ACOs: A model for better health outcomes, lower costs

Accountable Care Organizations (ACOs) are dot connectors in today’s health care system. ACOs are designed to provide coordinated care for employees and their families by creating a network of quality providers that deliver outcome-based results – lowering total cost of care along the way.

One of the primary reasons ACOs are successful is because members can connect with a quality designated primary care physician (PCP) upon enrollment. In this Q&A, Ernie Bourassa, vice president of network solutions for UnitedHealthcare national accounts, discusses the role of the PCP in the ACO framework and highlights the key benefits that employers and employees can realize within this model.

Q: Generally, why is it so critical for a member to have the ability to access a quality designated PCP as the quarterback of one’s care?

A: If we can offer networks and advocacy that link a member to a quality PCP – all other things equal – we know we have much better opportunity to realize that simpler, more positive experience for members. At the same time we position the PCP to really be a true care manager to help guide the member. That includes the PCP recommending that their patients use high-value specialists, hospitals and other care providers in their organizations or within a network of quality providers. That PCP relationship and “steerage” to those quality providers is helping generate better health outcomes, a better member experience and lower costs.

For example, consider these statistics for UnitedHealthcare patients who saw Tier 1 physicians for more than 75% of their care. While not all physicians within an ACO are considered Tier 1 or UnitedHealth Premium® designated physicians, the ACO framework exists to connect members with those providers when possible:

  • The patients had 28% fewer emergency department visits.
  • Almost 40% had fewer hospital admissions.
  • They resulted in 24% lower risk-adjusted spending – $217 vs. $286 per member per month (PMPM).

Adherence also is higher when using a Tier 1 provider. For example, within a Tier 1 ACO structure, patients were 17% more likely to seek out a well-care visit compared to patients with a Tier 2 provider.1 This increased likelihood to comply extends to needs such as cancer and diabetes screenings, as well.

Q: What’s the UnitedHealthcare definition of an ACO?

A: It's an organized provider system that is clinically integrated and taking responsibility in a contractual relationship for improving quality and reducing total cost of care. So you have hospital systems and physician organizations of all sizes caring for large populations of people, and those providers have financial and clinical accountability for quality and total cost of care. With this ACO model, you have a construct that really has potential to move the needle in a very meaningful way on quality and cost.

Q: What does UnitedHealthcare do to steer members to quality providers?

A: We have developed network configurations and new network products that feature a subset of high-performing physicians from the standpoint of quality and cost efficiency. And we feature them in products and network configurations that allow us to better connect members with those quality physicians. 

Not only are we promoting and displaying who those physicians are, but we have products that either have a narrow network or a tiered benefit design with meaningful benefit differentials so members have a clearer financial incentive to use the quality providers. In the narrow networks, we've reduced the size of the network so that it contains a larger portion of or, in some cases, only these quality providers.

Our digital tools also help promote the use of these quality providers. When searching for a provider, a member sees a Tier 1 icon within their computer’s web browser or within their app. That designation makes it clear to members that these are the physicians they should use if they want to maximize their benefit in a tiered plan design.

Q: What data and results demonstrate the impact of ACOs on increasing care quality and decreasing costs?

A: Simply put, ACOs outperform non-ACOs on quality measures. Our data clearly supports that ACOs have better performance on things like readmission rates and HEDIS(Healthcare Effectiveness Data and Information Set) performancescores for things like diabetic screenings, cancer screenings and pediatric preventive care. Here are a few data points2 related to utilization:

  • Members in an ACO visit a PCP at a 10% higher rate than with non-ACOs.
  • There are 14% fewer emergency room (ER) admissions than non-ACOs.
  • Commercial ACOs have 17% lower hospital admissions than non-ACOs.
  • Cancer screening compliance among ACOs is 8% higher than non-ACOs for breast, colorectal and cervical cancer.

Beyond these data points, ACO physicians and specialists are effective in optimizing the place of service where health care is provided – a key driver of costs for employers. Whether it's an MRI, a diagnostic procedure or a surgical procedure, those can be done appropriately and with good outcomes in non-hospital settings. Health care delivered in a hospital setting is more costly than when delivered in a non-hospital setting. So, not only does this ACO model help to minimize ER visits and avoid inappropriate or unnecessary hospital admissions, it's also effective in directing care as appropriate to non-hospital settings.

Q: What is UnitedHealthcare doing to help ACOs measure data to be able to impact individuals’ overall health?

A: Data has helped us redefine what we mean by gaps in care. In our clinical methodology, we look at data and find members whose escalating use of prescription drugs – in number or strength – can indicate a condition that's worsening. We also can look at the path of their care versus a best practice care approach to identify things that their doctor may have missed during a visit, for example.

When we open the hood for a particular client and they see which members they can impact – both making them healthier but also reducing the costs associated with their care – by putting them on a better quality care regimen, that becomes an “aha” moment about how we put data to work.

Q: What does UnitedHealthcare call its tiered products? What are the differences in those products?

A: A tiered product is any product or network configuration that uses a tiered benefit design. It could be 2 tiers or 3 tiers depending on whether there's an out-of-network benefit. The tiering is related to the benefits more than the network itself. Because UnitedHealth Premium designated physicians are available nationally, with very few exceptions, the tiered plan designs and tiered products are available to employers nationwide. From there, an employer can look at what’s available locally – narrow network products and ACOs, for example – and determine the best approach for a particular market.

Q: How would you characterize member satisfaction with ACOs?

A: There’s higher member satisfaction, and that comes from the fact that there's a more engaged relationship with a PCP. That physician is going to make everything easier in terms of accessing referrals and accessing specialists at the right time in the right place, taking care of those gaps in care, doing the follow up for patients who had an ER encounter, etc. A member is more likely to have an easier, simpler experience with an organized ACO and a PCP at the helm.

 

Tier 1 providers may be subject to change, visit myuhc.com® for the most current information or call the number on your health plan ID card.

The UnitedHealth Premium® designation program is a resource for informational purposes only. Designations are displayed in UnitedHealthcare online physician directories at myuhc.com®. You should always visit myuhc.com for the most current information. Premium designations are a guide to choosing a physician and may be used as one of many factors you consider when choosing a physician. If you already have a physician, you may also wish to confer with him or her for advice on selecting other physicians. You should also discuss designations with a physician before choosing him or her. Physician evaluations have a risk of error and should not be the sole basis for selecting a physician. Please visit myuhc.com for detailed program information and methodologies.

Footnotes

  1. UnitedHealthcare study conducted by looking at the total policy and continuous enrollment to allow for a like cohort analysis of 2017 vs. 2018 experience, eliminating the impact of population churn and utilization changes.
  2. 2018 Value-based Care Report, “How value-based care is improving quality and care,” February 2018.