What Would A Truly Patient-Centered ACO Look Like?

Health care leaders are busy talking to attorneys and consultants about how to set up Accountable Care Organizations (ACOs). A recent Advisory Board survey found that 73 per cent of hospital finance executives said that creating such an organization was a top priority for their health system.

Last year my most popular keynote topic was patient-centered medical home creation; this year everyone wants a presentation on ACOs.

However not everyone has jumped on the ACO bandwagon. Bruce Bagley, MD of the American Academy of Family Practice was recently quoted as saying, “There are probably no experts about ACOs. It’s a developing concept.” And Jeff Goldsmith, PhD, of the University of Virginia stated at the same conference: “I think this is a stupid idea. Managed care without the risk – that’s like gin and tonic without the gin. How do you end up making choices if you’re not forced to make them?”

I started thinking about what an ACO would look like if it was truly patient-centered. What if we designed an ACO that gave patients what they say they really want?

Don Berwick wrote an article in Health Affairs in 2009 that examined what patient-centered should mean, and since he became the head of Medicare in 2010 it might make sense to start there. After all, Medicare is pushing the ACO concept by creating pilot projects and encouraging the shift from fee for service payments to global payments for medical care reimbursement.

In the Health Affairs article, Berwick defined patient centered care as “They give me exactly the help I need and want exactly when and how I need and want it.” Berwick said he was ready to move beyond words like partnership and have providers become guests in the lives of their patients.

Berwick went on to imagine that really embracing patient centered care would mean having no restrictions on hospital visiting hours, inpatients choosing what food and clothes they wanted, patients participating in rounds and the design of medical services, patients really owning their medical records, and patients and doctors universally using shared decision making aids so that patients could make wise choices knowing the inevitable trade-offs involved in picking a treatment.

Such an ACO would invest heavily in patient education and self-management programs. And these presentations would go well beyond the currently offered traditional wellness curriculum.

For example, a truly patient-centered ACO would offer technology support so their patients could harness their smart phones’ computing power, audio, video, motion sensors, and GPS modules to explore new ways to self-manage their health and wellness. There are smart phone applications for fitness and weight control, diabetes management, sleep hygiene, stress reduction, and hearing and vision assistance. An ACO that partnered with their patients to fully utilize such technology could keep their clients healthier and out of the hospital. Such a strategy makes a lot of sense if your organization is accepting global payments where hospitalizations are not incentivized.

I could even imagine a truly 21st century ACO expanding their primary care team to include physicians, advanced nurse practitioners, physician assistants, and even robots and avatars. Dr. Joseph Kvedar of Harvard’s Center for Connected Health believes that we will need to embrace emotional automation and use robots and avatars to meet the manpower needs of taking care of all the retiring Baby Boomers. In a YouTube video he states that one Boston hospital has already found that hospital patients prefer a robot for discharge planning to a real life person. The robot has all the time in the world and does not make the patient feel stupid when they ask the same question over and over again.

At first, I had a hard time getting my head around this emotional automation concept, but reading MIT’s Sherry Turkle’s book Evocative Objects: Things We Think With has convinced me that humans have already formed trusting relationships with technology. “We think with the objects we love, and we love the objects we think with.” How many of us talk about love when we discuss our iPhones or iPads that have really become extensions of our brains? Admit it, do you sleep with your smart phone?

The Health System that designs an ACO that is truly patient-centered will be highly successful. In addition to consulting attorneys and payment reform consultants, I would suggest that health systems think about how the new disruptive technologies (smart phones, tablet computers, avatars and robots, video games, haptics, and artificial intelligence) could be used to better manage a geographically defined population of patients.

Kent Bottles, MD, is past-Vice President and Chief Medical Officer of Iowa Health System (a $2 billion health care organization with 23 hospitals). He was responsible for the day-to-day operations of a large education and research organization in Michigan prior to his work with in Iowa with IHS. Kent posts frequently at his new blog, Kent Bottles Private Views.

