Skin in the game: Technology, policy and stability can support accountable care organizations

The future of accountable care looks promising with new technology, supportive policy and long-term stability for medical groups using value-based payment models.

Accountable for Health is a Washington, D.C.- based organization that advocates for accountable care. The organization has been a keen observer of a crisis in Medicare spending on skin substitute treatments for patient wounds.

It’s a multi-billion-dollar issue — but certainly not the only one affecting accountable care organizations (ACOs) in the U.S. health care system. Accountable for Health CEO Mara McDermott, JD, spoke with Medical Economics about skin substitute spending and how at least two other trends relate to accountable care in the near future.

ACO human workers already have become better at detecting fraud and other health care trends by identifying spending patterns in the data they collect about patients. Artificial intelligence (AI) programs could help those efforts.

Meanwhile, accountable care has a place in the current effort to Make America Healthy Again under the tenure of Health and Human Services Secretary Robert F. Kennedy, Jr. Smaller practices could be better positioned to engage in accountable care because the administration has committed to a new level of stability for value-based payment models, particularly 10-year spans for the Long-term Enhanced ACO Design (LEAD) model and the Advancing Chronic Care with Effective Scalable Solutions (ACCESS) model.

This transcript has been edited for length and clarity.

Medical Economics: How do you foresee AI playing a role both in detection of fraud, waste and abuse, and then administration of accountable care overall, and guiding patient treatment plans?

Mara McDermott, JD: Our segment, like everybody's segment, is rapidly adjusting to the idea of AI. We have had some early adopters that are using AI for different functions. Ambient listening I think is probably the most common one that I hear about from the accountable care organization community, but I think there is a lot of enthusiasm around the future of chart completion and even potentially risk adjustment, lots of conversations happening about all of those avenues at once. I always have to caveat this every time I talk about it with the fact that my health plan, who will remain nameless, is still doing an awful lot of transacting on fax. So it's like the last remaining customer of the fax machine is our American health care system, perhaps. So I think in my mind, I've been trying to sort of harmonize our. Like. we live in fax land today, with a potential future for AI, and I think we just have a long way to go, but lots of promising stuff happening. I think we are seeing some of the back-end office management use of AI, picking things up, making it easier, helping to manage patients, helping to check in with patients, and compliance, and all of those really good things I think many of us are starting to experience with our own physician offices today. So lots of promise and potential there. But I'm just still waiting for the extinction of the fax machine myself.

Related coverage: Skin in the game: How accountable care can fight fraud while helping patients

Skin in the game: Medicare policy change is good, but more protections are needed for ACOs

Medical Economics: Can you discuss the current administration's policy and attitudes toward accountable care, and how does accountable care fit in with the movement to Make America Healthy Again?

Mara McDermott, JD: It's a great question. I think we see a ton of enthusiasm around accountable care and, in particular, two-sided risk, right? So we've seen most recently the announcement that the LEAD ACO model is coming as a successor to ACO REACH. Our membership is super excited about that. We've had a lot of enthusiasm around ACCESS. There have been a ton of announcements of late, but I think that demonstration underscores the commitment to modernizing the way that care is delivered, to trying to incorporate some of the MAHA themes around prevention and preventive care, incorporating, sort of like a whole-person view of health, health care, with nutrition and other things. I think one thing that's been very encouraging to us is the administration's focus on complex patient populations. So we see that theme carried throughout the LEAD announcement around a continuity strategy for high-needs REACH ACO, and I think a lot of interest in helping patients across their in their health care journey, particularly as they get toward the end of life. So, we see a lot to be enthusiastic about. I was in my own reflecting in the new year, compared to a year ago, where I think there were a lot of questions about this administration’s strategy around accountable care organizations and value-based care in general. I think that what we've seen is a really strong embrace of value-based care and a desire to continue to build on what has worked, which are two-sided risk models.

Medical Economics: In 2024 there was a Commonwealth Fund study that examined why many primary care physicians do not participate in value-based care. Can you discuss some of the barriers to entry for those practices, getting involved with value-based care and accountable care?

Mara McDermott, JD: I think that the most common things that we hear are instability. So there are models, it can be, I think, at times, unclear what's going to happen with those models in the future. It is a huge investment. We've done a lot of work around the investments to make the leap into these models, health, IT and staffing and myriad other — payment systems, revenue cycle, like, all these things have to change to get into these models. It is a big investment to make for a small organization if you think that model may only be around for three or four years. I think the administration has done a lot to try to address that problem by introducing LEAD as a 10-year model, by introducing ACCESS as a 10-year model, they are trying to give more time to create some stability there. The other thing, I think, is thematic for this administration, that where we hear feedback all the time, and I am, like, totally aligned, is around complexity. So the models, I think, by virtue of government programs, you've seen this sort of layering of administrative requirements, refinements to benchmarks, refinements to risk adjustment. But every time there's a refinement, there's a new set of rules that are incredibly complicated, especially if you haven't been following the ACO journey for 12-plus years. I think we see this administration taking really seriously the idea of burden reduction and trying to simplify, fewer quality measures, more transparent approaches to the financial methodology, and more tools for small and rural practices in particular to receive some funds upfront to make those investments and to support their journey as they move through these programs.

And then the last thing I would say is, I think that for a while, what we heard from clinicians is like, they could kind of ignore value-based care because it would go away, right? There's so many things that are trendy and was this just another trend? And maybe it would go away. I would say now, 12-plus years into the accountable care organization movement, same for kidney, same for oncology, we've been at this for a long time. It should be pretty clear that it's not going away and that the best path forward is to find a way to participate, whether that's through a convener or directly participating in a model. But those are some of the critiques that we've heard in the past.