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Survey Results: ACO Patient Engagement Strategies

With nearly 52 percent of American adults suffering from at least one chronic condition, according to data from the Centers for Disease Control and Prevention (CDC), properly engaging patients in their health care is essential. There are myriad approaches to engaging patients, and accountable care organizations (ACOs) have a vested interest in doing so as part of their overall efforts to enhance health care quality, reduce unnecessary costs, and improve patient outcomes. To learn more about ACO efforts in this space, the National Association of ACOs (NAACOS) conducted a survey about ACO patient engagement. This report reviews key findings from the survey, which focused on ACO initiatives that involve patient engagement and/or patient feedback. This builds on other NAACOS patient engagement work, including an ACO Patient Engagement Workgroup (PE Workgroup). ACOs participating in the PE Workgroup helped shape the survey goals and questions and provided feedback on topics connected to the content in the survey.

"Patient engagement" can mean different things to different audiences. For this survey, it was defined as including the following:

• Communications and/or education to patients about the ACO or about value-based care broadly;
• Communications and/or education about key ACO initiatives or services to support patients such as care coordination or clinical reminders, among others;
• Efforts to solicit feedback from patients and incorporate patient perspectives in the ACO’s communications or initiatives, such as through surveys or patient advisory forums; and
• Use of waivers or incentives to engage patients in their clinical care, or other tools ACOs employ to engage patients in creating and committing to treatment plans or enhancing relationships with their ACO providers.

Survey Methodology
NAACOS conducted the survey of ACOs in August and September 2023 to learn about their patient engagement initiatives and strategies and existing challenges or barriers to engaging patients. The survey was conducted online using Survey Gizmo and ACOs including association members and non-members were sent an email invitation to participate in the survey. Fifty-five ACOs across the country responded to the survey and shared information about their engagement strategies and initiatives for patients across public and private payers. Questions were largely multiple choice with some write-in responses. This report highlights de-identified aggregate findings from the survey, along with a few de-identified quotes from write-in survey responses. Detailed survey results are available in this companion chartbook.

Key Findings

ACOs highly value patient engagement and regularly solicit patient input.

Clinicians in ACOs have been evaluated on patient satisfaction since the inception of the Medicare ACO programs. Specifically, the Consumer Assessment of Healthcare Providers & Systems (CAHPS) survey is used by Medicare as well as other payers. Further, ACO quality measures in the past decade have emphasized preventive care (e.g., influenza immunizations and screenings for breast and colorectal cancer) and management of chronic diseases (e.g., control of hemoglobin for diabetes, controlling blood pressure, and statin therapy for cardiovascular disease). To be successful on these measures, it has been imperative for ACOs to effectively engage their patients. This dedication is reflected in survey findings, with 66 percent of respondents reporting that patient engagement is a very high or high priority for their ACO. Other ACOs reported that their patient engagement efforts are not limited to the ACO’s work specifically but rather administered more broadly across affiliated health systems’ populations.

To support ACOs’ goals and patient engagement prioritization, ACOs solicit patient feedback on a variety of initiatives. The survey asked how often ACOs seek patient feedback on communications preferences, ACO initiatives, or strategies. Thirty percent of survey respondents report that they very frequently or frequently solicit patient feedback.

The PE Workgroup shared a variety of initiatives for which they have solicited patient feedback, including the following items and more:

• Communications on care coordination programs to ensure they are presented in a culturally and linguistically appropriate way.
• Communications about the use of in-home healthcare tools, such blood pressure cuffs.
• Process flow improvements, such as how and when to discuss medication costs and adherence.
• Step-by-step instructions for patients, such as those related to post-discharge information.
• Use and design of posters in medical practices and other health care settings.
• Educational sessions at provider meetings that reflect a patient viewpoint.
• Design of specific population health programs, such as a “Healthy at Home for the Holidays” campaign.
• Waiting room content, including both TV content and print materials.
• Patient portal design, seeking input on the size, color, layout, and patient friendliness.
• Disease specific care programs such as diabetes management initiatives.

Receiving patient input on these initiatives can help ACOs improve them and increase their effectiveness. 

ACOs utilize a variety of patient engagement strategies and activities.

Recognizing that ACOs are regularly seeking patient input on a variety of topics, it is important to understand the ways in which they are getting that input. The survey asked ACOs to share the specific activities they do or are planning to do in the next year.

Chart 1: Patient Engagement Activities

Those that selected "Other" were asked to provide more detail which included the following activities:

• Engaging community health workers;
• Using direct patient emails;
• Sending a quarterly newsletter with ACO explanation, benefits, programs, health fairs, etc.;
• Using educational videos with additional links and/or surveys;
• Promoting patient surveys/feedback during check-out; and
• Highlighting social determinants of health (SDOH) survey tools and education about new initiatives and community-based services.

