ACOs Angling for a Bigger Role in Health Equity

WASHINGTON — Accountable care organizations (ACOs) can improve health equity in their patient populations, but they need more funding and flexibility to do so, according to a report from a group representing 370 ACOs.

“ACOs are already beginning to do the work of addressing negative [social determinants of health] to improve quality and control costs for the patients they serve. However, they cannot be broadly effective or achieve desired outcomes without proper funding and support,” said a white paper released last week by the National Association of ACOs (NAACOS), which represents groups of doctors, hospitals, and/or other healthcare providers that work together with a goal of providing better care at lower cost.

Some ACOs Are Taking Action

Some ACOs are already making efforts on the equity front. Gary Jacobs, executive director of the Center for Government Relations and Public Policy at VillageMD, a primary care provider based in Chicago with 200 locations in 13 markets nationwide, explained at the NAACOS Fall 2021 conference last week about the project his company — which includes many providers who participate in ACOs — is doing with the Walgreens pharmacy chain.

“We’re opening primary care centers — these aren’t like a little desk within Walgreens; these are 3,000-square-foot facilities in Walgreens facilities around the country, and part of our original deal was 50% of them would be located in underserved communities,” he said. “And that meant to us that we needed to identify providers — physicians, nurse practitioners, medical assistants that were also reflective of the communities that we were going into, because people want … people like themselves to take care of them.”

Mount Sinai Health System in New York City, which includes an ACO, is focusing on developing trusted partnerships with underserved communities, said Rob Fields, MD, a family physician there. His group is starting with a project at a public charter school in East Harlem, on the same block as a large public housing complex.

“We’re putting a community health worker there with telemedicine, so the … community health worker can facilitate social care referrals and physical care referrals by partnering with an FQHC [federally qualified health center] that’s one block over,” he explained. “If they’re already coming to the school — they’re already engaged with the school, they have that relationship — that community health worker can facilitate the process of signing up for a televisit,” which is helpful for patients whose families don’t have computers or internet service.

A Big “Aha!” Moment

Tracey Wilkie, senior director of population health analytics at UMass Memorial Medical Center, in Worcester, Massachusetts, which participates in an ACO, discussed her health system’s project in its pediatric division, looking specifically at why there were more cancellations and no-shows for well-child visits among Black and Hispanic populations.

“This was kind of a big ‘aha!’ moment for us, because when we started looking at scheduling data … the rates of no-show and cancellations were double those of the white population,” she said. “It was really important to look at those separately, and we learned early on that it’s really important to follow up on every no-show and cancellation.”

The medical center also hired an outside consulting firm which spoke with 30 families — 15 English-speaking and 15 Spanish-speaking — to find out the reasons for cancellations and no-shows. While the families understood the importance of the well-child visit, the consulting firm “identified six major barriers to these patient getting their appointments, and starting at the top was transportation,” she said. “Some families only have one car, and somebody uses it to go to work every day.”

Work itself was another issue, Wilkie said: “It’s hard to sometimes get time off from work to come in for a well visit.”

Other barriers included speaking a language other than English, appointment availability, and patients reaching adolescence — even though well visits go to age 21, it’s hard to get 18- to 21-year-olds to come in for the visits, Wilkie said.

“Our primary care practices are located in areas where patients have to pay for parking,” she added. “Sometimes for patients that are struggling to pay for parking, they have to make a choice: pay for parking or feed their family. This is the first barrier area that our work group is going to focus on.”

Recommendations for Improvement

As the NAACOS white paper noted, the pandemic has helped reveal health inequities, including “significant disparities in disease burden, access to testing and treatment, quality of care, and health outcomes.” The paper made several recommendations aimed at improving health equity among ACO patients, including:

• Providing funding to expand social services to address health equity. CMS could provide grant funding to ACOs to expand and develop their connections with community-based organizations and to enhance ACOs’ internal capacity to target underserved populations and meet social needs, the authors suggested. Additionally, the Center for Medicare & Medicaid Innovation (CMMI) could establish a voluntary model within the Medicare Shared Savings Program (MSSP) — Medicare’s most popular ACO program — for ACOs focused on health equity. These ACOs could apply to the model and detail to CMMI how they would use the upfront funding to address health equity gaps in their patient populations. If the ACO generates shared savings, the initial investment could be recouped by CMS. If it does not generate savings, the funds would be forgiven by CMS as long as the ACO remains in the program.
• Increasing benchmarks to benefit ACOs treating vulnerable populations. One study found that only 9.1% of health systems invest in social determinant or community health programs. Of those investing health systems, 86% participate in an ACO, compared with only 52% of non-investing health systems. “This shows that ACOs are more likely than non-ACOs to invest in social determinants work, and this work could be supported and expanded by providing additional compensation for this work to be done,” the authors wrote. “One way to achieve this is to update the MSSP benchmarking methodology to reflect the work that is being done. Benchmarks should be adjusted to fairly and appropriately compensate providers for providing care to vulnerable or underserved populations to reflect the differences in providing care.”
• Providing additional flexibility with Medicare rules for ACOs to deliver supplemental benefits to patients to help address health equity. The Department of Health and Human Services (HHS) and CMS could allow ACOs to deliver benefits related to transportation, housing, food insecurity, as well as supports for other social needs. “There is precedent in Medicare for allowing such flexibilities, recently illustrated by new policies in Medicare Advantage (MA) that allow premium dollars to go towards addressing social needs,” the white paper said. Some examples of supplemental benefits that may be offered include food, pest control, indoor air quality equipment, and structural home modifications.

Implementing these recommendations “will poise ACOs to integrate health equity initiatives into their programs” and will “help to ensure that ACOs are equipped to effectively measure, track, and address health equity in their work,” the authors concluded.