“Will Accountable Care Organizations (ACOs) work?”
That question has been thrown around for years, serving as fodder for Twitter-fights, myriad health care blog posts, and hours of beer-soaked barroom debates (if you’re shameless as I am). Adding to the discussion are Clayton Christensen, Jeffrey Flier, and Vineeta Vijayaraghavan (or CFV, as I’ll refer to them), of Harvard Business School, Harvard Medical School, and Innosight fame, respectively.
In a recent Wall Street Journal article, they answer the question with a resounding “No.” But, in doing so, they treat ACOs and other health care delivery mechanisms – part of what I’ll call the “New New Thing in Health Care” – as mutually exclusive. Contra CFV, ACOs may help spur the exact disruptive innovation in health care that Christensen is known for discussing.
These should be the best of times for the patient safety movement. After all, it was concerns over medical mistakes that launched the transformation of our delivery and payment models, from one focused on volume to one that rewards performance. The new system (currently a work-in-progress) promises to put skin in the patient safety game as never before.
Yet I’ve never been more worried about the safety movement than I am today. My fear is that we will look back on the years between 2000 and 2012 as the Golden Era of Patient Safety, which would be okay if we’d fixed all the problems. But we have not.
A little history will help illuminate my concerns. The modern patient safety movement began with the December 1999 publication of the IOM report on medical errors, which famously documented 44,000-98,000 deaths per year in the U.S. from medical mistakes, the equivalent of a large airplane crash each day. (To illustrate the contrast, we just passed the four-year mark since the last death in a U.S. commercial airline accident.) The IOM report sparked dozens of initiatives designed to improve safety: changes in accreditation standards, new educational requirements, public reporting, promotion of healthcare information technology, and more. It also spawned parallel movements focused on improving quality and patient experience.
As I walk around UCSF Medical Center today, I see an organization transformed by this new focus on improvement. In the patient safety arena, we deeply dissect 2-3 cases per month using a technique called Root Cause Analysis that I first heard about in 1999. The results of these analyses fuel “system changes” – also a foreign concept to clinicians until recently. We document and deliver care via a state-of-the-art computerized system. Our students and residents learn about QI and safety, and most complete a meaningful improvement project during their training. We no longer receive two years’ notice of a Joint Commission accreditation visit; we receive 20 minutes’ notice. While the national evidence of improvement is mixed, our experience at UCSF reassures me: we’ve seen lower infection rates, fewer falls, fewer medication errors, fewer readmissions, better-trained clinicians, and better systems. In short, we have an organization that is much better at getting better than it was a decade ago. Continue reading…
Rapid change is engulfing health care across the United States, but the strategic responses of organizations to these changes are sharply divided. In the shift that has been broadly shorthanded “from volume to value,” many organizations across the country are deeply engaged in moving toward “value” by building new partnerships, affiliations, capacities and economic structures, striving to bring better health and health care to more people for less money.
At the same time, some organizations are using the chaos and fluidity of the moment to double down on the old way, aggressively seeking greater volume reimbursed at higher rates. For now, within their regions, some of these organizations appear to be “winning” at the game, building greater market share and margin and increasing their budgets. But is this in fact the wisest strategy to follow in the long run, not only for their institutions but for the good of their missions and the people they serve?
Moving toward Value
Virtually all serious attempts to answer the question, “Why do we pay so much more for health care in the United States?” have pointed to the competition for reimbursements under a commodified, insurance-supported fee-for-service system. If what you pay for is items off of a list, what you will get is lots of items, especially the more profitable ones. That’s how we end up with a system in which waste (stuff we could simply do without) is pegged by repeated studies at one-third or higher.
Over the next few months, the majority of my time will be spent discussing topics such as care coordination, healthcare information exchange, care management, real time analytics, and population health. At BIDMC, we’ve already achieved 100% EHR adoption and 90% Meaningful Use attestation among our clinician community. Now that the foundation is laid, I believe our next body of work is to craft the technology and workflow solutions which will be hallmarks of the “post EHR” era.
What does this mean?
