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ACOs
A Guide for
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Physicians
should you join an accountable care organization? here’s what you need to know about these emerging care-delivery models.
By RosemaRie NelsoN
Accountable care organizations have been described as unicorns, because none have been seen but everyone knows how to describe one.” So says Medical Group Management Association independent consultant Owen Dahl. Because we haven’t yet seen any ACOs in action, many practices have put off thinking about them. But ACOs are emerging, in more than just theoretical form, and understanding market changes just makes good business sense.
Should you get involved with an ACO? The answer depends on your practice’s strategy, culture, and tolerance for risk.
An ACO is an organization of healthcare providers that can receive additional funds from Medicare (and an increasing number of private payers) if it can demonstrate that it provides higher-quality care at reduced costs to a defined group of patients. An ACO must measure quality, outcomes, patient satisfaction, and cost, for which it will need a sophisticated IT infrastructure, and it must form a legal organization to receive and distribute shared savings among its providers.
The regulations governing Medicare’s new Shared Savings Program have formed the framework around which ACOs will organize. To participate in that program, an ACO must: • Define processes to promote care quality, report on costs, and coordinate care.
• Develop a management and leadership structure for decision making. • Develop a formal legal structure that allows the organization to receive/distribute bonuses to participating providers. • Include the primary-care physicians (PCPs) of at least 5,000
Medicare beneficiaries.
• Provide CMS with a list of participating PCPs and specialists. • Have contracts in place with a core group of specialist physicians. • Participate for a minimum of three years.
ACOs will be led, for the most part, by hospitals and regional health-delivery systems, since only such large organizations have the scale necessary to meet the government’s regulations, which are centered on managing the healthcare outcomes of large populations. But ACOs are going to need affiliated community clinics to deliver many actual services to patients, so practices will have an opportunity to join ACOs.
Hospitals that are forming ACOs might offer to purchase your practice outright, or may propose (or be open to) some lesser form of formal affiliation. Such offers might be attractive, as declining reimbursement and increasing practice expenses have driven many physicians in recent years to consider paths that include hospital employment, hospital integration, and various other professional service arrangements.
When affiliating with a hospital, you want to reduce the headaches of practice management, increase your access to capital, mitigate the risks of an uncertain future, and improve your income potential. But the flip side to all that is a loss of control. Entrepreneurial private-practice physicians tend to underestimate what it will mean to have the hospital as their “boss.” Before making any decisions about affiliating with a hospital, consider the nature of your current relationship with its administration. Bear in mind that a new kind of affiliation might bring with it additional bureaucracy and make it harder to do what you want to do. But it might bring benefits, too, like income stability and resources for new technologies.
HOW’D WE GET HERE? The trends shaping healthcare today are consumerism and patientcentered care; transparency in healthcare cost-effectiveness; value, as represented by quality and safety in relation to cost; metrics; and information technology that delivers real-time data on the patient, processes, and systems.
As the population statistics change and baby boomers age, healthcare costs are rising. The growing rate of obesity adds to the number of Americans with other chronic conditions such as diabetes, CHF (congestive heart failure), and CAD (coronary artery disease). Employers understand the impact of health and wellness on the productivity of their work force, as well as the ever-increasing cost of insuring their employees. Consequently, employers continue to experiment with wellness programs such as smoking cessation, weight loss, and health coaching.
Change in the payment and delivery system is inevitable. Health reform will shortly deliver many newly insured patients to your office. Evidence-based medicine focused on outcomes and quality will be a central organizing principle for care delivery and payment. Cost management is a practical imperative for a sustainable delivery system. And information technology is essential plumbing to this increasingly sophisticated system.
SHIFT TO THE ACO ACOs represent less a paradigm shift in healthcare delivery than the coalescence of many tactics that have been tried at different times over the years to make providers accountable for their patients’ health status. For example, membership in HMOs increased in the 1990s as health plans, hospitals, and physicians sought to deliver more costeffective healthcare. More recently, medical homes have offered upfront payments to physicians to provide additional services, such as coordinating care with other providers.