The activities above show the breadth of ways ACOs solicit patient input and what that feedback is used for. A requirement for Medicare ACOs is they must include a beneficiary representative on their governing body and many other payers have similar requirements. However, the survey results show some ACOs go beyond the basic requirements to get richer input from patients. To learn best practices for recruiting and engaging patient representatives in ACO governance and initiatives, please refer to this NAACOS resource.

ACOs communicate about what it means for patients to receive care in an ACO.

When asked what information is most important to communicate to beneficiaries about their participation in an ACO, many survey respondents emphasized the positive. For example, explaining additional benefits or services, such as extra clinical support and coordination across clinicians in different settings and fields of expertise. Survey respondents commented that it is helpful to emphasize the benefits of establishing a primary care relationship, managing chronic diseases, and seeking the right care in the right setting to avoid an emergency room visit when appropriate. 

Additional positive communications included:

• ACO providers are genuinely engaged in keeping patients healthy;
• Patient satisfaction is an important focus for ACOs; and
• Patients may have access to waivers for things like skilled nursing facility (SNF) care and telehealth.

In contrast to highlighting positive aspects of ACOs, other ACO respondents noted that it is important to emphasize what doesn’t change. For example, traditional Medicare beneficiary rights don’t change for patients who are part of an ACO, and they are free to see providers of their choice. Others noted it is important to communicate that there are no additional charges for added services and benefits and that patient data is protected. Many ACOs highlighted the importance of educating patients on the benefits of staying engaged with your care team and how the ACO helps to coordinate care across the continuum. ACOs also expressed the need to dispel misconceptions, such as:

• The ACO is not a Medicare Advantage plan, and does not change your insurance, networks, or benefits.
• The physician/provider chose to participate in the ACO, not the patient, and there is no cost or action needed on the patient’s part.
• ACOs are a trusted partner of CMS and CMS works with ACOs to make care more affordable and achieve better health outcomes.

It’s not just ACO executives who think it’s important to highlight how patients benefit from value-based care models such as ACOs. A recent United States of Care report, Shifting the Health Care Approach: Quality Over Quantity, underscores that patients have a high level of support for the core concepts of value-based care (VBC). Namely, patients support a system that pays doctors and providers for improving overall health, delivering higher-quality care, and helping coordinate patients’ care. Their research found patients resonate much more with the care improvements from ACOs/VBC as opposed to hearing about the complexities of a particular VBC model. That report is available on this webpage.

ACOs would prefer to shift from communicating via paper to more electronic forms of communication.

How an ACO communicates to its patients can affect the usefulness of the information. As such, it is important for ACOs to determine the most effective form of communication within certain constraints such as technological and budgetary. When asked about the current state of communications compared to an ideal state, survey respondents favor moving away from mailing letters and relying on in-office posters to using more sophisticated approaches such as educational videos.

The timeliness of a message is also important with ACOs sharing that they would prefer to communicate when a beneficiary signs up or renews Medicare coverage. Chart 2 compares current to ideal efforts across a variety of communication channels for traditional Medicare ACOs.

Chart 2: Current Versus Ideal State of Communication Efforts for Traditional Medicare ACOs

Some ACOs have different patient engagement strategies/initiatives for different payer populations.

While patient populations can vary notably across payer type, nearly 60 percent of survey respondents shared they do not have different patient engagement strategies by payer type.

Those who responded “Yes” elaborated, sharing why they have different strategies for various payer types and what those are:

• High or rising risk patients receive more in-depth services and engagement outreach.
• Private payer patients often work full time and appreciate later hours and improved access.
• Patient groups have varying communications preferences (e.g., text versus call).
• Payer strategies depend on the benefits available to the patient and level of risk assumed by the ACO for that population.
• Action plans may vary based on payers/patient subsets to ensure equity in outcomes.
• Outreach and engagement sometimes must be prioritized due to staffing constraints.
• The geographic spread of populations can alter engagement efforts.

Availability and use of ACO patient engagement tools varies across payers.

Another important component of patient engagement is the use of tools and incentives to activate patients in their care. When asked about available patient engagement tools, incentives, and/or flexibilities/waivers across payers, ACO respondents shared that these are very valuable, though availability and use varies across payers.

Survey participants were asked to identify which tools and incentives they use by payer to involve patients in their care and incentivize improved health. The payer categories were: Traditional Medicare, Medicare Advantage, Medicaid, and Commercial (non-MA). Survey results showed that ACOs use these tools and waivers the most in their Medicare Advantage contracts, closely followed by Traditional Medicare, then Commercial (non-MA) and Medicaid.

When asked which payer type offers the most beneficial patient incentives, tools, or waivers, Medicare Advantage was the clear leader. No respondents selected Medicaid.

ACOs participating in the Medicare Shared Savings Program (MSSP), the largest and only permanent traditional Medicare ACO program, have had limited waivers available to date. Despite the Innovation Center's testing of several waivers in ACO demonstrations, most waivers have not been made available in MSSP. CMS should work to expand MSSP waivers and create a process to accept public nominations for waivers in MSSP. Creating a transparent process for adding new waivers to MSSP would increase ACOs’ flexibility to meet the needs of their populations and support CMS's goal to advance accountable care.

