Whitney Palmer

Healthcare. Politics. Family.

Accountable Care: Let the Work Begin

Published in the Dec. 12, 2011, Billian’s HealthDATA/Porter Research Hub e-newsletter

By Whitney L.J. Howell

One of the hottest topics in the health sector today is accountable care. The premise seems simple: Providers and clinical settings of all types will closely collaborate and share responsibility for providing patient care. Implementation, however, can be challenging, according to many hospital leaders and industry experts.

The Centers for Medicare & Medicaid Services (CMS) released its final rule on accountable care organizations (ACOs) in October, detailing how its version of an ACO – the Medicare Shared Savings Plan – should be structured. If facilities choose to enroll in this program, they must offer services to at least 5,000 Medicare recipients for at least three years. Providers and clinical settings are also free to design and implement their own collaborative care model that uses a network of physicians and facilities to provide coordinated care.

Past attempts at managed care have failed, and there is still a chance the U.S. Supreme Court could declare ACOs unconstitutional. But that hasn’t stopped some in healthcare from working toward more team-based care. They are advocates of a new form of healthcare – one that ultimately focuses on the health of the patient rather than the bottom line. They are betting that the changes that come with accountable care, repealed or not, will help to usher in and get providers comfortable with this more team-based approach.

“The path forward to accountable care seems brighter and more achievable to many health systems, community providers and small practices,” said Justin Barnes, Vice President of Marketing, Industry, and Government Affairs at Greenway Medical Technologies Inc. “There is flexibility within creating a model for accountable care; and, with the final rule, many care providers are seeing that accountable care is the future of where healthcare is going.”

Barnes was also central to the formation of  the Accountable Care Community of Practice, a group of healthcare information technology providers committed to helping providers and facilities successfully design and implement either a formal ACO business model or less formal accountable care strategy.

Although this care model is getting significant attention, Barnes said, much still needs to shake out before it can be declared a success. In the meantime, many providers are putting the pieces that will support it – healthcare IT, shared-risk plans and provider networks – in place.

Mentors can Make the Difference

However, pivoting from a fee-for-service delivery model to one that prizes teamwork and increased quality at a lower cost isn’t necessarily intuitive. Many hospitals – large, small, urban and rural – need guidance, said Julie Sanderson-Austin, RN, a quality management professional with the American Medical Group Association (AMGA).

“The ACO model and even accountable care are very different animals,” she said. “It’s clear that this isn’t business-as-usual and that the change to healthcare is significant.”

To support facilities moving toward team-based care, the AMGA launched its learning collaboratives program last year. The goal, Sanderson-Austin said, is to help hospitals design ACO models that fit their specific needs by pairing facilities just embarking on accountable care conversations with mentor institutions that are further along in implementation.

Defining and Addressing Challenges

Hospitals just approaching accountable care voice some of the same concerns and encounter similar challenges, Sanderson-Austin said. For many, the biggest problem is integrating their data across care settings to offer patients a complete continuum of care. Having an electronic health record (EHR) connecting the hospital to its outpatient clinics is a good start, but it isn’t enough.

“It’s great to have an EHR that connects to ambulatory sites, but it has to be connected to your other sites, as well,” she said. “Otherwise, how are you going to get data from your nursing homes or home health agencies? If your patients either have to or elect to go to a nursing facility, you need a way to access their information for any possible future care needs.”

The initial capital investment needed to acquire good technology or build fluid health information exchanges can also present substantial problems, especially for smaller facilities, said Erik Johnson, Senior Vice President of consulting firm Avalere Health.

Although physicians are slated to play a vital role in any collaborative model, they can also be a significant sticking point for administrators looking to re-vamp how their facilities provide services. Even hospitals that began looking to a more team-based approach years ago have struggled to bring any changes to fruition.

“Improving engagement between physicians and hospitals continues to be an up-at-night problem for hospital executives,” Johnson said. “It’s difficult to get this kind of alignment.”

The Greenville Hospital System University Medical Center (GHSUMC) encountered this problem when it first considered its own type of ACO roughly a decade ago. According to Chief Medical Officer Angelo Sinopoli, M.D., convincing the doctors was an uphill battle.

“It took 10 years for physicians to embrace the model,” he said. “The concept is foreign because physicians train as individuals and are not accustomed to working in teams.”