But these initiatives usually lack mechanisms to tie providers’ pay to their patients’ ongoing clinical outcomes — one of the hallmarks of the ACO model. Unlike previous iterations, moreover, ACOs will rely on providers to review their own work and set standards. Their success will depend on how well providers, payers, and patients navigate the challenges that limited the effectiveness of previous efforts.
The core principle of accountable care is the alignment of payments, benefits, and other healthcare policies with measurable, meaningful progress in improving healthcare while lowering costs. Under Medicare’s Shared Savings program, an ACO that succeeds in both delivering high-quality care and reducing the cost of that care to a level below what would otherwise have been expected will share in the Medicare savings it achieves.
Access to high-quality information systems, medical management protocols for monitoring patient adherence, and compliance with regulatory requirements are all essential to ACO development and management. Clearly, the costs and effort associated with these activities are substantial.
Having an enterprise-wide EHR is not enough. The capability to develop information from the data within the EHR to facilitate changes in the practice, and then demonstrate the results of those changes to payers, is essential to population health management, which is at the heart of the ACO model. Patient engagement requires secure messaging, patient portals, patient-maintained health records, and tools for patient self-care such as telemonitoring, mobile health applications, and telemedicine. Having knowledgeable managers with relevant experience will be important to effectively implementing and managing ACOs.
In an ACO, providers are accountable for achieving better results for all of their patients at a lower cost. However, physician groups may resist policies that put them at risk. ACOs will have to offer incentives that make the risk worthwhile for practices.
An ACO can be made up of a multispecialty group; an organization of individual practices (like an independent practice association, for example); partnerships or joint ventures between hospitals and medical practices, in addition to physicianhospital organizations and integrated delivery networks; or hospitals with their employed physicians.
A functional ACO most likely needs to include primary-care physicians, specialists, and a hospital. It also needs to be able to administer payments, set benchmarks, measure performance, and distribute shared savings (or allocate losses).
Implementation of the Shared Savings program began on January 1, with 32 “pioneer” organizations. Medicare’s Pioneer program is designed for healthcare organizations that are already experienced with coordinating care for patients across care settings, so they can move more rapidly from a shared-savings payment model to a population-based payment model as they demonstrate specified levels of savings during the first two years of the program.
Most of the Pioneer ACOs are linked to integrated delivery networks, academic institutions, and independent physicians’ associations. The Renaissance Medical Management Co., for example, is an organization led by primary-care physicians in southeastern Pennsylvania that includes a network of approximately 200 family and internal medicine practices and an established relationship with a health plan.
The initiative will test the effectiveness of several payment models and how they can help experienced organizations provide better care for beneficiaries, work in coordination with private payers, and reduce Medicare cost growth, according to HHS. The Pioneer ACOs are required to engage other payers in similar efforts to the Shared Savings program. Pioneer ACO payment models include the risk of financial penalties for providers should healthcare spending accelerate. The risk of financial loss is perhaps greatest for the option that pays providers under a capitated model starting in the third year. Eligible savings range from 50 percent to 75 percent of the amount providers save, depending on the level of risk the ACO accepts.
SHOULD YOU PARTICIPATE? All this leaves many providers with a decision to make: Should you jump into ACO participation?
“A lot depends on the market and who the players are,” says Kim Harvey Looney, who leads the healthcare regulatory practice at Waller, Lansden, Dortch & Davis in Nashville.
What is your relationship with the hospital — do you trust its management enough to be business partners going forward? “Rather than jumping on board, be a little wary and be thinking about doing something to align with other physicians,” suggests Looney.
Pioneer ACOs will prospectively know who their included beneficiaries are, and will be able to contact them. But patients will continue to enjoy freedom when it comes to their healthcare choices — nice for them, but a challenge for the ACO, which is responsible for their health outcomes. Novant Health, owner of 13 hospitals and hundreds of clinics in states from Virginia to Georgia, considered joining the Pioneer ACO program. But Fred Hargett, Novant’s executive vice president and CFO, says he didn’t see enough in the regulations about the patient’s responsibility or accountability. “Their mobility is a question mark for us,” Hargett says, referring to patients’ ability to seek care outside of the ACO. Novant Health is working to develop ACO-like concepts with commercial payers, but is holding back on the government’s version.
