With the advent of Accountable Care Organizations (ACO) making a splash in the healthcare market, healthcare providers are facing yet another challenge in their efforts to cost effectively provide care for their patients. The ACO model, a main component of President Barack Obama’s healthcare reform, is supposed to provide the prospect of better, more coordinated care for patients and reduced costs. The ACO payment and care delivery model aligns physician reimbursement with quality metrics in an effort to reduce healthcare costs.
Simply stated, an ACO is a group of healthcare providers who agree to take on a shared responsibility for the care of a defined population of patients while assuring active management of both the quality and cost of that care. At the core of this model is that the pay for physicians and hospitals in the ACO is contingent on their ability to meet the defined quality of care indicators. If the providers are unable to keep costs down and are not improving the health of patients, they receive lower payments from Medicare.
The concept of the ACO is in its infancy, but the primary purpose is two-fold. One is to provide incentives for quality care as we are moving from a volume-based reimbursement model to a value-based reimbursement model. The second purpose is to drive down cost.
Dozens of ACOs in one form or another are already being organized, and some are up and running. Most, though not all, include hospitals, physicians and other providers.
Shad Williams, president and CEO of Sergemd in Memphis, which provides electronic medical records support software, has already seen the emergence of ACOs among his clientele. “We have several clients that are in the early stages of ACO formation,” said Williams. “Most ACO leadership is being driven at the health system level, but it impacts many of the owned or affiliated clinics/providers.”
The Electronic Health Record is central to an ACO. “Being accountable requires measuring and managing data, ideally in an automated fashion,” said Williams. “In order to streamline care delivery, efficiently engage and update the care delivery team, eliminate duplication and friction in the process, effective use of an EHR is paramount.”
The EHR is an important component of reimbursement because care will be driven based on clinical data, as opposed to financially based claims data.
“So, successful care will be rewarded, and duplicative care – labs, images, etc. – will be detrimental to maximum reimbursement,” said Williams. “The EHR will capture labs, allergies, meds, recent images, etc., so the care team will have access to the clinical data needed in order to make appropriate decisions regarding care delivery.”
Care delivery will focus on the total care of the individual, leveraging the primary care physician as the leader of the care team in an effort to drive wellness and manage disease. “Terms like personalized care, disease management and wellness are commonplace today, but the EHR will become a major enabler of the process by becoming the repository for the individual’s clinical data,” said Williams. “It is this data that will be used to drive wellness. For example, ensuring each year that a diabetic patient completes his or her A1c. It sounds like a simple example, but a paper system cannot provide an efficient way to proactively monitor the care needed in order to effectively manage a person’s health.”
Another key component of the ACO is the Patient Centered Medical Home. Essentially, the Patient Centered Medical Home is the single point of coordination for the total healthcare needs of the individual. In order to coordinate care, manage disease, provide access to data and communicate efficiently with the care team and the individual, the EHR must be employed. Coordination of information can be an issue when providers use different EHR platforms.
“The Health Information Exchange (HIE) is the common denominator for disparate EHRs,” said Williams. “It’s the vehicle that enables data sharing between venues of care and members of the care team. It’s an important component because it’s another link in the streamlined continuum of care and the care team. And as a practical matter, we are the local expert. We deal with multiple EHRs and we understand the data elements required to contribute to the HIE that will ultimately enable the disparate systems that will likely comprise the ACO.”
The ACO model is projected to ultimately drive down the cost of care by proactively managing the health of the population the provider serves, and by aligning all resources needed during an episode of care.
“Through proactive disease management and more proactive communication, etc., the patient will become more involved in the process,” said Williams. “So, assuming the model plays out – and there is still learning to be done – the cost of managing a healthy population will be less than the cost of managing episodic entries into the system. The projected savings of the wellness model will be shared with the care team, creating an incentive to align the care team.”
caption: Shad Williams
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