Move to accountable care puts case managers in the spotlight

Success hinges on managing care across settings

No matter what model of accountable care organization (ACO) the Centers for Medicare and Medicaid Services (CMS) settles on, case managers are sure to be key players as providers focus on managing care efficiently and effectively across the continuum.

"The strategic placement of case managers into an ACO system will be critical in the success of the organization," says Denise J. Hall, RN, Atlanta-based partner in Pershing, Yoakley & Associates, a national healthcare consulting firm. "Case managers can have the same potential impact on patient outcomes in an ACO as they have had in the emergency department in many facilities. They have the opportunity to ensure that the patient receives the right services at the right level of care and can coordinate communication among all providers caring for the patient."

Reimbursement for an ACO encompasses all the care provided by individuals across all levels of care, says Washington, DC-based Blair Childs, Washington, DC, based senior vice president for public affairs for the Premier healthcare alliance with headquarters in Charlotte, NC. "ACOs benefit financially if they provide efficient, cost-effective care, and that means that someone has to coordinate the care a patient receives throughout the continuum and not just by the individual providers," Childs says. "Whatever final rule CMS issues, case managers are going to be essential to the success of accountable care organizations."

CMS announced proposed new rules for ACO on March 31 along with the proposed Medicare Shared Savings Program to reward ACOs that lower health care costs and meet quality standards. The final rule is expected later this year, perhaps as early as September.

To participate in an accountable care organization, providers must form or join an accountable care organization and apply to CMS. If accepted, they would have to serve at least 5,000 Medicare patients and agree to participate in the program for three years. CMS proposes to share savings with ACOs that lower health care costs and meet quality standards. The rewards based on its performance on 65 quality measures spanning five key areas: patient/caregiver care experience, care coordination, patient safety, preventive health, and at-risk population/frail elderly health.

Instead of providers in one entity being reimbursed for an episode of care, reimbursement for an ACO encompasses all the care provided for an individual across all settings by all the components of the organization, Hall points out. "From a case management perspective, this represents what we have been asking for forever. An accountable care organization ties patients, physicians, hospitals, skilled nursing facilities, home health agencies, and other providers together and creates an alignment between their services," she says.

Beverly Cunningham, RN, MS, vice president, clinical performance improvement, Medical City Dallas Hospital, and partner and consultant in Case Management Concepts, LLC, based in Dallas says, "Case managers are essential to any accountable care organization or any ACO-like framework. They are experts in transitions and this is what an ACO is supposed to do."

Providers working together in accountable care organizations must change how care is delivered to patients to improve quality and efficiency of care. They must have the ability to manage the care of patients across different settings including the physician office, inpatient hospital, and post-acute care. John T. Kelly, MD, managing director at Huron Healthcare, a Chicago-based healthcare consulting firm adds, "Increasingly, the focus on quality and efficiency of care puts the spotlight on case management activities such as reducing length of stay for complex patients, facilitating discharge plans, and following up to ensure that patients' needs are met after discharge. Case management responsibilities will expand significantly as the emphasis on care coordination goes beyond the acute care setting."

In an accountable care organization, case managers will be needed to communicate information about office visits, tests and procedures, medications, and treatments among providers in every level of care and to assist patients and family members in navigating the healthcare system. In addition to being involved in the daily care and discharge plans of the patient, acute care case managers in an ACO will work hand-in-hand with case managers in other settings.

Accountable care organizations offer case managers a huge opportunity to impact the success of the organization. "It pushes the case management function outside the acute care setting and into the entire continuum of care," Hall says.

Even if hospitals choose not to be part of an ACO, market pressures for accountability are increasing, and the emphasis on managing resources effectively and efficiently is accelerating, Kelly says. Changing public and commercial payment systems are starting to encourage more integrated care across the continuum, he adds.

Cunningham adds, "Improving transitions and making them seamless to the patients are really what the concept of accountable care organizations is all about. Truly case managing the patient during their hospital stay, developing programs to reduce readmissions, community case management that is sponsored by a hospital, phone calls following discharge are all components of an ACO. The concept is the right thing. The challenge is providing the efficiencies in such a tight time frame."

The changing healthcare environment presents opportunities and challenges for case managers, Kelly says. Case managers will play a central role as hospitals and healthcare systems develop more effective ways to manage patients, he adds. "Clearly this is an environment where the roles and responsibilities for case managers will expand as the emphasis on care coordination moves beyond acute care to the outpatient arena," Kelly adds.

