Accountable Care Organizations (ACOs) know they need to follow regulations. That means adhering to Centers for Medicare & Medicaid Services (CMS) requirements for REACH ACOs to develop and maintain comprehensive health equity plans. For 2023, REACH ACOs are not being penalized for their health equity plan if it does not work in practice and only works on paper. However, next year REACH ACOs will have to show success, and by kicking the can down the road they risk not knowing enough about their patient population in terms of what works better and what doesn’t. With the first year of such requirements already halfway underfoot, some ACOs many already feel the pain of actually complying with the requirement in practice.

A study recently published in JAMA Internal Medicine quantified a component of that pain point in dollars, estimating it costs $60 per member each month to provide evidence-based support for housing, transportation food, and care coordination. However, federal funding only covers half of the average cost of such solutions, leaving the burden on risk-bearing organizations.

Additional funding could help. Improving health equity on a patient by patient level could, too. That means not just checking a box that an ACO Reach complies with requirements and then moving on. Rather success in lowering cost per patient would require ACO Reach organizations to iterate on a continuous basis. Their bottom line and patients’ health will quantify if they did enough. This year offers an ideal time to implement so they can see what works for their given patient population.

Here’s what that can look like in practice.

Address the evolving sociodemographic landscape

Race, ethnicity, socioeconomic status, and geographic location influence health disparities. Though some of these sociodemographic factors do not change, the landscape as a whole continuously evolves. People move. Someone loses their job. A partner dies. A teen has children. The communities served by REACH ACOs are not static entities. Attempts towards health equity cannot treat these groups like they are static.

ACO Reach organizations need to anticipate and account for changes in population demographics, migration patterns, and other socioeconomic condition changes in their patient cohorts. Such movement necessitates ongoing assessment and refinement of health equity plans if a risk-bearing organization wishes to best serve its patients and deliver on health equity goals. Failure to do so could mean increased cost of care per patient. And the risk-bearing organizations do not have the budget for such errors. Continuous iteration can empower ACOs to adapt their strategies to address emerging disparities and prioritize resources effectively.

Act on data-driven insights

Data plays a vital role in understanding health disparities and guiding interventions. For example, knowing the risk profile of a diabetic patients living in a food swamp could support an ACO in curating a tailored plan to best manage that comorbidity. Like sociodemographics, such data continuously changes. Say the diabetic breaks her leg and can no longer exercise. Or the cardiovascular patient moves into low income housing where smoking is permitted and his lungs suffer. Risk-bearing organization could leverage that knowledge to appropriately update each patient’s care plan if they had access to said information.

Continuous iteration of health equity plans is facilitated by ongoing data collection, analysis, and evaluation, which can really impact the quality of care patients receive. By monitoring key metrics, such as health outcomes, utilization patterns, and patient experiences, REACH ACOs can identify disparities and tailor interventions to specific populations on a constant basis.

Further, regular data analysis enables ACOs to measure the impact of their interventions, identify areas of success or improvement, and make data-driven decisions to promote health equity. These efforts can give the risk-bearing organizaton confidence in their choices knowing the actions likely can lower the cost per patient.

Pursue collaborative learning and engagement

ACO Reach organizations do not have to tackle health equity alone. Successful and sustainable health equity requires collaborative efforts involving healthcare providers, community organizations, policymakers, and patients themselves. In this realm too of involving stakeholders in the evaluation, consistent iteration brings the biggest payout in terms of both patient health and cost.

Through collaborations and revisiting, then revisiting again and again what is possible through partnerships, ACOs can gain valuable insights, uncover unmet needs, and foster a sense of ownership and accountability. Iteration also allows ACOs to share best practices, lessons learned, and successful interventions with other organizations, promoting collective learning and improvement across the healthcare system.

Though it might feel like a near herculean lift, health equity can mean a world of difference for patients and the ACOs who serve them. To help achieve this aim, ACOs can adjust their expectation to include a dynamic ongoing commitment of continuous improvement. This iterative approach enables ACOs to identify and address emerging disparities, optimize resource allocation, and enhance the overall quality of care.

Here’s the irony: ACOs can pay in the effort of continuous iteration or they can pay in poor health outcomes for their patients and the resulting increased costs. The choice is theirs, but one they each have to make.

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