I’ve written previously about BIDMC’s Accountable Care Organization strategy, which can be summed up as ACO=HIE + analytics.
In a “post EHR” era we need to go beyond simple data capture and reporting, we need care management that ensures patients with specific diseases follow standardized guidelines and protocols, escalating deviations to the care team. That team will include PCPs, specialists, home care, long term care, and family members. The goal of a Care Management Medical Record (CMMR) will be to provide a dashboard that overlays hospital and professional data with a higher level of management.
How could this work?
Imagine that we define each patient’s healthcare status in terms of “properties”. Data elements might include activities of daily living, functional status, current care plans, care preferences, diagnostic test results, and therapies, populated from many sources of data including every EHR containing patient data, hospital discharge data, and consumer generated data from PHRs/home health devices.
That data will be used in conjunction with rules that generate alerts and reminders to care managers and other members of the care team (plus the patient). The result is a Care Management Medical Record system based on a foundation of EHRs that provides much more than any one EHR.
My challenge in 2013-2014 will be to build and buy components that turn multiple EHRs into a CMMR at the community level.
Two-hundred-and-fifty-nine organizations have been named Medicare accountable care organizations. Most were formed by hospitals. Some were launched by physician groups.
And three were created by a pharmacy chain.
Walgreens’ move into shared savings is many things: unusual, eye-catching, a sign of the times.
But it’s not surprising, observers say, as the pharmacy chain has been cultivating a broader strategy to ramp up its role in frontline care. And through a handful of new programs, Walgreens already has “demonstrated … the valuable role our pharmacists can play working with physicians to meet the triple aim” of improving patient outcomes and satisfaction while cutting health costs, spokesperson Jim Cohn told me.
“ACOs are the next step.”
We should have seen it coming, really. It was entirely predictable, and the most recent RAND report proves it.
We incentivized comprehensive IT adoption, making it easier to bill for every procedure, examination, aspirin, tongue depressor, kind word and gentle (or not) touch without first flipping the American healthcare paradigm on its head, if such a thing is even possible.
According to analysis by the New York Times, hospitals received $1 billion more in Medicare reimbursements in 2010 than they did five years earlier. Overall, the Times says, “hospitals that received government incentives to adopt electronic records showed a 47 percent rise in Medicare payments at higher levels from 2006 to 2010 … compared with a 32 percent rise in hospitals that have not received any government incentives …”
To paraphrase the mantra of Bill Clinton’s successful 1992 presidential campaign: It’s the system, stupid. More specifically, it’s the business model, stupid, the fee-for-service system in which electronic health records are enabling tools.
It’s also the law of unintended consequences. You know … you take action, planning on this but instead you get that.
Like the introduction of cane toads in Australia to kill beetles (they couldn’t jump high enough). Like letting mongooses loose in Hawaii to manage the rat population (they preferred native bird eggs). Like Kudzu, the insatiable vine that’s devouring the South.
According to the authors of the RAND report, the problem is with the incentive structure that encourages more tests and procedures. Well, of course it is. Doctors and administrators have a clinic or hospital to run. They have expensive invoices from Epic and Cerner to pay. They can now track and bill for all this stuff they used to not get paid for. Are we surprised?
And meanwhile, fee-for-service leads us down a contradictory rat hole of massive healthcare costs and lousy public health.Continue reading…
The Accountable Primary Care Model: New Hope for Medicare and Primary Care
Primary care has long been something of an outcast in the medical profession — and despite convincing outcomes and a validated assessment tool, checkered reimbursement has brought the Institute of Medicine’s Primary Care Model to the brink of demise.
But the accountable care movement, and some Medicare Advantage plans in particular, have breathed new life into primary care and offered new hope for the struggling Medicare system. At St. Louis-based Essence Healthcare, a 4.5-star Medicare Advantage plan, network primary care physicians’ deep experience in providing accountable care has spawned innovations that advance primary care and make progress toward the “Triple Aim Plus One” (outlined in C9 below). Their success is the result of five years of active practice transformation and continuous improvement in a risk-bearing environment.
The best practice experience from these front-line physicians can be summarized in the Accountable Delivery System Institute’s Accountable Primary Care Model. This model embraces the four pillars outlined in the Institute of Medicine/Starfield model and expands them for Nine C’s of Accountable Primary Care Delivery. They are:
C1: First contact means that care is initially sought from the Primary Care Physician/Clinician (PCP) when new health or medical needs arise. In a nationally representative sample of more than 20,000 episodes of care, when these events began with PCP visits, as distinguished from some other source of care in the system, costs were 53% lower. This cost differential persisted after controlling for ER visits, health status, socio-demographics, and other relevant variables.
An often repeated saying in health care goes that patients lose about 80% of the information they heard during a doctor’s appointment by the time they reach the parking lot. It emphasizes that patients aren’t able to put followup care instructions into practice when they either forget or don’t comprehend what was said during a visit. Whatever the actual percentage might be, a guaranteed way to ensure that patients take home 0% of that information is to talk to them in a language they don’t understand.
Twenty percent of the United States population reported that they speak a language other than English at home, according to the U.S. Census Bureau. Many health care workers see limited English proficient patients every day, and within Accountable Care Organizations (ACOs) and Patient-Centered Medical Homes (PCMHs) it will be up to these workers to make sure that patients have the best health outcomes, no matter how high the language barriers are.
Today HealthEd Academy released the results of a survey that looked at the way non-MD health care professionals interact with their patients from multicultural backgrounds. The report examined responses from a survey of 192 health care extenders, which included nurses, social workers, pharmacists, patient educators, and more. One in five of those surveyed were part of an ACO or PCMH.
The respondents reported working with a huge array of languages. They were asked to name the most common languages spoken by their patient populations, and four out of 10 checked “other,” despite being able to choose from 10 languages identified by the Census Bureau as the most commonly spoken. Among the languages respondents wrote in were Arabic, Yiddish, several Indian/Pakistani languages, and sign language.
Recent articles highlight challenges with holding providers accountable for the care they deliver. One of the major thrusts of efforts to transform the American healthcare delivery system has been to become more patient-centered and to allow patients to provide feedback that matters.
Emblematic of this is the emphasis on patient involvement in the final rules for the Shared Savings Program accountable care organizations (ACO).
Echoing former Centers for Medicare & Medicaid Services Director Don Berwick’s plea on the behalf of patients (“Nothing about us without us”), the ACO final rules emphasize patient engagement in governance, quality improvement and the individual doctor/patient interaction.
Michael Millenson’s white paper provides a summary of the patient empowerment movement.
The development of the patient activation measure (PAM) and the Center for Advancing Health’s 43 engagement behaviors has allowed us to study patient-centeredness with more specificity. Studies have shown that activated patients are less likely to choose surgical interventions, have better functional status and satisfaction, are more likely to perform self-management behaviors, and report higher medication adherence rates.
Healthcare policy experts and payers have embraced the argument outlined above, and patients’ reports of their satisfaction with both physicians and hospitals have increasingly been used to calculate financial rewards.
Visit SDIndyACO.com, and you’re greeted by a Hawaiian shirt hanging in an otherwise empty closet. “Future home of something quite cool,” the page’s headline reads.
Forget unicorns, camels and all the other metaphors used to describe accountable care organizations these past few years.
The website — the homepage of the newly formed San Diego Independent ACO, which was one of 106 organizations named last week to Medicare’s Shared Savings Program — could sum up where we stand now on ACOs.
While we’re close enough to see their outline, some ACOs are still just teasing their promise. Many organizations have yet to launch a Web presence (or in San Diego Independent ACO’s case, are waiting to get CMS approval). And more health care providers are rushing to build the ACO structure in hopes of winning federal contracts — and filling out the details later.
Understanding the Medicare ACO Model
The ACO model is loosely defined as having integrated teams of providers share responsibility for caring for a select population of patients. (That isn’t a new idea — and based on that definition, California’s had dozens of physician-led groups and integrated networks essentially operating as ACOs for years.)