TACOs and Togetherness: Opportunities for HIV Service Providers
Many HIV service providers believe that their most critical asset is their understanding of HIV — how the virus is transmitted, how transmission can be interrupted, which medications treat HIV, and what are their side effects — but the expertise of these organizations extends much further. They also share an understanding of the practice of prevention, the capacity to engage vulnerable people in managing their own illnesses, and resourceful approaches to meeting the basic needs of their clients and patients for food, housing, and other essentials. These skills represent an important opportunity for HIV service providers to broaden their impact in the communities they serve.
Health care reform has led many organizations to work together in new ways to improve care and lower costs. Accountable Care Organizations (ACOs) — “groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care”— are a leading example of these types of partnerships. The design of ACOs is still maturing, but some are already showing success at improving the quality of care while reducing costs.Totally Accountable Care Organizations or TACOs extend the ACO concept for low-income and vulnerable populations. According to the article that first described the evolving phenomenon,
“Totally” refers to the expectation that these organizations will be responsible for services beyond just medical care (for example, mental health, substance abuse treatment and other social supports), as well as the aspiration that these organizations will assume accountability for all associated costs of care, ultimately, through global payment mechanisms.
TACOs are in an even earlier stage of development than ACOs, but they represent a growing trend in the care of low-income populations, particularly those who receive the most complex and costly care. Though they take many forms, all involve organizational partnerships and new funding models to support coordinated care at an affordable price. Within these partnerships, community based organizations that have been primarily grant-funded are finding ways to be reimbursed by insurance companies. At the same time, health care providers are finding ways to finance the important care that is delivered outside of hospital stays and clinic visits.
Three HIV service providers in the East San Francisco Bay Area are paving the way toward this new vision of health care as they develop new partnerships and receive funding from new sources. Each has expanded their target population, and each demonstrates a strategy that will be critical to the success of TACOs.
In 2012, through a grant from the California HIV/AIDS Research Program, the East Bay AIDS Center (EBAC) developed a partnership with researchers and community based organizations called the CRUSH Project. Although EBAC had long provided high-quality health care to young people living with HIV, the CRUSH Project allowed the clinic to provide comprehensive sexual health services to HIV-negative patients, including pre-exposure prophylaxis and peer support. Even though many of the new patients were uninsured when the grant began, as a result of the Affordable Care Act most will have health insurance when the grant ends. This will allow ongoing reimbursement for preventive care that translates into lower rates of HIV infection, better health, and lower costs for the population overall.
Casa Segura has provided needle exchange and other life-saving services to injection drug users in the East Bay for over 25 years. The organization is skilled at engaging clients who have significant barriers to care, and staff members are experts at HIV testing and linkage to care. Recently, Casa Segura has received new funding that allows the organization to build on its trusting relationships with injection drug users to expand access to testing and linkage to care for Hepatitis C and to provide overdose prevention services. Each new program includes health care partners, and each will prevent deaths while reducing emergency room visits and hospitalizations that both patients and health care insurers would like to avoid.
Project Open Hand has been providing “meals with love” to people living with HIV since the beginning of the epidemic. Recently, the organization has begun working with health care providers to offer its medically-tailored nutrition services to people living with other serious chronic illnesses. In a study of similar services for this broader group of patients in Pennsylvania, hospital visits were cut in half. As in the examples above, better care and lower costs are possible simultaneously, this time as a result of addressing the basic need for food. Leading policy experts already recognize that “food is medicine” and recommend that health insurers consider paying for it.
Although the ultimate recipe for TACOs is not yet clear, those who pay for health care, including especially the patients themselves, will continue to demand higher quality, better coordination, and lower bills. HIV service organizations that can develop partnerships demonstrating that their expertise in prevention, engagement, and fulfillment of basic needs saves both lives and dollars will be in the best position to expand and grow, in many cases by bringing the deep compassion and uncompromising spirit of the HIV service community to new groups of patients and new areas of health care.
Additional related links:
Affordable Care Act & Ryan White: Adjust Your Systems
Broadening the ACA Story: A Totally Accountable Care Organization
Integrating Community-Based Organizations and New Health Care Reform Health Homes
Opportunities & Challenges for Health Departments Around HIV in the Era of the Affordable Care Act
