Accountable Care Organizations: Patient Centered, Employer Friendly, Affordable Care Act Compliant

Tuesday, July 31, 2012 - 16:13

The Editor interviews James Barr, M.D., Chief Medical Officer and Vice President of Physician Network Development for Optimus Healthcare Partners.

Editor: Please start our discussion with a description of Optimus Healthcare Partners and of the accountable care organization (“ACO”) model as a whole.

Barr: Optimus Healthcare Partners is a Medicare-approved accountable care organization developed by physicians to provide a safe, affordable, high-quality, coordinated delivery system to patients and the purchasers of healthcare. I didn’t mention satisfying the bottom line of a large institution or business entity because our focus is the patient and making excellent care affordable.

The underlying principles to which we adhere run along three broad lines. The first focuses specifically on primary care. The Patient-Centered Medical Home (PCMH) model of care serves as the foundation for Optimus, recognizing primary care physicians as the mechanism to re-engage patients in managing their health. We rebuild a trusting relationship between the primary care physician and patient, then leverage this to promote healthy lifestyle behaviors, timely health screenings and management of all health conditions according to evidence-based guidelines.

The second emphasis is team-based care. Optimus supports office-based clinical coordinators within all primary care and specialty practices. This clinical staff member serves as the patient advocate, proactively communicating with them and coordinating needed care. The patient-centered team may also include specialists, nutritionists, therapists or other professionals. The key is integrating all team members so that patient care is fully coordinated.

The third focus is accountability. Our present healthcare system fails to recognize quality and instead rewards physicians to perform as many services possible. The Medicare ACO model identifies 33 quality metrics for ACO participants to achieve. It also changes the financial incentives and rewards value instead of volume. Optimus Healthcare Partners goes a step further with our Performance Management Program. Physicians who fail to improve performance gaps within expected time frames are aggressively managed, even to the point of being de-credentialed. The critical question is if the ACO can provide physicians and hospitals with the data, analytics and infrastructure to support a higher level of performance, and if these same physicians and hospitals can embrace a culture of change.

Editor: Are ACOs required to use the PCMH model?

Barr: Use of the PCMH model is not a prerequisite for becoming an ACO. Optimus Healthcare Partners voluntarily subscribes to this model because a complete redesign of the healthcare system from the bottom up is the only way to deliver sustainable solutions. Participation in the PCMH model involves compliance with seven joint principles that serve as the basis for redesigning patient care. Those principles are as follows:

  • A Personal Physician or Provider – A professional who is focused on building a trusted physician-patient relationship and understanding all the patients needs. This includes guiding a team of professionals that proactively coordinate and manage the patient’s care over time.
  • Team-Based Care – The team-based approach allows doctors to leverage a group of healthcare professionals, in line with each team member’s licensure, and to provide comprehensive services that no doctor can accomplish on his own.
  • Whole Person Orientation – Replaces the traditional silo approach in which each aspect of a person’s health (and each part of a person’s body) is treated separately; this orientation involves an integrated focus on the patient’s physical, emotional, psychological, cultural and spiritual needs. This approach naturally leads to enhanced care that focuses on prevention and creates a better patient experience.
  • Care Coordination and Integration – The Optimus team includes clinical coordinators, and we use patient registries and health information exchanges (HIE) to ensure that all participants in a patient’s care are informed of that patient’s history and ongoing needs.
  • Quality and Safety – Information technology systems play a role in adherence to this principle, which involves compliance with evidence-based guidelines for care management and clinical decision support tools.
  • Enhanced Access – Patients have access to same-day, off-hours and weekend services without having to go to the emergency room. This benefit extends beyond good patient medical care to systemic cost reductions. 
  • Payment Structure – Put simply, the PCMH model rewards keeping people healthy. Adherence to this principle requires appropriate information technology resources to monitor specific physician performance, organizational performance and patient outcomes.

Editor: Please expand on the concept of integrated care and services within the ACO model that enable it.

Barr:  The ACO model integrates the activities of a primary care doctor with those of specialists. Through the use of care coordination guidelines and protocols, along with tools like an HIE, patient care is coordinated and managed at the highest level, from primary care physician to specialist and back and forth as needed. Such management includes the timely exchange of clinical information and the patient being kept informed of all results and decisions.

Complementing the HIE, Optimus will use a care transitions program to coordinate required activities, such as ER use, hospitalization or home care. Finally, we exercise equal diligence in addressing post-acute or rehabilitative care, extending the ACO’s integrated care model to patient needs throughout the entire cycle of an illness or injury.

Editor: Does the ACO model’s central concept of financial accountability play a role in driving the quality of healthcare?