Reimbursement methods will continue to incorporate quality and outcome metrics, and affiliation with larger healthcare systems will provide physicians with a voice in the process of developing those metrics — as well as determinations of the incentives for meeting them. As opposed to direct employment, affiliation allows physicians to maintain some control in a time of transition. Affiliation with healthcare systems also provides support for physician participation in other delivery-reform efforts such as expanded use of medical homes, bundled payments, value-based purchasing, adoption of information technology, and payment reforms.
The decision to participate in an ACO is a serious and far-reaching decision. Rather than try to fit into a predetermined definition of accountable care, providers are exploring innovative approaches with commercial payers to reward quality and more closely align the pieces of the healthcare delivery chain as patients experience them. Have you explored your economic, political, and organizational options to maximize your chances of success? n
TRYIng TO DECIDE wHETHER TO jOIn An ACO? COnSIDER THE fOLLOwIng qUESTIOnS: Do you know what the vision of the ACO will mean to your day-to-day operations? Is productivity balanced with an incentive linked to quality? How is the ACO organized? Will you or a representative of your specialty be a decision-maker at the table? How much autonomy are you willing to relinquish? What is the process and timeline? Will you have to adopt new information technology tools? What is the plan for implementation and support? Does the ACO have the capital to acquire needed technology and the management and operational expertise to implement the ACO? What are the other specialties in the ACO? Are these physicians you have shared patients with in the past and is their governance and management style consistent with yours? Are you committed to the ACO’s philosophy and delivery model as well as other key aspects of the program — including participation in and adherence to data-driven, evidence-based medicine, use of defined practice management and EHR infrastructure, and participation in care protocol development using measurable care standards? is an aco for you? A SELf-CHECk qUESTIOnnAIRE
Rosemarie Nelson is a principal with the MGMA healthcare consulting group. She conducts educational seminars and provides keynote speeches on a variety of healthcare-technology and operational topics. Drawing upon her diverse experience, Nelson provides practical solutions to help medical groups succeed in their practices. She may be reached at www.mgma. com/consulting/nelson.
Thanks To new federal iniTiaTives and The increased use of smarTphones and TableTs, more physicians are communicaTing on The go
By Marisa Torrieri
For most physicians, coordinating care with other doctors and staff can be a time-consuming, backand-forth, error-prone process.
But for pediatrician Wendell Wheeler of South Park Pediatrics in Chicago, an EHR user of nine years who purchased his iPad and iPhone in January 2011, it’s as easy as making a few taps with his finger.
Armed with his mobile gear, Wheeler can open patient charts at any time, anywhere, and do everything from advising patients on medications and sending prescriptions to pharmacies, to communicating with outside physicians about specific patients.
“It’s a nice extension [to the EHR],” says Wheeler. “I’ve been using Amazing Charts for nine years. I went into private practice and I wanted something that would make it easier for me to keep up with my patients and [my iPad and iPhone] have done that.”
Wheeler’s use of mobile technology to collaborate and communicate with his healthcare peers is representative of a shift in the way many physicians are practicing medicine. And it’s a shift that will only continue to expand. In addition to CMS’ meaningful use incentive for EHRs, new initiatives under the Patient Protection and Affordable Care Act — including the muchpublicized accountable care organization (ACO) initiative that rolled out in April — call for greater communica-
tion between physicians. Additionally, a growing number of technology vendors are rolling out mobile versions of their EHRs that allow physicians to do everything from video chat with patients to send charts to hospitals utilizing different systems.
“If you think about healthcare IT, about a world where healthcare IT is being delivered in real time, you can see how mobile devices play a larger role, because physicians have a mobile device wherever they are,” says Albert Santalo, founder, president, and CEO of cloud EHR provider CareCloud.
In the future, mobile collaboration between physicians is expected to deliver even more benefits, though it requires some considerations.
