The Eight-Year Journey to Accountable Care

Now that the healthcare industry can work with clarity on care coordination strategies and programs, a new expansion of ACO models, trends in patient behavior and the companion issue of provider scope of practice have quickly emerged as critically-relevant spotlights. Historical perspective helps.

Simply put, even with the political tumult this fall, there is strong bipartisan support for aligning payment and care delivery models with improving quality to create a smarter and sustainable healthcare system, backed by historical precedent.

For me and my colleagues in the trenches of pursuing fiscally sound care delivery nearly a decade ago, it is well remembered that the origins of accountable care reside within a 2004 HHS document entitled “The Decade of Health Information Technology: Delivering Consumer-centric and Information-rich Health Care.” This “Framework for Strategic Action” (as it is also known) was delivered to then-HHS Secretary and GOP-appointee Tommy Thompson. And it was delivered by the nation’s first National Coordinator for Health Information Technology, Dr. David Brailer.

The document’s goals of introducing health IT solutions to clinical practices, electronically connecting clinicians, using “information tools” to personalize care and advance population health reporting followed an executive order calling for widespread adoption of interoperable EHRs within 10 years.

That core bipartisan support for these goals, also evidenced by the success of meaningful use, has weathered the political winds, and no doubt like many in health IT, I keep a copy of this foundational document at hand.

To continue to get us to where we are today, the report was followed the next year by the Physician Group Practice (PGP) demonstration, a five-year program of 10 sites pursuing early shared savings goals. This program was widely resurrected as a reference point when the current Medicare Shared Savings proposals were first issued.

A year later, Dartmouth Medical School’s Dr. Elliott Fisher began voicing the concept and vocabulary of accountable care during a Nov. 9, 2006, Medicare Payment Advisory Commission (MedPAC) meeting then put to paper by year’s end. MedPAC’s research over the past year only further supports this evolution.

Today, more than 27 state legislatures have proposed programs related to accountable and coordinated care, and there are more than 250 accountable care communities active in the vast majority of states. More than 70 of these are led by physicians, nearly double the number only eight months prior. And while closely associated with the CMS Medicare Shared Savings program (rightfully so now that an additional 10,000 Americans are becoming Medicare-eligible every day), health plan, private payer and even employer models are keeping pace.

Medicaid Models, Patients and Doctors Orders

Now following suit, state Medicaid officials are moving quickly to also understand and establish accountable care models around community ACOs, provider-led programs or hybrid models merging health plans and care providers.

This public-private initiative is being aided by organizations such as the non-profit Center for Health Care Strategies (CHCS) and the CMS Innovation Center, as all stakeholders realize the need for coordinated care for a patient population most in need of preventive and cost-efficient medicine that can build upon the Medicaid coverage expansion within ACA. Right now state Medicaid ACO pilot programs are being formed in at least seven states.

Meanwhile, many of the nation’s uninsured and elderly are increasingly taking advantage of the growth and accessibility of retail health clinics.

The number of Americans visiting these clinics for vaccinations, treatments for respiratory infections and preventive measures, for example, quadrupled – from nearly 1.5 to six million people – between 2007 and 2009, according to an August 15th Rand Corp. study published in Health Affairs. It is notable the study found that nearly 33 percent of these patients lack health insurance.

These rates will be impacted by the coverage mandate and the future of health insurance exchanges also within the Affordable Care Act, likely combining to fuel an increase in patient volumes at traditional practices as well, adding stress to our already strained delivery system in terms of the documented decline of the number of primary care physicians.

That dynamic will also continue to fuel expanding scope of practice debates on the roles of nurse practitioners (NPs) and physician assistants (PAs) moving within primary care. These issues are tied together provided that quality care can be achieved in retail settings, which I believe has been initially demonstrated and can continue to accelerate into more advanced primary care as an ambulatory option for more patients.

Steps to Accountable Care Success

Accountable care and care coordination in all of its forms is an essential building block for improved healthcare, along with EHR adoption, meaningful use and interoperability. In broad terms, this transformative journey seeks to improve patient safety and quality of care. The vehicle for that journey: further integration of care and a focus on disease management through new bundled payment models, value-based purchasing initiatives and benchmarking analysis. That’s where health information enters the picture. The robust use of data aggregation, analytics, and shared information directly support patient care coordination and population health management, which are the most critical clinical components of managing risk-based reimbursements.

For care providers and practices seeking to form or join an accountable care community, there are prerequisites to address:

  1. Begin by assessing your EHR, interoperability and overall technology infrastructure, as well as your beneficiary patient volume. Then engage your peers, associations, payers, employers, and health systems in your community to identify government, private payer, or combined opportunities.
  2. If your practice or organization is approached to participate in an ACO, evaluate it carefully. Consider your financial and strategic incentives for joining, data requirements, and access to bi-directional data and whether your commitment is binding or non-binding.
  3. ACOs positioned for success should have three- to five-year plans that incorporate growth strategies and best practices. These include utilizing health information technology, engaging and educating patients, developing care management resources, and monitoring care delivery and follow-up.
  4. It is also important to assess your own understanding of the different risk models being offered. Determine how much risk you can assume initially and over time.

The Supreme Court ruling on the ACA was a big step in this journey, and the next focal point is of course whether Shared Savings structures and the financial risk tracks succeed, causing more providers, health systems, private payers, and employers to embrace coordinated care and payment models.

We are seeing solid evidence of this already, which represents an encouraging sign of what the next several years will bring.

Justin Barnes is co-chair of the national Accountable Care Community of Practice (ACCoP), chairman emeritus of the EHR Association and a vice president at Greenway Medical Technologies. He has appeared before White House and Congressional panels on matters of health information technology on more than a dozen occasions since 2005, and has advised current and former presidential administrations on industry policy.

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  1. What this says to me is that, Obamacare aside, ACOs are basically apolitical.