In a recent blog, I examined whether the initial goals set by the Affordable Care Act (ACA) have been met. One of these goals was to “support innovative medical care delivery methods designed to lower the costs of health care generally.” Focusing specifically on that, you’ll notice that over the last decade there have been a number of payment models that have emerged, and evolved, to battle the increasing costs while still improving quality of care in the US healthcare system. One of these models is the Accountable Care Organization (ACO) model, which is defined as “groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high-quality care to their Medicare patients.” It was actually born out of what was originally the Patient Centered Medical Home. ACOs can be hospital-led or physician-led. Regardless of the organizational structure, patient attribution is used to identify those patients who are associated with the ACO via primary care services. Many physician-led organizations are mostly comprised of primary care providers, yet they are responsible for the total cost of care of each patient. However, primary care only represents 6-7% of the total healthcare spending. Primary care can have a significant influence on specialist referrals, diagnostic testing, pharmaceuticals, acute care, and post-acute care. Because of this, identification, and engagement of high-value providers, as well as the alignment of incentives across all stakeholders, is critical to the success of value-based care organizations such as ACOs.
The first step towards establishing a collaboration is identification of high performing providers within your geographic area to ensure accessible, high quality, cost-effective care across the continuum. This may include acute providers, post-acute providers, urgent care centers, and specialists. To complete this analysis, the ACO will need to identify which facilities their patients are currently using. Then, analyze the costs and quality of each of these facilities. Cost data can be obtained through claims data; quality data can be found via the CMS website. For example, CMS provides quality data on skilled nursing facilities on “Nursing Home Compare.”
A sophisticated data analytics platform will then be able to combine these files into a single scorecard. Once you have assessed the qualitative data, it is important to identify where these organizations are located. This can be accomplished with geo-mapping. Again, data analytics platforms can be used to generate these reports, but if your organization doesn’t have access to this type of technology, you can use another mapping interface as a rudimentary substitute with the understanding that it will take more time and effort, and unfortunately will not able to demonstrate proximity of facilities to patients’ home addresses.
Additionally, consider the services that the preferred provider organizations provide. For example, you may establish a collaboration with an independent-specialty group for common referrals, but you may want to ensure that the high-cost academic center is available for complex cases. Remember, it is important to ensure that the patient receives high-quality care both at the right time and in the right place.
Lastly, with the advancement of telehealth services, consider partnerships with organizations that offer telehealth services. For example, if you are in a rural area, is there a specialist that can provide telehealth services to increase access?
Once you have identified your partners, it is important to establish expectations to provide a framework for better communication, coordination of care, and transitions of care. Set frequent collaborative sessions, where the ACO, and their partners, can discuss best practices so you can learn what is working and what is not working. You can also use this time to review scorecards, and identify areas of improvement in quality and process, to continue to enhance patient care. For example, what is the best way to ensure patient records are exchanged? Are there processes for warm hand-offs? How do we eliminate gaps in care during transitions? As an ACO, remember to use these scorecards to identify whether any network leakage is occurring. Are all patients being referred to in-network facilities and providers? If not, why? Could there be an access issue? Are all providers aware of their network? Are there specific conditions needed to be seen out of network due to limitations?
The last step is to inform patients about the collaboration. Even if you have a great relationship with the preferred providers, your patients need to be aware of these relationships to utilize the high-value network that you have worked so hard to build. While it is always the patients’ choice in selecting a provider, primary care providers will need to establish practice workflows to manage referrals. Additionally, practices may consider providing patient-facing preferred provider patient cards to serve as patient-reminder, and a letter to inform the patients about your high-value network and the benefits of it. Additionally, ensure that all providers within your network are aware of these relationships. For example, if a patient is being discharged from the hospital to a home with home health, is the hospital aware of the preferred provider network?
The collaboration will establish a high-value network that not just the accountable organization will benefit from. These collaborations can be extended to your commercial value-based contracts and be used to negotiate your fee-for-service contracts with insurers. Many insurers are establishing preferred provider networks, with preferable cost-sharing arrangements for patients that use high-value networks. Bring in others- other insurance products.
Remember, patients, providers, and insurers must all work together to decrease costs and improve quality. Without the alignment of incentives across all stakeholders, value-based care cannot work. After all, we are all in this together.