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Partnering With ACOs to Improve Care for People With Medicare

H. Bard Coats, MD, MBA
Clinical Director

Jenny Lingle, RN, MAS, Population Health Management
Senior Improvement Advisor


As a Centers for Medicare & Medicaid Services (CMS) Quality Innovation Network-Quality Improvement Organization (QIN-QIO), Comagine Health works with health care delivery systems to improve clinical processes that support patients with Medicare to prevent and manage chronic diseases. Accountable Care Organizations (ACOs) present an important partner in these efforts. Together, we can implement sustainable quality improvement initiatives that improve care.

The term “Accountable Care Organization” was coined by Dr. Elliott Fisher in 2006. ACOs became a hot topic during discussion of the Affordable Care Act (ACA), and they were eventually included in the ACA’s final form. ACOs are groups of health care providers who coordinate care for people with Medicare to provide high-quality care that avoids duplication and achieves savings for the Medicare program overall. Managing chronic diseases is a big part of an ACO’s charge.

ACOs have grown dramatically in the intervening years and continue to evolve with more inclusive models and funding mechanisms. In January 2023, CMS reported there were more than 13 million people with Medicare in one of three ACO models that include more than 700,000 health care providers and organizations. CMS has a goal that all Traditional Medicare patients be in an accountable care relationship by 2030. 

While there are several specific CMS categories of ACOs depending on how the financing is arranged, the ownership and governance of each ACO is unique. In other words, if you have seen one ACO, you have seen just one ACO. Many ACOs we have engaged with have data about what needs to be improved but may not be able to provide in-depth support to providers to make sustainable improvements. Partnership with Comagine Health makes that possible.

Today, Comagine Health is working with two ACOs on two chronic disease initiatives — one to increase screening for chronic kidney disease (CKD) and the other to implement a program for self-monitored blood pressure. Both partners are Medicare Shared Savings Plan (MSSP) ACOs, focused on patients with Traditional Medicare.

Enhancing Screening for Chronic Kidney Disease in Nevada

CKD and end-stage renal disease (ESRD) are behind some of the highest expenditures in some ACOs, and ACOs are in an optimal position to identify patients with CKD and slow its progression through proactive primary care. Comagine Health recently began working with a large ACO in Nevada with over 35,000 members and more than 135 primary care providers to enhance CKD screening among patients with diabetes and hypertension. Together, we hope to increase screening rates by 15% from baseline by working with the ACO’s providers on:

  • The importance of CKD screening
  • Workflows to incorporate CKD screening into annual wellness and routine visits
  • Establishing referral management pathways with the ACO’s preferred nephrology group

In addition to working with providers, we will partner with the ACO’s quality improvement team and health IT vendors to look across clinics and identify areas of improvement as well as give providers the data they need to screen appropriately.

Improving Self-Measured Blood Pressure Monitoring in Idaho

In Idaho, we are leading a learning collaborative to improve the home self-measured blood pressure (SMBP) monitoring process among patients with hypertension. The leadership and board of a local ACO owned and sponsored by a regional health system with 34 clinics, 200 physicians and more than 5,000 people with Medicare invited Comagine Health to connect with their providers at their regular ACO meeting.

The ACO was interested in Comagine Health’s approach to improve and standardize home blood pressure measures in service of meeting CMS performance targets for hypertension. We are working with several clinics in this ACO, providing education to clinic teams and tracking patients as they learn how to accurately take and document their blood pressure at home. These efforts will lead to improved patient engagement and more accurate clinical decision-making to better manage hypertension.

QIN-QIO and ACO Partnership

ACOs are a natural partner for Comagine Health and other QIN-QIO organizations. We share an interest in supporting health care providers to achieve goals that improve the health outcomes of people with Medicare. We are excited about the possibilities afforded by our ACO initiatives and looking forward to future such collaborations in the coming years.

If you are part of an ACO in one of the states where Comagine Health works as a QIN-QIO (Idaho, Nevada, New Mexico, Oregon, Utah and Washington), please contact us to learn more about how we can support your chronic disease and other health care quality improvement initiatives.

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