USC Care Medical Group (USC Care) is spreading the word to patients and clinicians about the benefits of participating in an Accountable Care Organization (ACO), an option offered since January 2023.

Created as part of the Affordable Care Act Medicare Shared Savings Program, ACOs help patients navigate care, make lifestyle changes and get rewarded for activities that lead to better health.

USC Care, comprising Keck Medicine of USC clinicians at hospitals and ambulatory locations, participates in a national ACO managed by a company called Lore Health. Most USC Care Medicare fee-for-service beneficiaries in primary care can participate in the USC Care–Lore ACO.

Benefits for Patients

Medicare patients at USC Care who are eligible to participate in Lore ACO see numerous benefits.

Scheduling support: USC Care–Lore ACO participants receive support from USC Premier Care, the dedicated team of care managers and coordinators at Keck Medicine of USC. USC Premier Care schedules patients for their annual wellness visits as well as follow-up visits, which can ultimately improve health care outcomes. They can help patients who are unable to see a health care clinician in person arrange telemedicine or home visits as well. In addition, they can help patients with transitions of care after a hospitalization by connecting them back to primary care services.

Coordinating care: USC Premier Care supports patients experiencing high-acuity events or chronic illness. The team helps assess patient needs and communicates with clinicians to ensure that patients and their families get the care they need. USC Premier Care team members are also available to answer patient questions about ACO-related information. Finally, the team provides education and conducts wellness calls to engage patients and promote better health management.

Healthy social community: As part of the Lore ACO, USC Care patients can access the LoreBot app, which provides tools for patients to monitor and track their health progress. The app also lets them join the Lore ACO Community of patients who anonymously chat to support each other throughout their health journey. Finally, through Lore, participants can earn points for health-promoting behaviors, which can be redeemed for monetary and other prizes such as food and Fitbits.

“Patients receive financial incentives for engaging in health-related activities,” says Anita McCulloch, BSN, RN, Manager, Ambulatory Care Management, USC Premier Care. “The community also provides supportive, anonymous health ideas and social connections.”

Benefits for the Health System

In January 2024, the Centers for Medicare & Medicaid Services (CMS) reported an increase in participation in ACOs, noting that there are now approximately 480 ACOs nationally.

Overall, in 2024 there were about 13.7 million people with traditional Medicare aligned to an ACO, CMS reported. ACOs are now serving nearly half of the people with traditional Medicare, a 3% increase since 2023. CMS reported that ACOs have resulted in year-over-year savings for the Medicare trust fund. ACO participants qualify for CMS’s alternative payment model (APM) pathway with incentives and payments.

To date, USC Care reports approximately 6,400 of its Medicare fee-for-service beneficiaries participate in the USC Care–Lore ACO, with 20% of USC Care patients enrolled in the Lore ACO Community.

Among those supporting and promoting the USC Care–Lore ACO program are family medicine, internal medicine and primary care specialists at Keck Medicine, including USC Care physician leaders Jehni Robinson, MD; Katina Murray, MD; Michael Lee, MD; Jennifer Marks, MD; and Matthew Jung, MD.

“USC primary care providers are proud to partner with the USC Care–Lore ACO program to promote high-quality care for our patients,” said Marks.

USC Care is dedicated to creating value for the USC Care–Lore ACO population by improving clinical and quality outcomes for primary care patients. This includes prioritizing getting high-risk patients access to appropriate clinical programs and support, and improving quality of care with blood pressure, diabetes and mental health screening. In addition, USC Care aims to increase the completion of annual wellness visits to 50% — a percentage that stood at 6% for USC Care–Lore ACO patients in 2023.

“The partnership between USC Care and Lore Health demonstrates a shared commitment to value and high-quality primary care,” said Murray, who is also a Lore ACO board member. “Patients and families who engage in the Lore ACO Community are supported by emerging technology and gain thoughtful, evidence-based guidance on implementing effective lifestyle changes.”

McCulloch says participating in the USC Care–Lore ACO is ultimately good for patients and clinicians. For clinicians, she adds, “USC Care systems continually improve coordinated patient care.”

McCulloch also shares feedback from a parent who says they have experienced the benefits of participating in the USC Care–Lore ACO. “Having a disabled son can be very challenging,” the parent says. “The support and coordination I have received from the staff at USC Premier Care over the past year has been excellent. They have provided support for my son when he was discharged from the hospital by assisting with scheduling necessary follow-up appointments. Education and instruction on when to call with symptoms has helped address the issues with the clinician and has avoided my son being hospitalized. Calls from the staff come at the right time. Not only do they show compassion for my son, but they are also concerned for me as the caregiver as well. They take time to listen to me. I appreciate the team so much, which makes hard times easier to manage.”

Please contact USC Premier Care via email with questions about the USC Care–Lore ACO at USCPremierCare@med.usc.edu or call (833) SC-NURSE or (833) 726-8773.

— Jennifer Grebow