Rise of The Mobile Physician As with the general public, the use of electronic communications among physicians has picked up steam over the last several years.
For starters, the number of physicians who use the Internet has increased. According to our 2011 Technology Survey, 74 percent of hospital-owned and 66 percent of independent practices out of a pool of 1,013 respondents said their practice has a website. Nearly 40 percent of respondents said their practice uses e-mail to communicate with patients.
But the biggest, most obvious catalyst for the growth of electronic communications in the practice is CMS’ incentive program for EHRs that launched in July 2010, offering providers who demonstrate “meaningful use” of an EHR up to $44,000 under Medicare, or up to $64,000 under Medicaid. In 2010, 48 percent of 597 respondents to our annual technology survey said their practice had a fully implemented EHR. That number jumped to 55 percent in 2011.
The timing of CMS’ regulations couldn’t have been more serendipitous for the mobile electronics industry. In April 2010, Apple released the first version of the iPad tablet, which is still, to date, the most popular tablet brand among physicians. Per our technology survey, 20 percent of respondents (including
physicians and practice administrators) own a media tablet, and 54 percent own a smartphone. So it’s no surprise a growing number of EHR providers are offering mobile device access through these gadgets.
For physicians, using mobile devices makes stuff such as e-prescribing and looking up medication information easier.
“I’ve seen physicians go from Palm Pilots to having mobile phones, and vendors are making sure they have everything they need to treat a patient,” says Mary Griskewicz, the senior director of health information systems for Healthcare Information and Management Systems Society. “Many physicians have iPhones today, and many are moving toward Android [smartphones].”
Albert Santalo, health IT executive
in summary
Here’s why mobile collaboration is the way of the future:
•Use of technology is on the rise.
Twenty percent of practice professionals own a media tablet; 44 percent own a smartphone. • Mobile devices can eliminate time-consuming communication by physicians via faxes and phone calls. • New initiatives under the Affordable
Care Act call for greater communication between physicians. • More technology vendors are rolling out mobile versions of their EHRs, allowing functions like video chat. The Changing FaCe oF Care CoordinaTion When physicians think of collaboration and coordinating care with their peers, many envision faxing
medical records back and forth and calling other doctors. Though this is still being done, a growing number of physicians are opting to coordinate care through electronic — as well as mobile — means. In addition to the increased use and sophistication of technology, there are a couple of other factors that are driving this shift.
For starters, physicians are perhaps some of the busiest professionals on the planet. They’re often under tremendous cost pressure from their practices and payers to squeeze as many patients as possible into a day. But when the day ends for most people, it doesn’t end
for physicians. Using technology helps physicians make quick decisions anytime, anywhere about a patient’s care.
Hillsborough, N.J.-based family physician Richard Corson obtained his Cerner EHR four years ago, and as the EHR vendor extended its access to mobile phones and cloud environments, he started taking advantage of the ability to access his data from any location. Though Corson only uses his Android smartphone to access his Cerner EHR when there is no laptop available, he likes having the option of always being near his data and able to manipulate it.
“The EHR is going to be an integral part of how medicine will be practiced in the near future, and one of the great things about it is its mobility,” says Corson. “I was … recently on an airplane from Salt Lake City to Newark, and I was communicating with my offi ce, doing refi lls and such.”
And thanks to the healthcare reform law, new regulations are also incentivizing physicians like Corson to embrace collaboration. In early 2011, under direction of this law, CMS called for the establishment of ACOs, organizations that share the responsibility for cost and quality care received by patients in exchange for a share of savings they achieve for the Medicare program.
Corson expects to be coordinat-
ing care outside of the offi ce even more in 2012, as he recently applied to be part of the patient-centered medical home initiative led by the American Academy of Family Physicians, centered on collaboration between physicians to provide chronic disease management for specifi c patient populations.
“That’s one of the main pillars of the patient-centered medical home: coordinating care with other physicians,” he says.
