ACOs: Interoperability-dependent

Justine Cadet, Executive Editor

Experts are starting to formulate how accountable care organizations (ACOs) could take shape in various risk- and payment-sharing models, but the general consensus is that there is not enough interoperability between provider partners and internal systems to be successful—just yet. However, there seem to be steps in the right direction.

As suggested in a recent Commonwealth Fund report, “Providers do not have the data they need about the clinical or financial experience of their patients to manage patient care and financial risk effectively—the HIT structure necessary to coordinate care among providers is at varying levels of implementation,” wrote Suzanne F. Delbanco, PhD, executive director of the Catalyst for Payment Reform, and colleagues. “Providers also face operational and structural challenges related to the ACO model of care, which demand more coordinated, efficient processes.”

However, the report’s authors shed some light on the potential shared risk models that included:

• Bonus Risk Model: Provider is at risk of not receiving a bonus payment based on quality and/or efficiency performance;
• Market Share Risk: Patients are incentivized by lower co-pays or premiums to select certain providers so providers are at risk of losing market share;
• Risk of Baseline Revenue Loss: Providers face a financial or payment loss if they fail to meet certain cost or quality thresholds, and/or if actual costs exceed a target cost; and
• Financial Risk for Patient Population (Whole or Partial): Providers manage patient treatment costs for all or a designated set of services within a predetermined payment stream and are at risk for costs that exceed payments.

Each of these ACO models would require greater interoperability in order to share the data, as well as payments and risk. Likewise, in a recent Health Affairs commentary, Francis J. Crosson, MD, from the Kaiser Permanente Institute for Health Policy in Oakland, Calif., predicted that the ACO model likely to be successful will be a shared-risk arrangement between payors and ACOs where health plans would take on some financial risk but transfer some to the organization on an ongoing or annual basis.

“The reason, simply, is that such shared risk arrangements align incentives between plans and providers, generally leading to cooperative, innovative relationships between them rather than destructive, antagonistic relationships,” wrote Crosson.

Therefore, providers need to take the lead on adopting open-source technology, which could potentially be integrated between various facilities within a heath system and beyond, such as the service-oriented architecture platform recently adopted by Partners HealthCare System in Boston.

Please inform us of any plans you are making to become more interoperable internally and externally to prepare for the ACO model.

Justine Cadet
jcadet@trimedmedia.com