ACOs: Improving Care Through Nonmedical Services

More accountable care organizations (ACOs) are offering services that address patients nonmedical needs as well as their medical needs in an effort to reduce health care costs; however, many of these programs are still in their infancy and it is too early to tell which programs will be most effective.

Mitch Morris, global leader of health care at Deloitte, told First Report Managed Care that the industry as a whole is placing a greater focus on the role that social determinants play in health. These factors include aspects such as housing, transportation, availability of food, and the level of support within the community. 
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“We’re really beginning to realize the importance of some of those things, so it gets beyond behavioral health, which is part of it, it’s just also supporting people in their home settings, particularly the elderly and those who don’t have involved caregivers with them,” Mr Morris said.

Research has suggested that social determinants of health can play a large role in patient outcomes and mortality rates. For instance, a 2002 study in Health Affairs, by J Michael McGinnis, MD, suggested that only 10% to 15% of preventable mortality could have been improved by better medical care, while the remaining percentage could have been improved by behavioral, social, or environmental interventions. 

Additionally, a 2011 meta-analysis, in the American Journal of Public Health, of almost 50 studies led by Sandro Galea, MD, DrPH, found that social factors, such as education, social support, race, and poverty accounted for over a third of all deaths in 1 year. 

As the data surrounding the value of social, behavioral, and environmental interventions grows, many payers and providers are starting to consider providing some of these nonmedical services. 

ACOs are starting to get on board, Mr Morris said, because they have a financial incentive to keep the overall health care costs of their patients down. 

A recent study by Taressa Fraze, PhD, a Dartmouth Institute Research Scientist, found that 16 out of the 32 ACOs that participated in the study reported addressing nonmedical needs of their patients. The ACOs most commonly addressed issues related to housing stability, transportation, and food insecurity.

But while evidence is growing that ACOs are dipping their toe into the nonmedical needs arena, experts agree that it is still too early to tell whether these interventions will actually lower medical costs or be replicable on a larger scale. 

“We’re still in the anecdotal phase where people can talk about great successes,” David Muhlestein, PhD, JD, vice president of research at Leavitt Partners, LLC, said. “The challenge though is: what is the total cost of implementing it versus the total cost of savings—and that’s still unclear.”

Innovative Nonmedical Strategies

While experts say there is still a lack of evidence about the success of nonmedical interventions on a large scale, there have been anecdotal stories of ACOs that have adopted innovative strategies to address nonmedical needs. 

For example, Dr Muhlestein said he knew of an ACO who essentially created their own Uber for patients by hiring their own full-time driver to drive patients to and from appointments. 

He also pointed to the success of the Nuka System of Care in Alaska, which works to not only address patient’s medical needs but is also designed to address behavioral, dental, and social needs as well. 

According to the Southcentral Foundation, who developed the Nuka System of Care, from 2008 to 2015, the care system saw a 23% reduction in emergency room visits and a 25% reduction in primary care visits as a result of their efforts.

Mr Morris said he has seen other health systems adopt strategies to address another factor linked to poor health: living alone. Some health systems have trained and hired individuals to make home visits after patients are released from the hospital to try to reduce readmission rates and emergency room visits.

Anne Montgomery, MS, deputy director of the Center for Elder Care and Advanced Illness at Altarum, said that ACOs and other health care providers need to begin thinking about how they can address nonmedical needs as the need for chronic care and long-term care continues to grow in this country.

“When we think about the age wave and everything it implies, the doubling and the tripling of people and people with functional limitations, we really need to figure out how this pattern of care, which is a different pattern of care that can work most effectively or we’ll spend ourselves into bankruptcy,” she said.

Challenges Remain

Experts agree that addressing nonmedical needs is a promising strategy to curb health care costs and improve patient outcomes; however, ACOs also face significant hurdles to implementing some of these nonmedical services and strategies. 

First, there’s a lack of evidence about what strategies will be most beneficial or lead to cost savings.

“In many countries basic human supports are simply part of self-care and the need for disability adapted housing is right in there with whether we are going to pay for an expensive drug—while in our country we keep these entirely separate,” Joanne Lynn, MD, director of the Center for Elder Care and Advanced Illness at Altarum, said.

She added that in many ways, ACOs don’t have a roadmap of how to move forward.

“ACOs don’t have a strong body of research to say if you do these three things you’ll have a big impact, but if you do these three things you may improve some people’s lives but it won’t really help your bottom line,” Dr Lynn said.  

Experts agree that much of the initial progress may need to be the result of trial and error as ACOs adopt various strategies to address nonmedical needs and then evaluate their effectiveness.

The ACO structure itself is also—as Dr Lynn described it—”awkward” for addressing nonmedical needs because although an ACO may be able to identify a nonmedical need within their patient population that could potentially save them money if they addressed it, the resources necessary to address those needs may not be available in the community.

“For lots of things people need, the payback is so much longer and the access to how to fix it is so much more obscure from the doctor’s perspective,” Dr Lynn said.

For instance, if a physician is able to identify that a patient could benefit from a service like “meals on wheels,” but there is a long waiting list for the service, a physician may lack the resources to do anything further.

“Managed care companies can contract ahead for this and I think well established ACOs will start looking more like managed care, but in the meantime in this struggling period of trying to get on your feet, to contract with a social services agency in a community from an ACO is going to be an unusual ACO I think,” Dr Lynn told First Report Managed Care.

Part of the problem, Dr Muhlestein said, is many ACOs simply lack the experience and don’t know where to start or where the opportunities lie to partner with social service agencies in order to provide the most effective strategies among their particular patient population. 

“In medical school, you are not trained how to work with public health agencies,” Dr Muhlestein said. “You are not trained how to work with social workers, so it’s re-educating that.” 

Some ACOs have chosen to incorporate nonmedical services into their own structure, whether they hire a social worker to be part of the team or hire a driver to offer transportation services; however, Dr Muhlestein said smaller ACOs might not have the resources to make such investments. 

“Different organizations have higher barriers to entry with that,” he said.

Identifying impactful services

With hurdles and obstacles in the way, experts say ACOs will need to rely on analytics to identify who is at risk within their population and where the biggest opportunities exist for intervention.

“You’ve got to be able to understand the costs of the intervention and whether it’s going to make a difference and identify who is the high risk group,” Mr Morris said.

ACOs must also be able to evaluate the success or failure of the interventions they implement to track whether an individual effort was worth the time and money it took to put it in place. Mr Morris said one of the biggest ways  ACOs can find success is by learning from one another. 

Mr Morris recommends that organizations share their best practices and failures with one another.

“Saying what didn’t work sometimes is just as important as saying what did work,” he said.

While the move to providing nonmedical services may be slow for many ACOs, it is likely a movement that’s going to continue.

“I don’t foresee this trend going away,” Dr Muhlestein said. “I think it’s going to grow and I think we are going to see a lot of different models that are starting to be incorporated over time.” 

Ms Montgomery added that as ACOs move toward more population health management and they secure more stable financing, there may be an even greater interest in adopting strategies targeted at addressing a patient’s behavioral, social, or environmental needs.