The prevalence of using specific tools and incentives across payers revealed that telehealth was the most widely used and considered to most meaningfully improve patient care. This is unsurprising given the proliferation of telehealth use during the COVID-19 public health emergency, during which providers were granted additional flexibilities to deliver telehealth services. 

Chart 3: Patient Engagement Waivers/Tools/Flexibilities That Most Meaningfully Improve Patient Care

When looking at the use of each specific tools/incentive above by payer, the results were largely consistent across payers with the exception of wellness-related benefits. ACOs use those much more frequently with Medicare Advantage and Commercial (Non-MA), which makes sense due to restrictions in traditional Medicare and lack of funding in Medicaid, respectively.

Survey respondents provided comments about their use of patient tools and incentives which adds context to the rankings. Some commenters noted cost-sharing support is particularly beneficial for preventive services and care management programs. Others noted that financial rewards, such as a gift card, for participating in disease or care management programs are valuable though can be challenging to administer. When asked to share feedback on any patient tools/waivers/incentives not included in survey questions, respondents noted the following as beneficial: hospital at home, bonuses for preventive health activities, and direct patient incentives to complete recommended care.

ACOs face certain barriers with patient engagement.

Successfully engaging patients is not without challenges, which can vary depending on the payer type and/or patient population or individual patient. When asked to identify impediments or policies that create challenges for an ACO’s patient communications and/or engagement, which the ACO would like to see changed, survey respondents expressed significant challenges with traditional Medicare compared to other payers.

ACOs noted they would like more flexibility in traditional Medicare to communicate added benefits of being in an ACO, such as enhanced care and services, but many worry this would fall under marketing restrictions. Others said CMS should notify patients of their providers’ participation instead of the ACO or have a co-branded CMS-ACO notice. Other policy challenges identified included: marketing regulations, difficulty for home-based providers to communicate with patients, lack of patient email addresses from Medicare, limitations on waivers and voluntary alignment, less flexibility than what is available for Medicare Advantage, and hard to understand language from CMS.

The survey asked also about policies and impediments for risk-based arrangements for other payers (i.e., those outside of traditional Medicare) that create challenges for ACOs’ patient communications and/or engagement, which ACOs would like to see changed or removed. ACOs provided the following feedback on impediments:

• Certain privacy laws, such as those that vary by state, add barriers for some payers such as Medicaid or commercial payers;
• Varying patient experience of care surveys/questions create challenges and survey fatigue across payers/patients;
• Confusing attribution models make it hard to effectively engage patients who feel they shouldn’t be connected to the ACO; and
• Limitations on waiving patient co-pays create barriers to effective engagement. 

MSSP Beneficiary Notification Requirements
All MSSP ACOs are required to send a beneficiary notification, a standard form letter developed by CMS, to their traditional Medicare patients letting them know that their provider is participating in an ACO, as well as some other details such as that the beneficiary may choose a primary care doctor and can opt-out of data sharing. Beneficiary notifications were required in the early years of MSSP, and the requirement was later removed due to the administrative burden, beneficiary confusion, and operational complexity caused by the notifications. CMS later reintroduced the requirement and made changes to the policies but has not addressed the fundamental issues with the requirement. There is also a follow up communication requirement which was introduced in 2023, which has increased burden, cost, and beneficiary confusion associated with the requirements.

Some patients believe these communications are part of a scam or that they have been enrolled in a managed care plan without their consent. As a result of the notifications, some beneficiaries choose to opt-out of data sharing without understanding what the data sharing process entails, making it difficult for ACOs to coordinate and manage patients' care effectively. Medicare beneficiaries and consumer advocates have also expressed concerns that the language used in the notifications, which ACOs are not permitted to modify, does not resonate with patients, and may exacerbate mistrust in the health care system.

Many survey respondents commented that the requirement is costly and burdensome, creating confusion without real value for patients. This is a sore point for ACOs as many would prefer to put their limited resources into programs that provide more tangible benefits to patient care rather than what, as one survey respondent commented, is a “greater burden than benefit.”

Many comments also criticized the new follow up requirement for which many implementation questions have gone unanswered by CMS, despite repeated efforts to seek clarification. NAACOS will continue to engage with CMS and other stakeholders, including patients and consumer advocates, to improve beneficiary communications as they are critical to expanding the reach of accountable care and to the success of patient engagement activities.

Conclusion

This report reveals ACOs’ dedication to engaging patients in their care and learning from them how to improve communications and initiatives designed for patients. As policymakers create and modify ACO program policies, careful consideration should be given to how policy changes affect the patients served by these programs and engagement efforts. More attention should be given to effectively engaging patients and NAACOS encourages ACOs to share their patient engagement stories or challenges with us by contacting us at [email protected]. You can learn more about how ACOs are working to improve patient care and about NAACOS’ patient engagement work on our website and in this ACOs & Patients factsheet.   

NAACOS would like to thank the ACOs who contributed to this survey!