggest the following:
[For Medicare patients]…the use of nurse care managers who work with high-risk patients to coordinate care among providers, monitor and track outcomes, and engage patients in disease management has been successful in some cases. We also found that 20% of spending in this group is attributable to post-acute care, which suggests the need for strategies aimed at high-value post-acute and skilled-nursing care….[For Medicaid patients] accountable care strategies for this population to improve access to mental health care and to integrate mental health services into broader care-coordination and disease-management models…high cost commercial patients would…need to focus on ensuringappropriate use of specialtypharmaceuticals in treating chronicdisease.
Because high-cost patients in different populations have different needs, it is imperative for ACOs to tailor their case management programs to the needs of these specific patient groups.