By Elizabeth M. Dries, J.D.
A recent study conducted by the Commonwealth Fund reveals that accountable care organizations (ACOs) use a range of approaches to segment, or group, their sickest and costliest patients by the level of care and management they require. When primary care clinicians are engaged in refining segmentation approaches, ACOs can increase the usefulness of results and frontline providers’ willingness to use them.
Accountable Care Organizations. Five percent of the U.S. population has complex medical and behavioral or social needs, but this group accounts for 50 percent of the country’s health care spending. ACOs have prompted decision makers at health care delivery systems to seek the best ways to meet these patients’ needs while controlling costs. Many ACOs have used predictive modeling and risk stratification to sort their entire population into risk levels (such as low, medium, and high). ACOs typically linked their high-risk patients to the ACOs general care management program with mixed results. High-risk patients have wide-ranging needs and benefit from different care services. Few ACOs have tackled segmentation of the high-need, high-cost (HNHC) population into smaller subgroups with similar needs.
The study and findings. The study examined Medicare ACOs and a few Medicaid ACOs operating under CMS’ authority that had been in place for at least three years, or that had a long history of risk contracting before becoming an ACO. Interviews with 44 respondents comprising 10 national experts and 34 respondents from 18 ACOs were conducted via telephone. ACO respondents were medical directors, executives, care management program leads, clinician leaders, or data analytic leads. ACO characteristics were balanced by region, type (Medicare Shared Savings Program, Next Generation, Medicaid), ownership type, and the size of the population served.
The study revealed that ACOS use a range of approaches to segment their HNHC patients. Most ACOs use both quantitative information, such as claims data, and qualitative data, including clinician assessments, to risk-stratify their population. While, all ACOS engaged in whole population risk stratification, some further segment their HNHC patients into subgroups. Although there was no consistent set of subgroups, certain subgroups were common including the frail elderly, advanced illness, transitional care, homebound, comorbid medical conditions (diabetes, chronic obstructive pulmonary disease), comorbid medical and mental health conditions, chronic care, rising risk, disabled and end-stage renal disease. Furthermore, respondents noted that when primary care clinicians were engaged in refining segmentation approaches, there was an increase in both the clinical relevance of the results as well as the willingness of frontline providers to use them. Population segmentation results informed ACOs’ understanding of program need. Finally, respondents identified several challenges to population segmentation and resource tailoring. Ongoing needs include: (1) improving the availability of current, accurate data on patients’ clinical, functional, social, and behavioral needs; (2) strengthening analytic and clinical resources; and (3) improving the evaluation of segmentation and care management programs. Findings on how mature ACOs are segmenting their HNHC population can improve the future development of more systematic approaches.
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