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HHS releases proposed ACO rules, highlighting care coordination
Rules would add to financial, paperwork burden
Proposed rules for the creation of accountable care organizations (ACOs) will require participating organizations to provide primary care to 5,000 or more patients and to meet 65 quality standards. Since the new ACOs also will require substantial start-up costs, some experts say it will be both a challenge and an opportunity for hospitals.
"ACOs is a concept that would allow our hospitals to participate and get recognized for many things they're already doing well, including coordinating care for purposes of reducing readmissions and eliminating certain hospital-acquired conditions," says Lisa Graberg, MPH, senior associate director for policy at the American Hospital Association in Washington, DC.
The Centers for Medicare & Medicaid Services (CMS) recently released its proposed rules for creating accountable care organizations with a focus on extent of care coordination and treatment of Medicare beneficiaries who are sick and frail.
"These are things a lot of our members are already doing, and there's a financial incentive for doing these sorts of things," Graberg adds. "Under ACOs, when you drive down costs you generate additional savings overall for the Medicare program, and then you're eligible to share in that savings with CMS."
Hospitals are better positioned than most providers to form ACOs because many already have several components of continuous care coordination in their systems, she notes.
"Also, hospitals and health systems tend to have greater access to capital, and to become an ACO will require a significant investment that CMS estimates at $1.8 million for start-up and first year of ongoing costs," Graberg says. "We've done some internal analysis and hired a contractor, and we think it's actually much more than $1.8 million."
Large physician groups also seem interested in the ACO model, says Beverly Cunningham, MS, RN, vice president of clinical performance improvement at Medical City Dallas Hospital.
"CMS did an open-door call in April, and the people who called in and asked the most questions were mostly large physician groups," she says. "I think hospitals will take this slowly."
Many hospitals now are focused on understanding their own readmissions, particularly in the big three of pneumonia, acute myocardial infarction, and heart failure. They also are putting processes in place that will help reduce them, Cunningham adds.
"While hospitals wait to see what happens with the rollout of health care reform, they'll have these processes in place," she says.
ACOs likely will improve the overall coordination of care, reduce duplication, and enhance prevention efforts, says Donna Zazworsky, RN, MS, CCM, FAAN, vice president for community health and continuum care at Carondelet Health Network in Tucson, AZ.
"This includes working with primary care providers," Zazworsky says. "We have those pieces in place for diabetes coordination of care, and we're already showing cost savings in being able to coordinate care better in the primary care."
The point of forming an ACO is to provide care in different ways that might improve both health care access and efficiency. An example might be Carondelet Health Network's 24-hour, seven-days-a-week telecardiology program that serves rural hospitals, she notes.
Hospitals also are working more proactively in forging relationships with the next-level-of-care providers, the experts say.
"We're working with home health agencies and skilled nursing facilities to design agreements that help clearly define the transition process," Zazworsky says. "With home health agencies, we expect our patients to be seen within 24-48 hours post-discharge."
This immediate home health visit sometimes is necessary for step-down care, and it also ensures the discharge plan is being followed. Hospitals no longer can assume patients will follow through on discharge plans once they return home, she adds.
"Our experience now tells us they don't," Zazworsky says. "It's not because they don't want to, but they might not have the support system to get their medications for several days, which ends up with them returning to the hospital."
When home health care and other providers are not part of the major payer groups that serve the hospital's patients, the hospital will encourage payers to contract with the providers, Cunningham says.
"We encourage payers by saying, 'This is a company that is good; we have seen as we track them that they don't have a lot of readmissions and are really focused on managing the patient outside of the hospital,'" Cunningham says. "Then we tell the providers, 'So why don't you work together and get a contract so you can take our patients?'"
These kind of efforts might accomplish some of the same benefits and reductions in readmissions that ACOs are designed to do. Some hospitals might choose to continue their own efforts before committing to an ACO, she says.
"We're not jumping into an ACO endeavor, but we're aggressively looking at readmissions and that next-level-of-care provider," Cunningham explains. "We feel if they go to that provider, they won't bounce back to the hospital."
Medical City Dallas Hospital also uses mid-level practitioners to manage high-risk patient populations. These include a heart failure nurse practitioner who identifies high-risk patients who are at risk for readmission, she says.
"We have wellness clinics for them," she says. "We identify the people who will be the most difficult to manage, and we assure their transition is appropriate and at the right level of care."
This has been going on for a few years, but the health care reform bill has encouraged the hospital to improve and to become better organized, she adds.
"Health care reform has forced us to be better than we are," she says.
Beverly Cunningham, MS, RN, Vice President of Clinical Performance Improvement, Medical City Dallas Hospital, 7777 Forest Lane, Dallas, TX 75230. Telephone: (972) 566-6824. Email: email@example.com.
Lisa Graberg, MPH, Senior Associate Director for Policy, American Hospital Association, 325 Seventh St., NW, Suite 700, Washington, DC 20004. Telephone: (202) 626-2351. On Twitter: @ahahospitals.
Donna Zazworsky, RN, MS, CCM, FAAN, Vice President for Community Health and Continuum Care, Carondelet Health Network, 1601 W. St. Mary's Road, Tucson, AZ. Email: firstname.lastname@example.org.