Accountable Care Organizations

Accountable Care Organizations have been gaining traction for years in academic and policy circles. Now, the Patient Protection and Affordable Care Act aims to test the model in Medicare, and if successful, expand it to other patient populations using additional payment models.

ACOs are groups of affiliated health care professionals that agree to be accountable for the quality, cost, and overall care of patients for whom their physicians provide the bulk of primary care services. Several organizations could potentially form ACOs, including physicians in group practices, physicians in practice networks, hospital and physician partnerships, and hospitals employing physicians.

The ACO concept in the health reform law is modeled after the Medicare Physician Group Practice Demonstration, a five-year CMS pilot project that began in April 2005. Marshfield Clinic was one of ten participating practices eligible for an 80-percent share of Medicare savings, in addition to fee-for-service payments, if quality and cost targets were achieved. Marshfield Clinic received over $40 million in shared savings over the four-year program span.

WAFP believes primary care must be present in the development and direction of ACOs. Such involvement will be challenging for small, unaffiliated practices, and the WAFP will work to provide tools and resources for physician practices of all sizes.

Ultimately, Accountable Care must be about improving and maintaining the health of a population of patients and not just about controlling costs. It must focus on proactive and preventive, not reactive care; on outcomes, not volume or processes; and on leveraging the value of primary care and the Patient-Centered Medical Home.

Message from WAFP PCMH Committee Chair, David Eitrheim, MD

Accountable Care Organization Update
CMS ACO Accelerated Development Learning Session
Dave Eitrheim MD
Mayo Clinic Health System-Red Cedar
July 27, 2011

On June 20-22, 2011, the Center for Medicare and Medicaid Services (CMS) held its first Accountable Care Organization Accelerated Development Learning session in Minneapolis, MN. The message was clear: Accountable Care Organizations (ACOs) should be seen as the future roadmap for the practice of medicine in America.

CMS administrator Don Berwick, founder and CEO of the Institute for Healthcare Improvement, is no stranger to change in healthcare systems. In the words of Dr. Berwick, our “healthcare system [is] built on fragmentation” and “we can invent our way to success.” Dr. Berwick’s full keynote address (53 minutes) can be viewed here.

An Accountable Care Organization is a group of healthcare providers who agree to take on shared responsibility for the care of a defined population of patients, while assuring active management of both the quality and cost of that care. Using principles of the Patient-Centered Medical Home (PCMH), care coordination has improved the quality and reduced the cost of care given to patients. Although CMS has established the Medicare ACO shared savings program, the Accelerated Development Learning session focused on the development of ACOs that will require contracting between large medical groups and insurers. Many large medical groups are making the change from a fee-for-service system that financially rewards a high volume of medical services to an ACO/PCMH system that emphasizes the value of healthcare. The transition is not easy: it is like having one foot on the boat and one on the dock.

Some good ideas for medical groups seeking to improve the value of their healthcare services include the following:

A good starting point for improving value: work to increase generic prescribing by providers.
Good care coordination is the key to success in an ACO. Use care coordination nurses to prevent hospital admissions and readmissions by first focusing on congestive heart failure. When this has been mastered, COPD/asthma, coronary artery disease, and diabetes are other good targets.
Most hospital discharges should involve a follow up call from a nurse care manager within 24 hours, and a follow up office visit with their physician within three days.
Outpatient care visits that can be prompt and especially same day appointments with a patient’s primary healthcare provider can decrease frequent hospitalizations.
Let patients take the lead in end of life care. As family physicians we can often decrease the extraordinary amount of medical care that goes into the last months of life by listening to our patients and following their wishes.
Data entry is not a good use of physician time.
Don’t forget about the role of our specialty colleagues: patients should have health maintenance issues addressed by nursing staff at every visit, regardless of the physician’s specialty. Specialists should be accessible and have same day or prompt availability for managing more urgent consultations.
Activating our patients is the key, as they ultimately are responsible for their health. Setting goals, motivational interviewing, and self-care plans are tools that family physicians can use to improve patient health.

Family physicians working in Patient-Centered Medical Homes are being recognized as one of the building blocks needed to revamp a U.S. medical system that is unduly expensive and fragmented. The principles that built the specialty of family medicine forty years ago are the same principles that are needed to rebuild the U.S. healthcare system and forge ACOs today. As family physicians, we need to take leadership roles in this transition to a new ACO system and focus on what family medicine has always emphasized: the needs of our patients and their families.