14 replies »

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  2. You are so interesting! I don’t suppose I have read through something like this before.
    So good to find another person with genuine thoughts on this subject.
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  3. Dr Bottles
    truly a challenge to move the system to a patient centered approach. In the early 1970s we used the word MEMBER to make a distiction between those that joined the HMO and those who could go anywhere for care. This meant the patient is now a consumer who has made an exclusive commitment to your physician panel.
    Now we have ACOs. Dr Berwick has promised he will announce to all patients that are attributed to a particular ACO based upon thier current use of care with that particular doctor.
    This will provoke the question in the seniors mind whats an ACO ?
    If we try to explain the ACO to this senior and how wondeful it will be we think the consumer will now have higher expectations of a seamless coordinated care system THAT IS DIFFERENT from the system they now use. So ACOs need to build into thier budget a communication program , a front line of navigators to ease the complexity of using the system and a feedback loop to see how thier operation is faring. All of these requirements tie into the CHAPs and NCQA suggested requirments and recalls that past interpretation of the word member. In this case the member is NOT locked in and can go anywhere so selling the member at each visit is a priority .
    Consumer driven and physician driven means there needs to be a shared vison of expectations in the patient physican relationship.

  4. I can understand and respect the need for change. I’m not in the 65+ age group yet, but the way health care is today, it can’t be easy for this group of individuals to feel as though their concerns are addressed in a timely manner. The rule of thumb is that only one physical complaint can be addressed at a time (due to the payment system structure) and necessary time really isn’t allowed during an office visit for a real discussion on how to self-manage a condition. And for those individuals who have multiple conditions and specialists involved, they really do want all their providers on board understanding, knowing and contributing to their care in an interactive, teamly fashion. For them, the system has to feel so disjointed.
    In looking at an ACO… what if the system doesn’t have the services the patient needs? What if a different ACO system does some aspect of the service the patient needs better? So, then what? Where does patient choice come into the picture?
    My only expertise is in physical therapy… if I understand what I read correctly (H.R. 3590 [111th]: Patient Protection and Affordable Care Act, Sect 1899), physical therapists aren’t included as an ACO professional because physical therapists aren’t included as a “practitioner” as described in section 1842(b)(18)(C)(i).
    Physical therapists are cost effective options for musculoskeletal issues. So, if physical therapists aren’t included in an ACO – in which the real goal is a shared savings program and not some patient-centered care model, then an ACO is limiting the potential for cost-savings in the area of musculoskeletal issues.
    The one professional that could be an alternative option to reduce diagnostic testing, prescribed medications, surgical interventions, and side effects/harmful risks in musculoskeletal care isn’t even included within an ACO.

  5. @pcp –
    “I think that the public will quickly get the perception (true or false) that ACOs make money by providing less care. It will be very easy to demonize ACOs.”
    The Kinder and Gentler capitation/HMO model.

  6. “from the patient’s perspective, ACOs are a non-event. Patients already assume/expect that physicians and hospitals are accountable for the care they deliver . . .”
    I think that the public will quickly get the perception (true or false) that ACOs make money by providing less care. It will be very easy to demonize ACOs.

  7. Kent,
    I would make the case that from the patient’s perspective, ACOs are a non-event. Patients already assume/expect that physicians and hospitals are accountable for the care they deliver…or at least they should be. The notion of having to pay providers in order to get accountable ( good?) care is foreign to all but to the medial community. In any other industry, if the provider of a service gives sub-standard service, they are not paid.
    How do you think patients at your hospital would react Dr. Bottles if you were to tell them that you and your peers would now being providing patient care that was accountable? They would laugh and say I assumed you had always been providing care for which you are accountable.
    If you want to better understand what patient centered accountable care should be, I suggest you start by asking the patients themselves. They will tell you what you already know, e.g., listen to your patients, don’t make them wait endlessly for you, ask their opinion, provide information and support, learn about their lifestyle/context, exhibit a little empathy. After all they have been saying the same thing for 30+ years…but now doctors will be paid to listen.
    Aveids Donabedian once said, “patients are, in fact, overly patient; they put up with unnecessary discomforts and grant their doctors the benefit of every doubt, until deficiencies in care are too manifest to be overlooked.”