However, administrators repeated the facility’s long-term goal and worked to educate the doctors on the benefits of working with other providers. Eventually, Sinopoli said, the physicians became champions of the hospital’s new care model.

Laying the Groundwork

Even though these challenges exist, hospitals can lay the groundwork for accountable care success, said Eric Bieber, M.D., President of the Accountable Care Organization at University Hospitals in Cleveland.

“Creating a collaborative care system that works well requires a high-functioning, multidisciplinary team to work across the organization,” Bieber said. “This team will be responsible for negotiating how the different groups within the hospital come together and divide risk.”

In January, University Hospitals launched its own accountable care model – a self-insurance plan that covers approximately 24,000 people. The facility is still in the process of identifying what works well and what doesn’t, but Bieber said institutions looking to follow in his hospital’s footsteps should bring together representatives from human resources and the legal department, as well as case managers, to discuss best strategies.

Industry management consultants at Kurt Salmon Associates also recommend hospital administrators focus on a few fundamental changes to position their facilities ahead of the curve.

Perhaps the biggest shift for hospitals, according to Kurt Salmon consultants Kate Lovrien and Luke Peterson, will be that pivot from concentrating on what the facility provides to honing in on what the community needs. With the ultimate goal of preventing inpatient admissions, the hospital is no longer the center of healthcare.

“There needs to be a dramatic change in organizational culture from the inside-out thinking of ‘my care, my time, my location’ to the outside-in thinking of ‘right care, right time, right location,'” Lovrien and Peterson wrote in a statement about ACO preparations, adding that this altered view constitutes a vision change for many facilities, and to do it well, administrators must secure buy-in from their board and staff members.

In addition, a facility’s business model must change. Under accountable care, success will no longer be measured in patient volume or the amount of services provided. Instead, efficiency and efficacy will be based on how well facilities control their costs while providing superior quality. Lovrien and Peterson seem to agree with Bieber – outlining how responsibilities will be divided and shared is a critical step. This move will give the hospital a clear organizational model, bolstering the ambulatory care system and streamlining the continuum of care across settings. The result, they said, will be improved quality and cost control.

Physicians must also turn from being the biggest hindrances to accountable care to being the most enthusiastic foot soldiers in the ramp up to the new care model, they said.  With their knowledge of the interplay between clinical activities, healthcare economics, and provider-patient engagement, doctors can strengthen the bonds across care settings.

Lastly, success will also come easier if hospitals tailor any EHR system to quality measures that are unique to the populations they serve.

Whatever strategies hospitals choose to employ, all facilities would be wise to start giving serious thought to what their accountable care model might look like, Bieber said. Waiting for Congress to announce a directive would be a waste of time.

“Regardless of the result of the elections in November 2012, there’s real support on both sides of the aisle for accountable care concepts,” he said. “It would behoove all organizations to begin to think about a system that focuses on maintaining wellness and managing chronic disease.”

To see the article at its original location: http://www.porterresearch.com/Resource_Center/Blog_News/Industry_News/2011/December/Accountable_Carex_Let_the_Work_Begin.html


December 14, 2011 Posted by | Healthcare, Politics | , , , , , , , , , , , , , , , , , , , , , , , , , , , , | Leave a comment

Academic Medicine Explores ACO Model

Published in the December 2011 AAMC Reporter

By Whitney L.J. Howell

The release of the Centers for Medicaid and Medicare Services (CMS) final rule on accountable care organizations (ACOs) in October is helping some AAMC members take a second look at ACOs. Experts are debating whether the final rule, which excludes indirect medical education payments from the shared-savings mix, will help academic medical centers embrace the ACO model.

In an ACO, a network of doctors and hospitals will share responsibility for providing patient care to a minimum of 5,000 Medicare beneficiaries for at least three years. CMS begins accepting applications for the Medicare Shared Savings program in January.

If the U.S. Supreme Court rules that the health reform law is unconstitutional, ACOs and shared savings could become irrelevant. However, many in academic medicine are proactively aligning resources to provide services in quality-focused, collaborative ways to control costs. For some, that means launching multi-disciplinary, patient-centered care centers. For others, changes include integrating health information technology or adding “total health” courses into curricula.

