Shift to ACOs: A Marathon, Not A Sprint

Transforming to an accountable care organization (ACO) is a marathon, not a sprint, says Craig E. Samitt, MD, MBA, CEO of Dean Health System, based in Madison, Wis. "It takes time to evolve the vision, values, incentives and operations around a very different paradigm."

However, that change in paradigm was inevitable, he says. "We need to evolve to better care, not just more care. We're seeing a tectonic shift from volume toward value."

Getting to a 'new normal'

There are numerous challenges on the road to accountable care, Samitt says. For one thing, accountable care is a culture change that takes time. "Organizations can get buried if they feel the need to make the switch in a short period of time. Start somewhere. Make a decision to go in a new direction and progressively move to that destination."

Organizations can't dabble in accountable care, he says, by putting some patients in the volume boat and others in the value boat. "[Dean] couldn't keep a foot in two canoes for too long. We have to make that the new normal in the way we practice."

Providers also must accept that the healthcare world is going virtual. "When you make the decision to pursue accountable care, you slow down your investment in buildings and ramp up your investment in technology, processes, people, data and culture. Once you see the world through the clarity of value, new roads appear in front of you in how to accomplish that." The shift in the way care is delivered now means patients might prefer Skype visits to in-person visits, for example.

Meaningful Use of EHRs is not sufficient for accountable care, Samitt says. Dean has implemented an EHR and attested at 100 percent, "yet to be an ACO, we have to move far beyond Meaningful Use."

Stephen M. Shortell, PhD, MBA, dean of the School of Public Health, University of California, Berkeley, agrees. "Lots of practices have EHRs, which they might use for lab and radiology results but haven't expanded it for other functions such as drug alerts, drug interactions and communicating with other providers." EHRs need to be linked to each other, he says, rather than group practices each having their own record that can't be transferred to the hospital and vice versa.

Aside from this much-needed EHR optimization, Shortell says there is a lack of understanding that "you never adopt EHRs once and for all." Because the system requires ongoing maintenance, organizations need an IT staff that can work with physicians, nurses and practice leaders day in and day out to handle the changes that emerge over time.

Successful accountable care is a "team sport," says Samitt. "There's still tension between hospitals, physicians and health plans who are jockeying for power in their markets." Instead, these three key players need to come together with patients to form a team of equals in care.

Teamwork among physicians and between physicians and nurses is necessary for successful accountable care, says Shortell—something that many underestimate because managing the care of chronically ill patients is "a difficult challenge."  

Volume to value

Greater EHR functionality and improved interoperability can help align financial and clinical performance as well as help ACOs reach the goal of becoming a one-stop shop for providers to get all the information they need to make the transition from fee-for-volume to fee-for-value, says Charles D. Kennedy, MD, CEO of aligned care solutions for Aetna.

Aetna is developing a commercial ACO and ACO-like relationships with several providers with 10 agreements in place and a total of 20 expected to be under contract by the end of 2012. The payer plans to develop a national ACO network over the next five years, investing more than $1 billion in various capabilities to support its ACO business, including several health IT (HIT) company acquisitions.

The HIT infrastructure efforts happening on a federal level are improving the ability to exchange information, Kennedy says, but "it doesn't fully solve the challenge of getting all physicians and, most importantly, patients themselves to act in a way that consistently allows everyone to share information."

Interoperability is required to create a single understanding of what's going on with the patient and allow that single understanding to be shared across all individuals involved in taking care of patients. "When that's done, you begin to see very significant efficiencies as well as quality gains," he says.

Citing a specific example, Kennedy points to patients who have undergone a splenectomy and are at increased risk of pneumococcus, which can potentially result in pneumococcal sepsis. The pneumonia vaccine is a high-value intervention available to prevent this and is relatively straightforward to measure.

The question becomes, if you deploy health IT, is it really helping you deliver the type of high-value care necessary in an ACO environment? In an Aug. 11, 2011 New England Journal of Medicine article, Partners HealthCare revealed that only 17 percent of its splenectomy patients received the pneumonia vaccine. "Embedded in the record is evidence that the patient had a splenectomy, but digging that out and acting upon it is extremely challenging within a 15-minute visit," says Kennedy. "To be successful in the ACO world, we've got to make sure those kinds of interventions happen all the time."

Aetna is using HIT to turn the "data dumpster" of EHRs into actionable information. "We have to take advantage of the power of technology to improve clinical care," says Kennedy.

But that's not the end of the story, he says. "We have to constructively engage patients and get them motivated to use the technology and the insights that it generates." As more chronic care happens in the home, technology can influence activity by providing actionable information that guides the patient to do the optimal thing for his or her condition.

It's too early to determine whether the efforts underway will "get traction and start to produce more accountable care at a lower cost while hitting quality measures," says Shortell. He hopes to see accelerated movement toward integrated groups but says organizations are stepping up to the plate. For example, Blue Cross Blue Shield of California has committed $18 million to the development of 20 ACOs. "There's a lot of encouragement that we can take from these developments."

In the future, the highest performing ACOs will be the groups that not only focus on the patient at the center but involve the entire healthcare community, Samitt says. Currently, organizations are recognizing the need to transition from volume to value. "We need to see commercial health plans step up and follow suit, aligning with providers and forming their own ACOs. Payers have a responsibility in helping providers transition to value."  

