ACOs and the Case for Advance Care Planning

Medicare Accountable Care Organizations (ACOs) are groups of doctors, hospitals, and other providers who voluntarily come together to provide high-quality care. The goal is to provide coordinated care to ensure the individual gets the right care at the right time, avoiding duplication of services while preventing medical errors. When an ACO provides high-quality care, resulting in less healthcare spend, the ACO will achieve shared savings.

Given that advance care planning is the process that enables individuals to make future healthcare decisions should they be unable to communicate those decisions themselves, there are a few reasons that we would think advance care planning is widely implemented across ACOs. The truth is that most ACOs have limited processes in place. As 10,000 people age into Medicare daily, it’s important that this population start thinking about these future healthcare decisions, and that ACOs prioritize these important conversations.


While there have been many changes throughout the years, one major change is the growth of ACOs since 2012:

  • Number of ACOs
    • 2012/2013 – 200
    • 2020 – 517
  • Assigned beneficiaries
    • 2012/2013 – 3.2 million
    • 2020 – 11.2 million
  • Total earned shared savings
    • 2012/2013 – $315 million
    • 2020 – $983 million

While there are approximately 60 million Medicare beneficiaries in the U.S., only 19% of these beneficiaries are covered by these ACOs. Outside of those individuals with serious illness, advance care planning conversations with Medicare beneficiaries should be prioritized. These conversations could easily be incorporated into Annual Wellness Visits.

How and Where Are Advance Care Plans Documented Today?

The reality is that most individuals, if they are even planning for their future, are doing so outside of the healthcare system. 84% of Medicare aged individuals say they have not had an advance care planning conversation with their doctor. These conversations may be happening with estate planners who are not trained to engage in these important conversations. Advance directives and other like forms may get documented on paper, but are rarely available when it is most needed – in an emergency. When these documents are attempted to be accessed within the EHR, they are unable to be located 69% of the time. This provides an opportunity for processes and technology to be put in place to help support ACOs and other healthcare organizations improve and streamline advance care planning.

Implementation of Advance Care Planning Services Among ACOs

Many ACOs have limited end-of-life care processes in place – 21% having few to none and 60% saying they have some processes in place (note: some is not defined). ACOs that are most likely to have programs to support end-of-life care are those that have:

  • A hospital within the ACO
  • At least one Medicaid contract
  •  Shared savings contingent on quality
  • Advanced shared decision making

More recently, a 2018 survey revealed 58% of ACOs have partially implemented advance care planning, while less than 20% have widely implemented advance care planning services. Advance care planning was the second least widely implemented initiative in this survey, with community-based palliative care being the first.

Case Study: Improving Advance Care Planning for High-Risk Beneficiaries

Integra Community Care Network ACO made a concerted effort to improve advance care planning. In order to tackle this, the ACO:

  • Developed and deployed curriculum on the principles of geriatric and palliative care
  • Refined the process for enrollment in its complex care management program and added goals of care conversations
  • Provided discussion guides to providers to support these conversations
  • Provided a tool for providers to document the conversations

By implementing all of these tactics and tools, Integra increased goals of care conversations with its chronic care management beneficiaries from 39% in January 2018 to 88% in December 2018. Post-training, clinicians felt more comfortable in conducting goals of care conversations.

Making a Case for Advance Care Planning

While it is our belief that advance care planning should happen early and often, we understand that as a society, we are a long way from that. Where does it make most sense to start? The most vulnerable populations, and one of those is the Medicare population. ACOs should really be focused on implementing and standardizing advance care planning, as it allows:

  • Increased revenue opportunities by leveraging advance care planning CPT codes
  • Increase potential of shared savings
  • Alignment of multiple value-based quality measures
  • Reduction in unnecessary hospitalizations and rehospitalizations
  • High-quality care at a lower cost

By having these important conversations, ideally during the Annual Wellness Visit, ACOs can ensure care is delivered in the most appropriate care setting that aligns with the members’ end-of-life wishes.