There is no cookie-cutter approach to adopting the ACO model. Academic medical centers must identify strategies that work best for them, but it will be challenging, said Scott Berkowitz, M.D., M.B.A., Johns Hopkins Medicine’s accountable care medical director.

“There will be cultural and financial obstacles,” he said. “But academic medical centers have a golden opportunity to create value in the post-reform era through providing exceptional patient-centered care, engaging in the science of care delivery to supplement more traditional research, and by educating the next generation of health care leaders.”

Johns Hopkins is still reviewing the Shared Savings program but has improved care quality in recent years through several initiatives. The institution expanded its community physician group to more than 250 doctors, including many to augment patient access to both preventive and follow-up care, Berkowitz said.

There are, however, academic leaders who doubt their centers can achieve the ACO model, said John Kastor, M.D., a professor at the University of Maryland School of Medicine. In a February New England Journal of Medicine perspective, Kastor reported that of 37 senior faculty he surveyed nationwide, most believe the ACO structure will prevent care coordination and cost savings.

“Of the people I interviewed, none has figured out how to make this concept work at their center,” Kastor said. “Medical school deans and hospital CEOs often report to different people. Clinical departments tend to be in silos, and training students takes time. These issues will hamper an institution’s ability to form a successful ACO.”

Changing characteristics of teaching hospitals, including paring down didactic resources, to cut costs requires a significant culture shift, he said. But not all would be beneficial. According to AAMC, siphoning money from educational efforts to achieve savings—such as indirect medical education payments—undermines academic medicine’s tripartite mission.

“In our philosophy, these payments are for education and care of the uninsured,” said AAMC Chief Health Care Officer Joanne M. Conroy, M.D. “Excluding them from savings calculations prevents negative impacts on patients, and it stops any gutting of our care system or educational programs.”

However, the onus now weighs heavily on teaching hospitals and health systems to identify cost-saving strategies and demonstrate that they work.

“It’s still a tough road,” Conroy said. “It’s a complex rubric. Academic medical centers must drill down quickly to see what will be successful.”

For Greenville Hospital System University Medical Center in South Carolina, success is already here. According to chief medical officer Angelo Sinopoli, M.D., Greenville began working toward collaborative care nearly seven years ago and first tested the ACO model on its 17,000 employees. Using a $2.7 million Duke Endowment grant, the institution increased preventive care for employees and provided case managers for the sickest patients. The result was a 26 percent drop in emergency department visits and a 55 percent decrease in hospital stays.

The true key to success, Sinopoli said, was when hospital administrators offered on-site health care services to area businesses.

“It was part of our system change. We took our wellness programs to them,” he said. “Depending on the organization’s size, there is a nurse practitioner or physician there to provide a continuum of care, give high-risk patients health education, and eliminate social barriers to care.”

Having a Greenville-affiliated provider in the workplace gives patients more than the typical 20-minute doctor’s visit. They also have access to social workers, case managers, and practitioners who address their needs between appointments.

Achieving this goal was difficult. According to Sinopoli, Greenville faced two challenges when creating its collaborative-care environment. It took 10 years for physicians to embrace the model. The concept is foreign, he said, because physicians train as individuals and are not accustomed to working in teams.

The medical center also purchased health information technology to track accurate patient data, integrate it between sites, and make it readily available to providers. Along with an electronic health record system, the medical center installed a data warehouse so practitioners can mine existing data.

The institution is a newcomer to academic medicine, having joined South Carolina’s University HealthSystem Consortium in 2006, but it pivoted easily to train students about team-based care.

“Our curriculum and students are oriented to total health,” Sinopoli said. “Instead of teaching just the biochemistry of heart failure and what drugs treat it, our curriculum teaches how to coordinate care for a congestive heart failure patient and what resources and evidence-based practices can keep that patient from being readmitted.”

Greenville is still considering whether to apply for the Medicare Shared Savings program, he said. Regardless of the institution’s eventual route, Sinopoli said one thing is certain: Leaders in academic medicine must continuously promote culture change to create a true shift toward patient-centered care.

To read the article at its original location: https://www.aamc.org/newsroom/reporter/december2011/268852/aco.html


December 12, 2011 Posted by | Education, Healthcare | , , , , , , , , , , , , , , , , , , , , , , , | Leave a comment


%d bloggers like this: