ACOs emphasize prevention, coordination

Partnerships aim to improve care, eliminate waste

As talk of reimbursement reform and pay for performance escalates and health care stakeholders look at ways to improve patient access and outcomes while reducing waste and costs, payers and providers are joining together to create accountable care organizations (ACOs), partnerships that agree to be accountable for the quality, costs, and overall care of a patient population.

Accountable care organizations are patient-centered partnerships between payers and providers and have an emphasis on prevention and care management across the continuum.

In an accountable care organization, the payer, the providers, and, in some cases, the purchaser agree on a payment model and share the savings as waste is eliminated.

According to Richard Bankowitz, MD, MBA, SACP, enterprise-wide chief medical officer for Premier, an alliance of health care providers with a mission to improve the health of the communities, the ACO initiative has a triple mission:

  • to improve population health;
  • to improve the care experience;
  • to reduce the total cost of care.

"To be part of an accountable care organization is any case manager's dream. Accountable care brings to the forefront what case managers have been talking about for decades: the need to have solidly constructed and effective multidisciplinary teams. As case managers, we know how important it is for the patient experience across the continuum of care to be seamless; but it remains a bumpy ride. ACOs are designed to eliminate the bumps and gaps in care," says Victoria Choate, RN, CCM, RN-BC, CCP, PAHM, vice president of performance excellence and chief quality officer at Cheyenne Regional Medical Center in Cheyenne, WY.

Cheyenne Regional Medical Center is partnering with a local health plan and a physician organization to develop and implement an ACO.

The accountable care model places the focus in health care back where it belongs — on improving the health of individuals, says David Epstein, MD, CIGNA senior medical director for Georgia. The Philadelphia-based health service company and Piedmont Physicians Group, part of Atlanta-based Piedmont Health, have launched an ACO pilot program.

"Health care in the United States has shifted away from prevention and primary care, which has resulted in a 'disease care' system that relies more on specialist intervention and rescue procedures rather than improving health and providing greater value to patients. The patient-centered model places the emphasis on improving the health of individuals through comprehensive primary care services and delivering better outcomes through enhanced care coordination," Epstein says.

The goal of the accountable care organization initiative is to improve quality and moderate costs, Choate says.

"We don't want to eliminate necessary costs, but by anticipating what the patients' care needs are and by shepherding them across the care continuum, we want to eliminate the costs associated with unnecessary care," she says.

Studies have shown that up to 30% of health care funds are spent on unnecessary and duplicative tests, treating complications that could have been avoided, and providing care in an expensive setting when it could have been provided at a lower level of care, Bankowitz says.

"The current system simply is not sustainable. The accountable care model is an exciting concept and one that is badly needed," he says.

The primary problem with the current health care system is that care is fragmented and not coordinated from the patient's point of view, Choate says.

"Patients often see several providers in multiple settings. Sometimes their records are available, and sometimes not. There is a lot of duplication of services and waste. Accountable care organizations provide a mechanism to coordinate care and eliminate duplication across the continuum," she says.

Fragmented care can lead to medical errors and waste, Bankowitz says.

Accountable care organizations are designed to eliminate waste and unnecessary spending and to ensure that patients get preventive care that will keep them well by proactively managing chronic disease and coordinating care provided in multiple settings, Bankowitz says.

"Everybody tries to eliminate waste, but one of the realities of the current model is that if you eliminate waste and reduce unnecessary emergency department and hospital visits, the savings go to the payer, and hopefully back to the purchaser and the consumer. There is no incentive on the part of the provider to eliminate waste," he says.

Accountable care organizations require an infrastructure that includes a person-centered health home provider, a mechanism for coordinating care, and a way to share information.

"We need health care professionals who are trained to think about the whole continuum of care, how to coordinate care, and how to be proactive to help patients get the level of care they need but not receive wasteful or unnecessary care," Bankowitz says.

The model may differ depending on the needs of the communities and the structure of the collaborating organizations, but all include payer/provider partnerships and reimbursement models that reward providers for providing value rather than on the basis of patient volume, Bankowitz says.

Payers always have been especially interested in cost and quality, he says.

"Their role is to provide for efficient care of the patient, and that hasn't changed. What is changing is that we are looking at the whole delivery model and not just the payment model. The delivery model is changing with better coordination of care and emphasis on the patient's health home," he says.

Premier is partnering with nearly 80 health care systems nationwide to help them develop and implement the accountable care model in their areas.

The ACO Implementation Collaborative is designed to assist health systems in partnering with payers and physician practices to implement the model in their area. Twenty-four health systems with more than 80 hospitals are participating in the collaborative.

More than 50 health care systems are part of Premier's ACO readiness collaborative and are developing the organization, skills, team, and operational capacities needed to develop the model in their areas.

"We brought hospitals to the table because the organization's owners are hospitals, but it can't be solely a hospital activity. Patients receive care along the continuum within multiple levels. If care isn't coordinated, it results in excess services and waste and has the potential for errors," he says.

Regardless of the structure of the model, accountable care organizations all include people-centered health homes that deliver primary care and coordinate with other providers as patients move through the health care continuum, Bankowitz says.

"Historically, continuity of care has been a series of hand-offs. Now, people are sitting at the table and discussing what the patient needs in their environment and what is needed when the patient goes to another level of care," Choate says.

The initiative refers to "person-focused care" rather than "patient-focused" care and "health homes" rather than "medical homes," because an accountable care organization looks at the health of a population and keeping a population healthy.

"Many individuals in that population may be healthy and they're not patients. We want to keep them as healthy as possible. That is why this model has greater emphasis on primary care and preventive care," he says.

Under the accountable care model, the case managers' role will continue to be to promote better coordination of care, elimination of waste, and duplicated efforts, Bankowitz says.

"The scope of work for case managers may change, because now case managers tend to focus on a patient or a case, whereas in the new accountable care organization, their job may be more of health management. We are not interested only in taking care of sick people; we want to keep people healthy and out of the system if they don't need to be there," he says.

The principles and goals of accountable care organizations are similar to those envisioned in the capitated payment programs in the 1990s, Epstein says.

"The premise of the capitation program was to empower the primary care physicians to improve their patients' overall health and to guide them effectively through the health care system when necessary, as opposed to simply referring them to various hospitals and specialists when they need specialty care. Some primary care groups were prepared to take on population health management tasks and did quite well under the capitated system. But the program did not succeed in moving the quality dial due to lack of infrastructure and constructive dialogue between the provider community and the payers. Accountable care organizations have the potential to deliver more efficient care and better health outcomes through enhanced care coordination," he says.