  8. Alan J. Burgener of Iowa City is one of the smartest people I know in health care. He is not an early adopter of technology, so he shared his criticisms of this post in an email which I now share. He thinks I got it all wrong.
    “You’re really on a roll when it comes to the production of interesting and thought-provoking blogs and other articles over the past several weeks. However, I don’t think that you could be any more off target than you are in your thinking about what patients want from a truly patient-centered ACO. As an early adopter of technology, you are representative of a segment of the population that enthusiastically welcomes smart phone applications and any other latest-and-greatest technological breakthrough that makes access to information quicker and easier for you. Most of the population under the age of 30 is just like you — routinely relying upon hand-held technology for information and communication. This is the new “normal” for this segment of the population and there is no question that, as is always the case, this type of technology will spread inexorably as this group ages and as the technology becomes cheaper, easier to use, and more accessible to older populations and slower adopters. BUT….. This tech-savvy population is not the predominant user of health care services today — and won’t be for another several decades. Look at the introduction of technology at airports as an example…. I don’t know any frequent traveler who doesn’t prefer an automated kiosk (or smart phone or web-based application) to a real human for check-in, rebooking of flights, etc. Yet when I traveled over the recent holidays, I couldn’t help but notice how befuddled and intimidated the older and infrequent travelers were by the entire process. Despite the simplest and most intuitive screens one could imagine, most were absolutely incapable of checking themselves in for their flights without assistance from an agent. These are the people — and in most cases the age group — that patient-centered ACOs must serve. And they must do so at a time and often in a setting in which patients are stressed and separated from their social support structures.
    While there is always a minority of any age group that would welcome what you’re suggesting, my experience with today’s Medicare population is that the last thing they want from a patient-centered health system is what you’ve outlined. What they really want is a system that is accessible, responsive, makes the time to communicate with them at their pace and their level of understanding, and shows some evidence of actually caring about their well-being. Not many of today’s health systems do any of those things particularly well. Instead, the health systems of today are designed around the needs and desires of those who work within the systems — both physicians and others — and have identified (or had thrust upon them) efficiency, throughput and profit maximization as their primary outcome measures. The gap between what patients want and what health systems of today are designed to produce has never been greater, but I don’t believe that the answer — at least in the short term — is more technology at the interface between patients and the health system. That day will come soon enough, but if we don’t first fix health care systems so that they embody the characteristics that patients really want, we’ll only end up automating, de-personalizing and ultimately exacerbating the worst traits of today’s systems, rather than creating a new and better way of providing patient-centered care.
    Thanks for a provocative piece, even if it’s on the wrong track. Happy New Year!”

  9. I just don’t understand the thinking behind ACOs.
    Who (insurers, hospitals, docs) is going to be the one to volunteer to take a smaller slice of the pie?

  10. Great concept – offering something that people actually like will increase customer retention.
    However, how about the flip side? How about ACOs building something that healthy(er), (better)educated, (more)affluent people like, while taking a broad detour around those who do not sleep with iPhones (and don’t take their pills)?
    Also, the assumption here (I assume) is that what people really want is cheaper than what they currently get…
    “..we will need to embrace emotional automation”
    With all due respect to Dr. Kvedar, I don’t believe we will “need” to transfer our emotions back to objects (toys?), no matter how automated and “responsive” they are.
    I believe we will need to learn to live with much less emotion and very little human “touch”. We already are.

  11. @Richard B. Wagner, JD
    “Without focusing on the patient, ACOs are different from managed care in name only. And we all know the latter’s track record.”
    Copy that. First time I heard of the ACO thing my reflexive reaction was “smells like Teen Spirit capitation.”
    I would recommend Dr. Toussaint’s book “On The Mend” for some fine examples of the payoffs from true patient-centered care.

  12. Thank you, Kent Bottles, I could not have said it better. (except perhaps for the sleeping with I-Phone part.
    Patient-centered does not mean a ring of professionals all looking in at a patient. It means the patient at the center looking out at all the people, information and tools that will help them make the best medical decisions and achieve the best health outcomes.

  13. This article underscores an important point that I think many aspiring ACO participants are overlooking. Savings distribution among participants, legal protection, and governance issues are all important considerations. However, these all take the backseat to the query of whether the patient benefits from an ACO system. If not, patients will seek care outside of the ACO (since there are no restrictions on “patient drift”) and the entire accountability system unravels.
    Value has to be shown to the patient in order to keep him or her in the ACO “network.” The suggestions that Dr. Bottles makes should be at the fore of a provisional ACO structuring itself. Relegating them to TBD status will only introduce cracks to an ACO’s foundation.
    Without focusing on the patient, ACOs are different from managed care in name only. And we all know the latter’s track record.