It’s been nearly a decade since Elliot Fisher, director of the Center for Health Policy Research at Dartmouth Medical School, first coined the term Accountable Care Organization, or ACO. In the years since, nearly 400 ACOs have emerged, and the approach remains a key element of the Affordable Care Act.
Yet, in many ways, the jury is still out on ACOs. Critics continue to claim that ACOs won’t generate the cost savings that advocates hope for, pointing to the fact that some ACOs are still struggling to achieve the care coordination required to get the favorable patient results necessary for payments. Meanwhile, supporters remain confident that the ACO model will ultimately serve as an incentive for health systems to create new efficiencies and improve collaboration in ways that will benefit hospitals, physicians, and ultimately, patients.
Compiled by Scott Westcott, Contributing Writer
Leaders from three established ACOs share their perspectives on whether or not the model is delivering on its promise.
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It’s been nearly a decade since Elliot Fisher, director of the Center for Health Policy Research at Dartmouth Medical School, first coined the term Accountable Care Organization, or ACO. In the years since, nearly 400 ACOs have emerged, and the approach remains a key element of the Affordable Care Act.
Yet, in many ways, the jury is still out on ACOs. Critics continue to claim that ACOs won’t generate the cost savings that advocates hope for, pointing to the fact that some ACOs are still struggling to achieve the care coordination required to get the favorable patient results necessary for payments. Meanwhile, supporters remain confident that the ACO model will ultimately serve as an incentive for health systems to create new efficiencies and improve collaboration in ways that will benefit hospitals, physicians, and ultimately, patients.
Amid the conflicting views on the current state and future potential of ACOs are healthcare systems that are already in the game, operating under the ACO model. Leaders from three of these organizations shared their perspective on how they are approaching successful implementation of an ACO, as well as the critical issue of whether ACOs are achieving the key goal of enhancing care coordination.
Q: How long has your organization been operating as an ACO — and what model do you follow?
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Jackson: Banner Health Network was incorporated in July 2011, though our journey toward accountable care began long before in managed care plans, including our own self-insured employee health plan. Banner Health Network was selected as one of the original 32 Medicare Pioneer ACOs in December 2011. Our ACO is comprised of the Banner Health hospitals, Banner Medical Group (employed providers), and two affiliated partners, Banner Physician Hospital Organization (BPHO) and Arizona Integrated Physicians (AIP).
Augusta: Managed by Apollo Medical Holdings, Inc., ApolloMed ACO is a physician-led organization that has been operating as an ACO since July 2012. The organization is part of the Medicare Shared-Savings program. ApolloMed ACO is part of a publicly traded integrated healthcare company with other physician businesses such as hospitalist, IPA (independent physicians association), and clinics.
Gomberg: Aria Health created a mixed commercial and Medicare value-based delivery organization about two years ago. Currently, we work with Independence Blue Cross (IBC) in the management of 20,000 Aria Health patients in northeast Philadelphia under two IBC value-based care contracts — Integrated Provider Performance Incentive Plan (IPPIP) and Quality Incentive Payment System (QIPS). These plans reward doctors and hospitals for delivering high-quality, coordinated, and efficient care. Our network consists of three hospital campuses, three emergency departments, two outpatient centers, and multiple independent practice locations.
Q: What technical and clinical challenges have you encountered as an ACO?
Jackson: Our hospitals use a Cerner EHR. The employed providers leverage NextGen, while our affiliated providers are on a variety of different EHRs. This makes care coordination across the network extremely complex. We are offering subsidies to our affiliated providers in an effort to reduce the number of systems that we will need to integrate. Active Health is our population health platform and physician registry. It allows us to integrate claims and clinical information from a variety of disparate EHRs, with the goal of providing a holistic view of member encounters.
Augusta: We set ourselves up fairly quickly to receive data from CMS, yet we initially faced complexities around formatting data. It took us about six to nine months to get the right processes down to generate data in a way that was useful for us as an ACO. It was also important to put the right technology in place to support the clinical integration necessary to deliver more proactive care to the higher-risk populations. Working with Medecision’s Aerial platform helped us overcome those challenges by allowing us to quickly begin building a multi-disciplinary network focused on the physician-patient relationship.
