A look inside two ACOs

Accountable care organizations, or ACOs, are designed to bring together acute and ambulatory providers to deliver seamless, well-coordinated, patient-centered, high-quality care. Two ACO executives described how their organizations are attempting to do just that, at the recent Market Insights conference, sponsored by MDSI, publisher of ACO Insights

Toledo, Ohio-based ProMedica is an IDN comprising 11 hospitals, 450 employed physician providers and 310 total sites, accounting for nearly 4 million patient encounters annually. Its health insurance plan, Paramount Health Care, has more than 200,000 members enrolled in commercial and government insurance products.

Started in July 2012, ProMedica’s ACO – ProMedica Physician Group Inc. – comprises 300 of their 450 physicians and specialists, explained Terri Thompson, corporate director of accountable care for ProMedica. The focus of ProMedica’s ACO is patient-centered primary care, and it provides that care to about 18,000 assigned Medicare patients through its participation in the Medicare ACO and Paramount ACO programs, she said. “We were already well on our way to clinical care coordination prior to receiving ACO status from the Centers for Medicare & Medicaid Services. Our focus – not just for the ACO, but for all of our providers – has been to improve the quality of care and resulting health outcomes as well as reduce the cost of care for all of our patient populations.”

The ProMedica ACO rests on three key components – collaboration, integration and communication, said Thompson. Soon after attaining ACO status, ProMedica selected one information-systems vendor to integrate the myriad of information gathered at all care sites, including hospitals, physicians offices, ancillary providers, labs and radiology, as well as data from payers. With that “big data” system in place, all providers and administrators will be “talking the same language, eliminating duplication and collaborating in ways we’ve never considered possible,” she said.

Part of the mission of the ACO is to improve the care transition process, whereby a patient moves from one care site to another, or to home. To facilitate this process, acute “care navigators” are stationed in the hospitals to monitor high-risk patients and work with discharge planners to ensure that patients have all they need arranged or in place prior to discharge. A team of ambulatory “care navigators” working in the physician offices monitor high-risk patients who are not in the hospital. For Paramount products, the health plan case managers monitor medium-risk patients, their goal being to prevent them from becoming high-risk ones, while disease managers monitor low-risk patients. For Paramount members, the entire care management team works together, but it’s crucial that patients also get involved in their own care, said Thompson.

AtlantiCare Health Solutions
As in many communities across the country, the people and employers in the Greater Atlantic City, N.J., area have just about reached the breaking point in terms of healthcare costs, said Paige Younkin, past assistant vice president for clinical integration, AtlantiCare, an IDN with 50 locations. “Employers are saying, ‘We can’t afford healthcare anymore,’” she said. “And they’re looking at us to come up with solutions.”

AtlantiCare participates in an initiative led by the Premier health alliance to identify best practices in accountable care. “It’s about collaborating, developing relationships, sharing information and coming up with new ways to care for populations,” said Younkin.

In October 2011, AtlantiCare announced the creation of its accountable care organization – AtlantiCare Health Solutions. In January 2013, the ACO became part of the CMS’s Medicare Shared Savings Program. That program is designed to facilitate coordination and cooperation among providers to improve the quality of care for Medicare fee-for-service beneficiaries and to eliminate unnecessary costs. AtlantiCare Health Solutions also works with employer groups and AtlantiCare’s employees.

Citing the “Triple Aim” of improved quality, lower costs and greater patient satisfaction, Younkin said that AtlantiCare Health Solutions is attempting to de-link payments and in-person visits and treatments, increase investment in primary care, provide culturally appropriate health coaches and care managers, improve pharmacy services, integrate behavioral health services, and coordinate data so providers can act in real time.

Patient engagement is critical, said Younkin. As an example, staff in AtlantiCare’s Engaged health plan who have annual preventive health visits and appropriate screenings and participate in other wellness activities, earn wellness credits to pay a lower or no deductible.

Physician engagement is critical as well. That’s why physicians participate in the marketing and governance of the ACO, and have input into provider growth and development, as well as clinical integration opportunities.

In order to participate, physicians must agree to four “hurdle criteria” – implement an electronic medical record system, provide open-access appointments, make use of the ACO’s care managers and hospitalists, and use the ACO’s clinical practice guidelines. Care managers in outpatient and inpatient (including emergency room) settings communicate with each other to “streamline efficient transitions of care, so patients don’t get lost in the cracks,” said Younkin. “This has helped us avoid the occurrence of preventable hospital readmissions.”

AtlantiCare has identified four clinical measures (hemoglobin A1c, LDL, eye exams, and blood pressure) to be monitored for patients with diabetes. Physicians must also agree to collaborate with AtlantiCare Health Solutions on four utilization metrics – emergency room visits, medical inpatient admissions, hospital readmissions, and generic drug utilization. AtlantiCare has attempted to standardize medical supplies across the system. This means that regardless of care setting, patients will receive the same glucometer, insulin pen and education materials. The ACO is currently standardizing other things, such as blood pressure cuffs.

What AtlantiCare is attempting to achieve is truly transformational, said Younkin. “It is looking at different ways of partnering and providing care, redesigning care, improving outcomes, looking at the cost of infrastructure development and transformation, and creating a culture of change within the organization.” And the results are promising, including lower overall medical and pharmaceutical costs, an average drop in systolic blood pressure, decreased smoking rates, and better management of diabetes.

Bottom line for suppliers

Providers attempting fundamental changes, such as ProMedica and AtlantiCare, can use the support and cooperation of their suppliers, Thompson and Younkin told the Market Insights audience, which included a large percentage of manufacturers and distributors.

Suppliers who want to be part of their customers’ transformative approach to healthcare should do the following, said Younkin:

  • Gain a clear understanding of the provider organization’s strategic direction and priority initiatives.
  • Understand the provider’s cost structure.
  • Understand in what areas the provider has identified a need for cost reduction, and areas in which the provider wants to grow.
  • Understand the provider’s key clinical initiatives.

“If you want to find out how to connect as a supplier, you need to understand what we’re dealing with,” she said. One IDN or ACO may have care models in place for diabetes, heart failure or asthma, while another might be more focused on orthopedics. “Understanding their priorities is key.”

Suppliers should understand that providers such as ProMedica are attempting to increase standardization across their health system, said Thompson. Suppliers can expect reduced access to product and equipment decision-makers with this more streamlined approach. More important, as providers develop clinical “best-practice” standards of care, suppliers must be able to demonstrate the value of their products and how they fit into those “best practice” standards.

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