Case managers should monitor the rapidly evolving healthcare landscape and become familiar with all of the rules being proposed by Medicare, Medicaid, and commercial payers, and educate the hospital administrators about the role of case managers in helping the hospital meet the new payer requirements, he says. Case managers must work with their managers and colleagues to ensure that they are staffed with individuals who have had appropriate training and who have been provided effective tools to handle their increasing responsibilities, Kelly adds.

If your hospital decides to become part of an accountable care organization, case management should be involved in the planning process, to ensure that everyone understand the important role case managers will play and that case management responsibilities are clearly spelled out.

"Without a clearly defined role in an accountable care model, case managers can easily be put at risk by becoming everything to everybody," says Hall, who cautions against insufficient case management staff to cover all the tasks necessary in an ACO structure. "The hospital or physician office may not want to add more FTEs, but if they want to have a successful ACO, serious consideration of case management demands is warranted," she says.

ACOs: Just part of the bigger picture

Payers emphasize quality of care

The Centers for Medicare and Medicaid Services (CMS) move toward accountable care organization (ACO) is the most recent move in the agency's efforts to change the way healthcare is reimbursed, points out Washington, DC, based Blair Childs, senior vice president, public affairs for the Premier healthcare alliance, with headquarters in Charlotte, NC.

CMS already has announced other changes in its reimbursement system to focus on quality rather than quantity of care. Beginning with admissions on Oct. 1, 2012, hospitals will be penalized financially if their readmissions for heart failure, myocardial infarction, and pneumonia exceed national benchmarks. In addition, the agency has announced a move toward value-based purchasing and has proposed bundling payments for acute episodes of care.

Denise J. Hall, RN, Atlanta-based partner with Pershing, Yoakley & Associates, a national healthcare consulting firm adds, "The emphasis from CMS is to move from an episode of care and a numbers type of payment mechanism to developing a payment system that is based on providing good, quality services. Accountable care organizations are intended to encourage hospitals, physicians, and other providers to integrate care by holding them jointly responsible for Medicare quality and costs."

CMS is using two methods to encourage healthcare providers to increase efficiency and effectiveness, Childs says. Accountable care organizations are the "pull" method, offering incentives, such as shared savings, for providing cost-effective care. The "push" method includes initiatives the penalize hospitals for not providing efficient care, including value-based purchasing and the readmission payment reduction program.

If hospitals are going to be pressured to integrate care and create efficiency measures, it's better to be in a system that shares savings as well as penalizing inefficiencies, Childs says.

Commercial insurers are also putting programs into place that have concepts similar to those being initiated by CMS, says John T. Kelly, MD, managing director at Huron Healthcare, a Chicago-based healthcare consulting firm. For example, several commercial payers already have developed pay-for-performance programs with reward and risk linked to performance on quality, efficiency, and patient satisfaction metrics. In addition, some commercial payers are beginning to focus on avoidable readmissions, he adds. "There are many different models for accountable care that go beyond the specific accountable care organization program being proposed by CMS. We're entering an environment in which government payers and commercial payers are focused on performance and linking reimbursement to performance," Kelly says.

Accountable care is a way of realigning the healthcare payment system to reward coordination and integration of care, Childs says. "The current payment system breaks providers into silos. Care needs to be coordinated and integrated across levels of care in order to make the most of our healthcare resources," he says.

The primary purpose of an ACO is to deliver seamless high quality care for Medicare beneficiaries instead of the fragmented care that often results from different providers receiving different, disconnected payments. Under the current healthcare reimbursement system, hospitals, physicians, home care agencies, and post-acute facilities are all paid in a separate way with very little incentives to coordinate care as patients move through the continuum of care. In fact, the way the payment system works tends to impede collaboration and coordination of care among providers, Childs points out.

"Accountable care organizations are designed to change the payment system by bundling payments across providers. Instead of the hospital, the physician's office, or another provider looking at a patient and one particular episode of care, the providers coordinate care as the patient moves through the continuum. An ACO breaks down the silos and rewards savings that are achieved through greater efficiencies," he says.

Hospitals and other healthcare providers already face tremendous financial pressures as payers tighten up on reimbursement and begin to link compensation to performance. Kelly adds, "The links between reimbursement and performance are expanding rapidly. Providers must focus on ways to manage patients more effectively and more efficiently during the acute care process and outside the hospital."

Accountable care organizations and other initiatives from CMS and commercial payers put the spotlight on hospital performance, and on the care coordination process. "Whether or not an organization chooses to participate in an accountable care organization, there are many other developments that require them to look at the important role of case managers," Kelly says.

Hall adds that hospitals simply can't afford to ignore what CMS is proposing for accountable care organizations. "The proposed rule may not be the final answer, but at the end of the day, the healthcare reimbursement system is going to change," she says.

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