Serious Illness Approaches by ACOs

  • Published on:
  • April 25, 2019

Provider: U.S. Medical Management

Background: Frail elderly, homebound patients have complex and/or multiple chronic conditions, are often unable to travel, and struggle accessing clinical care. Given these challenges, these patients often have poorly managed conditions, which cause regular symptom exacerbations that require emergency department (ED) visits or hospitalizations.

Focusing an entire care model on such a challenging patient population is a high-risk proposition for an ACO. Care for these patients requires significant infrastructure investment, new methods of care coordination, and many other reforms. Additionally, unexpected, catastrophic events involving a small share of enrollees can dramatically swing financial results. Furthermore, technology and care approaches remain imperfect, and evolving regulations that can make running a predictable program difficult.

At the same time, improving care for serious illness patients would reduce unnecessary (and expensive) ED visits and hospitalizations, thereby providing shared savings under the ACO model. Can an organization successfully operate an ACO targeted specifically at high utilizers? U.S. Medical Management (USMM) offers a strong test case, but impending changes hint at an uncertain future.