Barr: Yes. Medicare and most health plans’ traditional fee-for-service payment system reward doctors and hospitals on the basis of quantity of services, tests and procedures performed. While ACOs don’t eliminate this payment structure, they do provide incentives to healthcare providers who keep costs down – and the key way to do this is focusing on preventative care, carefully managing chronic diseases and better coordinating care. The goal is to keep patients healthy and reduce the need for costly emergency room or hospital care, therefore allowing savings that are shared between Medicare and ACO participants. This same model can be used with commercial health plans and self-insured employers.

Another key factor in the financial accountability analysis is the PCMH principle of whole-person orientation, which I discussed earlier. Instead of looking at patients as diseases or conditions, the PCMH model recognizes “a person” that may have concerns, fears or other needs in addition to his or her health issues. Our traditional, reactive healthcare system doesn’t reach proactively into behavioral health issues that may double or even triple healthcare costs. By identifying these early, better management can lead to fewer subsequent health issues and reduced costs.

Essentially, the financial accountability model ties in with quality of care by seeking to eliminate unnecessary expenditures and to maximize the value of healthcare dollars spent. Take emergency room services as an example. It is estimated that 45 percent of all ER visits are avoidable because the medical issues presented don’t require that level of care. There is great potential for cost savings if patients start relying to a greater extent on their primary-care facilities, reserving costly ER visits only for true emergency situations. As I mentioned earlier, enhanced access to primary care is one of the PCMH joint principles.

Further, it is estimated that 30 to 50 percent of all healthcare services either provide no value at all or, in fact, may be harmful, so there are plenty of financial rewards within the ACO system, which incentivizes streamlined, high-quality and better-coordinated care. Those rewards are substantially realized by avoiding medically unnecessary, high-cost treatment and, as with Optimus Healthcare Partners, by reallocating healthcare dollars toward prevention and the proactive management of conditions.

Editor: Please talk about Optimus Healthcare Partners’ information technology infrastructure.

Barr: We are presently deploying a patient registry, health information exchange, and a host of analytics capabilities – all of which provide direct benefits to patients.

The registry includes all patients within a physician’s attributed membership and can identify gaps in medical care based on the total available information. Those gaps can include everything from preventive screening, specific testing or certain treatments that must be done within a discrete time frame, and the registry prompts the primary care office to reach out to the patient based on his or her unique history and needs. Instead of waiting for patients to call us, we call them.

The health information exchange provides a common care coordination platform for the patient registry information, claims files, labs and all other available healthcare data. This allows specialists, emergency rooms, hospitalists and other appropriate professionals to share information in a secure environment, which is critical to better patient management.

The analytics function is there to track activity and statistics. For example, we can identify people who are frequently using the ER and, therefore, may need more aggressive medical management and a more proactive care plan. Analytics also provide metrics that enable us to do internal quality control assessments, for instance, as may relate to evidence-based care management guidelines within the PCMH model.

Having an effective IT infrastructure also assists our compliance efforts regarding Stark Laws. The Federal Trade Commission and Office of Inspector General will be looking for clinical integration within ACO organizations, and our patient registry, health information exchange and common analytics show the connections among physicians that drive better patient outcomes.

Editor: Are your services fully compliant with coverage provisions of the Patient Protection and Affordable Care Act (the “Act”)?

Barr: Yes, the operations of ACOs and the coverage provided are aligned with provisions of the Act.

Editor: What should employers understand about the benefits of partnering with ACOs like Optimus Healthcare Partners?

Barr: Just as with the patient relationship, our employer relationships represent a true alignment of interests. Rather than shifting the costs of healthcare premiums to employees, there is greater potential for a successful healthcare benefits program if financial incentives are aligned with the on-the-ground efforts of patient-centered providers. The middle men offer no value or solutions and have failed to engage physicians or patients. It’s time for purchasers to work closely with physicians to drive sustainable innovations in healthcare delivery.

Clearly, keeping people healthy will reduce direct medical costs, but employers should also understand the indirect costs of health-related issues, which can be two to three times greater than the direct costs. Absenteeism, presenteeism and productivity are all issues easier to manage when employees stay healthy. Consider further the costs of workers’ compensation or disability, and employers have multiple cost reasons to get involved with a physician-driven ACO.

Editor: Do you have any final thoughts for our readers?

Barr: First, we need physicians and patients to be part of the solution. We can’t continue our same top-down management and expect a different outcome. It will also take more than a modest change in benefit design or fancy disease-management programs. We need a complete redesign that engages physicians and patients, similar to the direction the PCMH and ACO models provide.

Second, and most important, we must bring clarity of purpose back to healthcare. The magnitude of issues combined with powerful private agendas can make us apathetic towards any solution. At Optimus, our patient-centered approach provides clarity as we chart the future of healthcare. I like to consider us an “accountable compassion organization,” delivering patients the type of care they truly need. With clarity and change, we can all do it.

For further information, please visit www.optimushealthcarepartners.com.