Q: Do you leverage a centralized EHR or HIE throughout your ACO?
Jackson: As mentioned, members of our ACO use a variety of EHR platforms. However, Active Health leverages Medicity as its HIE. Medicity integrates Care Continuity Documents (CCDs) from multiple EHRs in near real time. Claims data feeds are also supplied to Active Health, integrating both the administrative and clinical data to get a more robust view of the member’s history. This platform is available throughout our ACO; however, we have not completed deployment to all of our practices due to the variability of EHRs and the time and effort it takes to integrate each system. A centralized EHR across the entire ACO would enable more robust, timely data sharing with less IT effort required for system integration. We plan to transition our employed providers to our hospital EHR in an effort to centralize where possible.
Augusta: As our physician groups were working off of different systems when they were acquired, one of our biggest complexities from a technology perspective has been issues around EHR interoperability, as we don’t have a centralized, dominant EHR that’s leveraged across our facilities. That said, both the EHR and centralized HIE are initiatives we are exploring for the future.
Gomberg: Aria Health is in the process of clinically integrating its network and standardizing to an Allscripts EMR — both for ambulatory and acute care. The complexities are vast, but they are what you would expect — customization, workflow, training — in a massive undertaking such as this. The benefits of EMR standardization include technology efficiencies, such as being able to gather the same information for every patient and for the population. Once you integrate EMR/encounter information with claims/cost data, you can manage a population, ensure better clinical and financial outcomes, and make improvements in the business and delivery of care across the entire network.
Q: Do you have a centralized system for tracking and reporting MSSP (Medicare Shared Savings Program) clinical quality measures?
Jackson: Yes, we collect inpatient and outpatient clinical and administrative data, claims data from payors, as well as other data feeds, such as pharmacy and labs, which is then integrated into our internal enterprise data warehouse. We utilize DART, an Aetna analytics and reporting product, as well as custom developed scorecards to track and report our clinical quality measures across the network.
Augusta: We use a care management solution to track and report clinical quality measures. This is vital to ensuring we’re regularly identifying and mitigating specific cost and quality outliers, and we’re consistently improving the way we’re delivering care to patients. Tracking quality measures has allowed us to zero in on areas where, with a couple of quick fixes and communication, we were able to make a big impact on enhancing care.
Q: How is your ACO currently managing/tracking population health?
Jackson: We leverage a combination of custom-developed applications and dashboards, as well as Active Health, to track and manage our members’ health. One of our internally developed dashboards allows us to quickly identify our members when they enter one of our hospitals seeking medical attention. Our care managers have access to this information and can then notify the care team to ensure all available resources are utilized in support of the member’s plan of care.
Custom applications in conjunction with Active Health have been established to identify high-risk members and gaps in care, chronic disease member panels, members without recent office visits, and other triggers that prompt care and track care in an effort to help us better manage our population.
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Augusta: We work with Medecision’s technology to track population health, especially among higher-risk patients, such as those with congestive heart failure, COPD, diabetes, and dialysis needs — these were the areas in which we saw the highest cost and most complex patients. The technology has helped us identify high-risk patients, prioritize them, and provide this information to our case managers so they can manage a certain fixed number of high-risk patients. We’ve also focused on further educating patients, ensuring that they receive preventative care, such as education and training.
Gomberg: As our long-term partner for population health, Lumeris will be helping us track and report our performance on QIPS and IPPIP measures beginning in July. Their Accountable Delivery System Platform (ADSP) will help us to combine clinical and claims data for our population providing Aria Health’s care delivery network with the near-real-time ability to monitor and measure our performance on key metrics, such as reducing hospital readmission rates and increasing life-saving health screenings. This level of data transparency will help our providers more proactively address the health needs of our population and respond with the appropriate care, in the appropriate place, at the appropriate time.
Q: How has your transition to an ACO impacted/altered office and patient workflows?
