Can Accountable Care Organizations Deliver Healthcare Reform?
Can the ACO align with the PCMH to deliver improved patient and financial outcomes?
By Jay I. Pomerantz, MD – Executive Medical Director for Health Integrated
Let me start by defining Accountable Care Organization (ACO). In the healthcare reform debate, one of the main issues was to find a way to incent physicians to deliver quality of care vs. a focus on additional services or volume of patients. An ACO offers one method of incentive. An ACO is a local healthcare organization and related set of providers (nominally primary care physicians, specialists and associated hospitals) that can be held accountable for the cost and quality of care delivered to a defined patient population[1]. The ACO by definition has a focus on quality care by offering incentives to increase the integration of clinical services and care coordination. The foundation of an ACO could be considered primary care and the PCMH.
An ACO puts the primary care physician back in charge. ACOs are provider led and have a mission to manage the continuum of care. Unlike the PCMH process though, there is yet no official certification process similar to what is offered by NCQA. In the spirit of aligning any future ACO guidelines, the NCQA is seeking input from stakeholders on this topic.
So, you might ask how the ACO fits in with the Patient-Centered Medical Home (PCMH). I like to think of these two concepts as very complimentary. Dr. David Ehrenberger of the Colorado Clinical Guidelines Collaborative in Denver, CO, likes to call this the ‘Medical Neighborhood’, combining several or many ‘medical homes’. The ACO looks at all of the care organizations outside of and including the immediate PCMH-based practice, and combines them into an accountable entity – one that is responsible for the delivery of quality care and lower overall cost. PCPCC also has an interesting graphic which describes this model. At the center is the PCMH – a collection of them in fact. The Medical Home is supported by Population IT (including EHR) and data management services to target certain populations. Other alignment structures including pharmacy, home care, long-term care, public-health agencies, specialists, hospitals and other organizations which provide further support. This multipart entity then can be managed and coordinated under the overall ACO umbrella. Given this organization, all care is coordinated for the patients. This then begs the question of how to motivate and incent this synchronized collaboration.
Integrated and coordinated are the two adjectives that to me best describe the ACO’s optimal functionality. The ACO has a shared responsibility for treating a designated patient population and are therefore ‘accountable’ for the quality and cost of care. To this end, many ACO programs drive incentives and provider payments based on the care the ACO as a whole delivers to the patients. The payments might include fee-for-service (FFS) along with supplemental payments related to shared savings as an additional incentive for instance.
The effectiveness of ACOs in meeting the overall goal of broad-based clinical outcome improvement and financial savings can be dramatically impacted if certain measures are taken. Mathematica Policy Research, in a Policy Brief[2], suggests such policies as follows. Not many are really radical, but all are important to gain the coordination and integration that is needed:
- Setting realistic expectations regarding reconfiguring and realignment
- Engaging providers – both in process and incentive
- Incentive focus for individual provider participation, matched to organizational capacity, improved performance measures, purchasing economies, and alignment with other initiatives
- Setting of challenging but doable goals for providers
- Accommodating geographic diversity, (but appropriately challenging it as well)
In the recently passed healthcare reform bill, the only ACO project planned is for a pediatric ACO demonstration. It is hoped that this ACO project will spawn other new integrated demonstrations as well. ACOs will continue to be promoted though. By January 2012, the HHS Secretary will establish a shared savings program targeted at ACOs. The goal of the program is targeted at putting integrated programs, including infrastructure and process to coordinate full-continuum care for specific patient populations, and the accountability of such programs by the ACO. Corresponding incentives which are yet to be determined will accompany these programs as they are executed.
Below are several good papers, articles and links I found that further define ACOs in the context of implementation, applicability and healthcare reform. I hope you find them useful. If you have others, please share them with the group.
Thanks for reading and I welcome your comments. You are welcome to contact me directly at pcmhdialog@healthintegrated.com. As always, I have listed some future topics in which I would welcome your review and comments.
Best Regards,
Jay I. Pomerantz, MD
Some informative ACO articles, papers and links
- http://www.mathematica-mpr.com/publications/PDFs/health/account_care_orgs_brief.pdf
- http://www.aafp.org/online/en/home/publications/news/news-now/practice-management/20091216aco-principles.html
- http://www.healthreformwatch.com/2010/03/11/a-guide-to-accountable-care-organizations-and-their-role-in-the-senates-health-reform-bill/
- http://rwjfblogs.typepad.com/healthreform/2010/03/health-reformers-lexicon-accountable-care-organization.html
- http://healthaffairs.org/blog/2009/08/17/the-accountable-care-organization-not-ready-for-prime-time/
- http://content.nejm.org/cgi/content/full/NEJMp0909327
- http://diseasemanagementcareblog.blogspot.com/2009/08/patient-centered-medical-home.html
- http://www.integratedprimarycare.com/PCMH%20&%20ACO.pdf
Upcoming topics for the Health Integrated PCMH Collaborative Community
- Patient safety and injury – utilization, evidence-based medicine and iatrogenesis
- Value of Disease Management
- How will the post-bill debate really affect implementation of healthcare reform?
- Targeted Population Health Management – how will adoption affect PCMH outcomes?
- Reimbursement schemes under the new healthcare reform
- Additional demonstration examples – success in the making
[1] Robert Wood Johnson Foundation: http://rwjfblogs.typepad.com/healthreform/2010/03/health-reformers-lexicon-accountable-care-organization.html
[2] Mathematica: www.mathematica-mpr.com/publications/redirect_pubsdb.asp?strSite=pdfs/health/account_care_orgs_brief.pdf
