Data Support Considerations in Medicaid Accountable Care Organization Programs
Medicaid accountable care organizations (ACOs) need data on their attributed populations to successfully improve health outcomes and manage patients’ total cost of care. This includes data on members’ health status; emergency department and inpatient utilization; and risk scores, ideally accounting for social risk factors — such as homelessness, past incarceration, and child protection involvement. State Medicaid agencies have developed a number of approaches to provide data to organizations participating in Medicaid ACO programs.
This technical assistance brief, made possible by The Commonwealth Fund, outlines what types of data Medicaid ACOs need to successfully operate and details how several states provide data to organizations participating in ACOs.
Overview of article
- This brief reviews 3 types of data support that states can provide to help ACOs improve their performance: 1) Patient attribution; 2) Cost and quality; and 3) Care management information. It concludes with lessons and challenges related to sharing data for Medicaid ACO programs, based on state experiences to date
- Patient attribution data: States have detailed methodologies to attribute patients to ACOs, usually focusing on beneficiary choice or beneficiaries’ prior utilization of healthcare resources (e.g., Maine, Massachusetts, Minnesota, Rhode Island)
- Cost and quality performance data: ACO programs use financial incentives to create a business case for providers to improve healthcare quality and slow cost growth in ways that meet the needs of their patients and community. To succeed, ACOs must have access to relevant data to manage the cost of care and develop targeted quality improvement activities for their attributed population (e.g., Minnesota conducts the quality calculations internally and inform ACOs of their performance)
- Care Management information data: Many patients require only minimal care management, but for those with complex medical and social needs, additional care coordination can help improve their quality of life and reduce utilization of expensive interventions such as ED use. There are a variety of data reporting approaches that states can use to support ACO care management activities as well as efforts to address social determinants of health (e.g., Maine and Massachusetts provide ACOs with information on beneficiaries’ total cost to facilitate ACOs’ care coordination activities)
- With data support from states and/or managed care organizations, ACOs can: 1) Identify the needs of their attributed beneficiaries; 2) Understand the total cost of care (TCoC) and quality improvement opportunities of attributed beneficiaries; 3) Stratify their patient population to target care coordination for beneficiaries who could benefit most
- States can empower participating ACO organizations to more effectively coordinate services and support financial incentive efforts to reward providers for better quality care
- Lessons and challenges: 1) There can be a significant time lag for usable utilization data, which limits the ability of ACOs to refine programs that are not achieving desired results; 2) To be used by ACOs, data must be clean and reliable, and states must ensure that anything it delivers to ACOs meets those criteria. There is often wide variation in the quality of encounter data that MCOs deliver to a state; 3) Managing the data required by a Medicaid ACO program can be a substantial undertaking. Offering various levels of data support can meet the needs of ACO program participants that have a wide range of data capacity; 4) Some of the data analytics that ACOs must perform can be conducted more easily by MCOs because they already have all the encounter data for their beneficiaries, and an MCO may also have health information technology infrastructure; 5) Some states have also provided limited datasets to applicants considering participation in Medicaid ACO programs, so they can determine whether they have the data analytics capacity to successfully participate; 6) 42 C.F.R. Part 2 prohibits the disclosure of patient records involving treatment for substance use disorder without the patient’s consent and limits certain types of care coordination activities in which ACOs may want to engage