Samitt also calls for efforts to engage the broader community in ACOs, including patients, employers and the general community. "Everyone needs to have an equal interest in wellness, prevention, adherence and avoidance of unnecessary services—not just healthcare organizations." Also, a clear definition of value, he says, would drive many more to avidly embrace accountable care.

Advanced Payment Model

Coastal Carolina Health Care, a multi-specialty group with more than 40 physicians in New Bern, N.C., is one of the participants of the Centers for Medicare & Medicaid Services' (CMS) Advanced Payment Model, which were announced earlier this year. Coastal mainly proceeded with its application for the program because they felt they were well positioned to succeed with a strong primary care supported by good subspecialists, a fully operation EHR and a large Medicare patient base which comprises 60 percent of its business. The application process was fairly extensive, says CEO Stephen W. Nuckolls, and required a business plan and budget. The group is now using its monthly ACO payments to develop its program, including a care management department. That involved hiring a supervisor and five nurses who work as care managers, and the practice plans to hire five more before the end of the year, says Ronald A. Preston, MD, internist and vice president of medical affairs at Coastal.

Since 1 percent of Medicare patients are responsible for approximately 20 percent of healthcare charges, the practice targeted the 2 to 3 percent of its sickest patients. The care managers conduct a two-hour initial home visit and then keep in touch via telephone, prospectively checking in to catch patients before they are sick enough to require a hospital stay or emergency care. "With this method, we try to achieve the triple aim—better, safer care, better patient experience and fewer costs," says Preston.

Going forward, Preston envisions each care manager with a panel of 60 to 70 patients. "This is what nurses really want to do. They're highly engaged and excited and patients will find it a real benefit."

The practice's progress with EHR adoption over five years "has positioned us to be an ACO," says Nuckolls. "For the most part, we have really good buy-in with our physicians. We're really talking about better, safer care and that's not a hard sell."

The payment model contract lasts three years and nine months during which Coastal must submit quality metrics. "I'll be surprised if we don't slow the growth of expenditures and maybe even reduce them," says Nuckolls. "We don't want to get too excited or discouraged from the initial numbers because we have a long way to go."

Although the tracking and reporting required by the government's Advance Payment Model program is a lot of work, "it's not a big switch for us," says Amit Rastogi, MD, president and CEO of PriMed, an integrated medical group based in Shelton, Conn., with more than 110 providers in 38 locations.

Cultivating an attitude, or culture, that seeks to provide high-quality care in a cost-efficient manner can take many years, Rastogi says. "We can build the infrastructure over the next few months, but changing the culture is a much more daunting task." A new practice would have a hard time establishing the culture required for accountable care, he says.

However, someone must manage the process. CMS requires reporting on 33 metrics and hosts weekly webinars on the various regulations and guidelines. Hiring care coordinators to help with discharge planning has not been challenging, Rastogi says, but finding a project manager has been more difficult. "No one has experience managing an ACO. This is absolutely new."

Having already embarked on EMR implementation, Rastogi says "we already had a large back-office operation. Now it's a matter of expanding that." Software and the IT infrastructure must take data from the EMR, such as blood pressure levels, mammography screenings, preventive colonoscopies and other measures, and report that information to the physicians in a meaningful manner to determine how well the practice is managing its patients. "The EMR just becomes an electronic notebook if you don't do that. We need to harvest data to get to the next step."

Rastogi urges providers to consider accountable care for their patients' sake as well as the sake of their future business. "The way we have been doing things does not work and providers should not be complacent. If they wait too long, they may end up completely left out as a healthcare provider." It takes a few months to build the infrastructure, and then a few years to change the culture. If three of the five healthcare organizations in one community make all the necessary changes, for example, what will happen to the other two? If those three are highlighted as efficient, high-quality organizations, the other two could end up losing market share, he says.

It's never too early to begin working to change the culture—much like the diligence and drive to train for a marathon—and with penalties, incentives, market share and, most importantly, patient care on the line, it's well worth the effort.

CMS' ACO Models Take Off

Accountable care organizations (ACOs) are a diverse group of organizations, says Sean Cavanaugh, acting deputy director of the Center for Medicare and Medicaid Innovation. The center named 32 Pioneer ACOs last December, considered early adopters of coordinated care, who will be rewarded for improved outcomes and reduced costs. The five-year initiative could save more than $1 billion, according to the center. “Through the Pioneer ACO Model, we have partnered with a variety of organizations including large integrated health systems, independent practice associations and multi-specialty groups. Through the Advance Payment Model, the Centers for Medicare & Medicaid Services (CMS) has offered smaller rural and physician-owned organizations an opportunity to participate as ACOs.  Additionally, accountable care is not unique to CMS—private sector ACOs are forming across the U.S.” It’s too early to know whether these payment models are successful. Because the first performance period began in January, CMS does not yet have results with which to formally evaluate the model. “CMS will oversee a complete evaluation of the Pioneer ACO Model for its effectiveness in improving health and care made available to Medicare fee-for-service beneficiaries, and for its effectiveness in lowering costs,” says Cavanaugh. CMS will use the results from this evaluation to determine whether the model has proven effective. Each of the participating ACOs “has already taken steps to improve how they provide care to beneficiaries, and we are excited to continue these partnerships.”