As we stand on the brink of 2025, the healthcare landscape is poised for a transformative shift. The transition to value-based care presents significant opportunities and challenges for Accountable Care Organizations (ACOs), particularly for healthcare executives, financial officers, and clinical leaders.
This blog discusses the changes that ACOs will face as they move towards 2025 and beyond. Such a transition leaves much to anticipate for top management, especially for Chief Medical Officers (CMOs), who must navigate an increasingly intricate healthcare environment, particularly in integrating new technologies and overseeing the clinical workforce.
ACO Key Challenges Faced by CMOs
One of the biggest challenges has been the integration of technology into existing workflows. CMOs often face resistance from physicians who simply don’t have the bandwidth to spend time on new tools, which is critical in the shift towards value-based care models.
- Integrated Solutions: In essence, risk adjustment for ACOs demands a solution offering user-friendly platforms and flawless integration capabilities, causing minimal disruptions to current processes and saving valuable time for clinicians. This is particularly crucial in environments where Hierarchical Condition Categories (HCC) coding and accurate documentation directly impact Risk Adjustment Factor (RAF) scores and ACOs’ financial sustainability.
- Fair Reinbursments: Aligning incentives for healthcare providers within an Accountable Care Organization (ACO) is another significant pain point. Risk-based contracting requires precise coordination among care teams to ensure shared savings and performance metrics are met.
- Patient Data Security: Furthermore, patient data security remains a top concern for CMO teams. Patient data security and privacy are non-negotiable in today’s healthcare environment, particularly as interoperability in healthcare continues to evolve, requiring secure data sharing across platforms.
Additionally, the extensive time clinicians often spend reviewing past documentation—particularly when evaluating cases with incomplete or insufficient MEAT (Monitoring, Evaluation, Assessment, Treatment) evidence and clinical indicators—is a significant concern for CMOs.
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RAAPID Risk Adjustment Solutions: Helping ACOs recognize time-critical challenges
Providing a prospective suite of solutions to support risk adjustment for ACOs enables data-driven decision-making, ensuring reimbursements are aligned with patient outcomes—an essential requirement for risk-based contracting models.
Indeed, our prospective suite of solutions is committed to helping CMOs maintain compliance with stringent healthcare regulations while leveraging technology to improve care outcomes. This also includes addressing social determinants of health (SDOH), an increasingly important factor in managing patient populations under value-based care models.
Prospective Solution Benefits
| Risk Adjustment Solutions | Benefits |
|---|
- Eases Physician Burnout: Reduces excessive administrative tasks and manual data collection in ACOs.
- Actionable Insights: It provides actionable insights that allow physicians to identify gaps in diagnosis that must be addressed during upcoming visits.
- Facilitates Annual Wellness Visits: Empowers pre-care teams by providing a comprehensive summary of annual wellness visits derived from 360-degree longitudinal patient data.
- HCC Coding Improvement: Boosts RAF scores, essential for the financial stability of ACOs
- Reduce Care Gaps: It enables providers to reduce care gaps efficiently and deliver comprehensive, data-driven care in every encounter.
- High-Quality Care: It enables ACOs to highlight clinical discrepancies directly within the EHR, allowing physicians to address these gaps during the visit.
- Documentation Accuracy: Improves accuracy in documentation, ensuring better patient care and operational efficiency.
- Interoperability: Facilitates seamless coordination across healthcare systems, enhancing care delivery and resource optimization.
- Accurate Coding: Ensures diagnostic codes are captured before claims submission, improving accuracy and compliance.
- Compliance: Critical for ACO success, ensuring claims align with care provided and reducing audit risks.
- Pre-Claim Audit: Audit HCC codes pre-submission, enhancing the accuracy and integrity of risk adjustment processes.
- Financial Integrity: Supports accurate claims, reducing provider audit risks and strengthening financial stability for ACOs.
Key Strategies to Help CMOs Achieve ACO Success
To effectively address the challenges discussed above, ACOs need to implement comprehensive strategies that emphasize employee training, technological advancements, and optimized processes.
One of the key strategies involves budgeting; therefore, for estimating a 2025 premium, CMOs can begin by analyzing 2023 data to identify key drivers that will shape future costs. These factors include trends in unit cost and utilization, population morbidity shifts, changes in plan design, and potential regulatory updates like risk model adjustments or coverage expansions. Through careful analysis, these components are estimated to contribute a plus 4-5% increase over two years. The ACO, in accepting this fixed increase, assumes the unknown risks of future service costs.
However, health plans are built to manage this “pricing risk” with their wealth of data, expertise, and capital reserves.
Other Key strategies include:
Rooting for Payer-provider collaboration
Payer-provider collaboration is vital for ACO’s success. It enhances resources and operational efficiencies, ultimately leading to better patient outcomes and care delivery. Collaborative efforts are also critical for addressing social determinants of health (SDOH), ensuring that external factors impacting patient health are considered in care plans.
Partnerships with Technology Providers
Engaging with third-party risk adjustment vendors and identifying the ideal risk adjustment vendor is crucial for integrating innovative solutions that streamline processes and enhance the quality of patient care. These partnerships also support the implementation of AI-powered risk adjustment, which provides deeper insights into patient health data.
Improving Patient Data Security Measures
Implementing advanced security protocols, including encryption and access controls, is essential to protect sensitive patient information and ensure compliance with HIPAA regulations. As ACOs rely on interoperable systems to share data across platforms, these measures become even more critical.
Care Network Development- For Better Health Plan Coverage
Building networks of primary care providers and specialists ensures timely, coordinated care, which significantly improves the health plan’s coverage as patients get increased treatment options within the network, so patients need not go looking for treatments outside the network.
Addressing Regulatory & Policy Challenges
Adapting to changing CMS regulations and RADV audit policies requires overcoming organizational barriers. This fosters effective communication and alignment, enabling CMO teams to maintain compliance and promote a unified approach to delivering high-quality patient care.
Accurate HCC coding and improved RAF scores further support these regulatory requirements.
Continuous Improvement and Quality Control
Continuous improvement is vital for maintaining high care standards, ensuring that ACOs consistently meet the evolving needs of their patient populations. This includes leveraging suspect analytics in healthcare to foresee potential risks and adjust care plans accordingly.
Utilization of Patient Feedback
Leveraging patient feedback through satisfaction surveys enables ACOs to customize services, enhancing patient engagement and overall care quality. Patient input can also provide valuable insights into addressing social determinants of health (SDOH), contributing to more holistic care approaches.
Benchmarking Against Industry Standards
Regularly benchmarking against industry standards and rating benchmarks helps ACOs remain competitive and dedicated to providing exceptional care, aligning with best practices in healthcare delivery.
Submission Timeline Planning
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Conclusion
As ACOs prepare for the transformative shift in 2025, Chief Medical Officers (CMOs) must navigate complex challenges while maintaining high care standards. By leveraging advanced technologies like RAAPID’s AI-powered solutions, CMOs can streamline operations, enhance collaboration, and ensure compliance with evolving regulations. Emphasizing continuous improvement, data security, and provider-payer collaboration will enable ACOs to thrive in the evolving healthcare landscape, ultimately delivering better patient outcomes and operational efficiency.