Joel Andersen, health IT executive
more online
To learn more about the pros and cons of coordinating care through mobile technology, watch our video interview with CareCloud’s Albert Santalo and physician/consultant David Lee Scher. Visit http://bit.ly/mobiletechvideo.
WHAT’S NEXT Physicians who’ve already hopped aboard the mobile collaboration bandwagon can’t say enough about the benefi ts they enjoy.
“It’s been very nice,” says Wheeler, who uses his iPhone and/ or iPad at least twice a week to coordinate care. “I can pull up a patient’s notes, their allergies, their medications, and I can write a note and sync it up when I get back to the offi ce. I can open it up in 15 seconds and it gives me full demographics including telephone number and pharmacy number, and all of the notes from every visit.”
Wheeler now has more time for patients and says he feels less stressed.
Benefi ts like these are what Joel Andersen, chief marketing offi cer of Lumeris, formerly ClearPractice, is banking on.
A little more than a year after ClearPractice launched its signature mobile EHR, which is tailored to the iPad, the company has changed its name and direction. One of its goals is to create products that help physicians improve mobile coordination. “Our strategy has changed a little bit, really, around accountable care,” says Andersen. “For accountable care to work, you’re going to need to engage physicians in new ways so they can do a better job of coordinating care for patients, or episodes of care for a specifi c patient.”
As such, Lumeris’s latest product, still in production, is a “physician engagement solution” that combines the company’s signature EHR with tools to collect and share data/ information from across the continuum of care. Though Lumeris is primarily targeting hospitals because they are leading the formation of ACOs, the product is designed to be compatible with most major EHRs used by practices.
“It’s a system that takes information from all these disparate systems to create what we call a ‘single version of the truth,’” says Andersen. “It’s an intelligent health information exchange … an integrated platform as a service that includes specifi cations to decode and exchange information in a meaningful way.”
CareCloud also has a stake in the mobile EHR game, and is developing products to help facilitate mobile care coordination — but not just for doctors to communicate with each other.
“There will be physician-patient collaboration in all this,” says Santalo. “You’ll be able to do video, voice, chat, sharing of records, and stuff like that.”
Santalo sees mobile tablets being especially helpful to mental health professionals, who will be able to talk to patients in different care settings, such as schools or prisons, from their office or another location. Potential Considerations Mobile collaboration’s benefits — making life easier and less stressful and allowing physicians to do a better job of caring for patients because they can coordinate care anytime, anywhere — aren’t cost and consideration free.
A number of issues need to be addressed by providers looking to do anything mobile, from accessing their EHRs to collaborating with physicians at off-hours. For starters, there’s the compatibility issue. Applications used by Physician A have to support whatever smartphone platform is being used by Physician B. And some older EHR technology isn’t readymade for all mobile platforms.
Then, there are the security issues. Per HIPAA, personal health information that is digitized must be encrypted or otherwise secured before it is sent across the airwaves. In addition, you have to make sure checks and balances are in place so the wrong user can’t access given data. “It’s one thing to set up an app to allow physicians and other caregivers to access the data, but you have to restrict what data and what data elements the user(s) can see,” says healthcare technology consultant Marion Jenkins. “So you would have to manage and authenticate users and their devices.”
Finally, don’t forget to consider the cost.
Media tablets run upward of $500 upfront, plus additional data-plan charges depending on how you will use the device to go online: A wireless operator’s data plan can run $25 per month and up. The same goes for smartphones: Even with a two-year contract, a smartphone can cost $200 or more a month, and that doesn’t include monthly service charges.
However, having mobility could be well worth the money if you value certain benefits.
“Mobile devices allow you to manage admission and discharge
ranks the payers in a report called PayerView. SM How well does your payer treat physicians? Find out
of patients, more aptly coordinate ancillary service offerings,” says by searching Payerview at PhysiciansPractice.com.. Andersen. “Physician-to-physician communication around a unified medical record, that’s the holy grail, where one doctor and another doctor can coordinate the transition of care from one doctor to another.” n
Marisa Torrieri is an associate editor of Physicians Practice. She can be MORE THAN reached at marisa.torrieri@ubm.com.JUST PRINT
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