Jackson: We are still evolving as an ACO from a point-of-care standpoint. It has caused our providers and their office staff to have greater focus on the patient as a whole, rather than just the issue that triggered the visit. This includes a renewed focus on a patient’s chronic disease, preventative care, and behavioral health needs. From a practical standpoint, chart preparation for a visit has changed significantly for our clinical teams. It now includes a thorough review of care gaps that may be present, and plans to address those gaps even before the patient arrives. Often, a team huddle occurs prior to the start of the clinic day. The interactions between the office staff and patients are changing as team-based care takes hold. Medical assistants have become a vital part of the team, and help identify care opportunities that need to be addressed. We are also encouraging a regular review of patient registries so that clinical teams can reach out to those patients who need to be seen. We are asking providers to rethink their approach to patient care, and, in particular, how they spend their time and manage their clinical team. At the same time we need to rethink how we will incentivize them to rise to this new concept in care.
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Augusta: As we’ve become an ACO, the needs of our patient population have grown. For example, our patient population speaks half a dozen different languages, so we’ve had to make sure we have the staff and care managers to appropriately and effectively communicate with patients to ensure they receive the best and most proactive care possible. Moreover, as new groups join the ACO — some of which aren’t located nearby — we’ve established standardized governance processes, such as regular executive meetings with providers, to ensure clinical and business objectives are being met.
Q: In your opinion, has operating as an ACO improved your care coordination efforts?
Jackson: Yes, we have improved care coordination for our members through the use of our population health management platform and through advanced data capabilities. We are able to identify opportunities for care proactively, and then reach out to our members to close their care gaps. Operational triggers are in place for care coordination when a BHN member is in need of care transition, is deemed high risk, or otherwise needs support. That being said, there are several areas we are focusing on to continue our improvement in this area. For example:
- We have a solid IT foundation — the challenge is to keep it current and reduce the cycle time for adding new layers. For example, integrating new clinical information from new partners.
- Operational workflows need to be improved to catch up to technology.
- Technology needs to be member-focused — allowing people timely access to information to participate in the process of managing their own healthcare.
Augusta: Operating as an ACO has definitely improved care coordination efforts across our enterprise, as our work to realize that vision has helped us build a strong infrastructure that will support our future expansion as a company. We believe a scaled, integrated physician and patient network is the future of healthcare and, as such, our integrated model thrives when we’re able to integrate with hospitals, specialists, and auxiliary providers to access the entire patient picture and power a one-on-one relationship between the physician and patient. Expanding care coordination across our enterprise is one of the reasons we’ve seen such significant recent growth.
It’s been nearly a decade since Elliot Fisher, director of the Center for Health Policy Research at Dartmouth Medical School, first coined the term Accountable Care Organization, or ACO. In the years since, nearly 400 ACOs have emerged, and the approach remains a key element of the Affordable Care Act.
Jackson: Banner Health Network was incorporated in July 2011, though our journey toward accountable care began long before in managed care plans, including our own self-insured employee health plan. Banner Health Network was selected as one of the original 32 Medicare Pioneer ACOs in December 2011. Our ACO is comprised of the Banner Health hospitals, Banner Medical Group (employed providers), and two affiliated partners, Banner Physician Hospital Organization (BPHO) and Arizona Integrated Physicians (AIP).
Augusta: We work with Medecision’s technology to track population health, especially among higher-risk patients, such as those with congestive heart failure, COPD, diabetes, and dialysis needs — these were the areas in which we saw the highest cost and most complex patients. The technology has helped us identify high-risk patients, prioritize them, and provide this information to our case managers so they can manage a certain fixed number of high-risk patients. We’ve also focused on further educating patients, ensuring that they receive preventative care, such as education and training.
Augusta: As we’ve become an ACO, the needs of our patient population have grown. For example, our patient population speaks half a dozen different languages, so we’ve had to make sure we have the staff and care managers to appropriately and effectively communicate with patients to ensure they receive the best and most proactive care possible. Moreover, as new groups join the ACO — some of which aren’t located nearby — we’ve established standardized governance processes, such as regular executive meetings with providers, to ensure clinical and business objectives are being met.
