In response to NYT Op-Ed, “The End of Health Insurance Companies” – January 30, 2012
After reading the 369 comments on this article, I noticed several recurring misconceptions about Accountable Care Organizations (ACOs).
THE TRUTH ABOUT ACOs
First, only a physician group or health system with physicians can apply for and run an ACO. Hospitals may be on a team or included in a health system but cannot start an ACO on their own, with the exception of certain rural facilities. Health insurance companies may be a partner of a health system as well, but may not lead the ACO or initiate funding for one.
Second, the fundamental objectives of ACOs are to:
1. Increase Patient Satisfaction
2. Create a patient centered system through care coordination
3. Reduce Costs
There are some 34 benchmarks that must be met by a certain percentage to receive the CMS bonuses in the Shared Savings Program; however, the purpose of moving toward the ACO model is to improve patient care, primarily through care coordination.
Third, the goal of ACOs is to make sure the patient sees a primary care physician more, NOT LESS, and the goal is to keep patients connected and not lost to follow up.
CARE COORDINATION
What does care coordination mean? It means that a patient who goes to the hospital gets a follow up call from someone the day after they are discharged home (or to a long term care facility) to make sure they, or their care providers, understand their discharge instructions and have made a follow up appointment with their primary care physician. It means that they have their medications and know how to take them. It means that the pharmacist can see all of the patent’s medications (via the patient’s Electronic Medical Record–EMR) and can review and make sure that there are not medications on the list that might cause an adverse interaction, and correct it before it becomes a problem. If any of these areas are not complete, the patient care coordinator/navigator/advisor who contacted the patient can contact the appropriate party to facilitate so the patient has what they need for an optimal recovery, and hopefully will not have an unnecessary hospital readmission. This world where there is a platform for all health care providers in a system to view each other’s care activities for a particular patient is called a Medical Home–another goal of ACOs.
The EMR and Medical Home platform of an ACO provides the primary care physician a comprehensive list of interventions the patient has had so that there are not redundancies in ordering tests, because they are all there listed in one place, hence, no money waste for unnecessary or repeat procedures.
HEALTH INSURER AS RESOURCE
One key role of the health insurance provider in the ACO is to be a resource for patient registry data, in order to identify and facilitate better management of the high risk, high usage, and high cost patients. There are many ways to improve care for these groups–patients with congestive heart failure (CHF), diabetes, and asthma, etc., including various telehealth activities (another important activity for ACOs to carry out). Remote monitoring of pertinent biometrics such as blood pressure, oxygen saturation, weight, blood glucose, peak flow, INR, etc. can be monitored at home and transmitted automatically to the patient’s EMR so trends in the wrong direction can be headed off at the pass, before they end up in the emergency room (high cost area).
So there is a team of players in the successful implementation of an ACO, not a top down, “We say you do it this way” approach. The patient is at the center, not the insurance company, hospital, or provider, but all are necessary to make it work.
I have read most of the ACO documents and have spoken with enough health centers with early ACO involvement to know that I hope my primary care provider becomes an ACO. It makes sense to me that I’m a satisfied customer–asked to give my feedback, have someone looking out for me, and that we are all working toward ways to hold down the cost of my healthcare. I understand that botox is not covered, but I want it in my EMR in case of an allergic reaction.
Hi Juli, Thank you for sharing your resourceful article with our group! “Care coordination” is sometimes the missing vital link in the smooth transition of patients back home because care provider directions are sometimes misunderstood. Unfortunately, the same confusion can occur when patients receive home care, hospice, nursing or rehabilitation services because communication is sometimes fragmented between the hospital and each out-of-hospital community care provider. Rob McClenahan Right at Home Social Media Specialist
Hi Rob:
I agree that effective transition from hospital to home care is critical to avoiding unnecessary complications and successful implemenation of the prescribed care plan. There are some simple and relatively inexpensive, cloud-based Medical Home software platforms out there that allow care givers, patients, therapists, etc., to access patient’s live status and physician recommended guidelines that will help with these issues. The addition of a care coordinator or liaison who follows patients through the care transition is another tool that is being utilized in the ACO environment. I’m very excited to see more of these programs implemented! Thanks for your excellent points.
Nice post Juli. Good info. I spoke with Harry Reynolds (radio interview- http://bit.ly/AA4HWD ) , Director of Health Industry Transformation for IBM Global Healthcare and he had some exceptional stories on the revolutionary and transformational changes going on in the health care industry including; Patient-centered medical homes, Accountable Care Organizations (ACO’s), Electronic Medical Records (EMR’s), Retail delivery of healthcareGlobal payments and how IBM’s supercomputer “Watson”could transform healthcare.
ACO’s are a hot topic.
Thanks for your post.