Internist Carlos Hernandez is very familiar with accountable care organizations (ACO). In fact, he says he's been part of one since before the term ACO was "even a buzzword."
Hernandez, president of WellMed Medical Group in San Antonio, leads about 400 employed and contracted physicians in a "full-risk" Medicare reimbursement model. If WellMed physicians don't reach quality and cost metrics for their 80,000 Medicare patients, they lose out financially.
When Hernandez first heard about the group's switch to full-risk reimbursement 20 years ago, he says he wondered, "What took it so long?" He says participating in the model has been a win-win for WellMed, which operates 22 primary-care clinics in the San Antonio area and about 13 clinics in other parts of Texas and Florida. In addition to improving patient care, he says, "it lets us start seeing [fewer] patients for either the same or more income than we would have gotten in the traditional fee-for-service."
Clearly an ACO-like model is working for WellMed, but will participating in one work for your practice? To help provide some answers, we've outlined the key challenges and considerations to keep in mind whether you've just joined an ACO or you're deciding if joining one is a good option for you.
The large number of emerging commercial and federal ACOs has resulted in confusion over what exactly an ACO is, says family physician Glen Stream, president of the American Academy of Family Physicians.
In broadest terms, an ACO is a group of providers (hospitals, practices, and/or other healthcare systems) working together to improve quality of care at reduced cost. If the ACO meets these targets, its participants share the cost savings achieved. Cigna HealthCare, a private insurer currently engaged in multiple ACOs throughout the country, refers to this as the "triple aim" of better health, better quality, better cost, says family physician Dick Salmon, Cigna's national medical director who oversees its ACO program.
In Medicare's ACO model, providers commit to three years of participation in either a one-sided model (sharing 50 percent of cost savings), or a two-sided risk model (sharing 60 percent of cost savings and losses).
Regardless of which model or type of ACO you are considering, there are four key challenges to keep in mind.
1. Tech needs
ACO participants need to take their EHR usage up to a new level, says Richard Lopez, internist and chief medical officer at Atrius Health, an ACO made up of six Massachusetts-based medical groups. That means in addition to using EHRs well, providers need to understand how EHRs can help monitor and improve patient care. "The EMR is more than just a repository of data like a word processor; it helps you with managing populations," Lopez says.
Prime ACO candidates are practices that are pursuing or have already achieved their patient centered medical home accreditation (PCMH), says Salmon. That's because these practices are already using EHRs to track, analyze, and improve patient populations, as required under PCMH accreditation standards. Their EHR usage goes "beyond just documenting what happened with the patient visit," he says.
According to Physicians Practice's 2011 Technology Survey, only 48 percent of you have fully implemented an EHR. If you are planning to participate in an ACO, mastering your EHR should be a top priority.
ACO participants also need an HIE (health information exchange) that works well in order to exchange EHR data with the rest of the ACO providers, quickly and efficiently, says Cindy Dunn, senior MGMA consultant. "It is not uncommon to find a hospital and a practice that are using the same software yet they can't exchange data," she says.
2. Operational changes
For the typical medical practice, ACO participation requires numerous adjustments:
• Evidence-based guidelines. To comply with ACO rules and regulations, ACO participants need to "reframe the care delivery within their practice," Dunn says. That means following the best-practice guidelines for your particular specialty.
• Efficiency. ACO participants need to operate at a high level of efficiency to treat patients quickly across different health settings, Dunn says. That includes promptly forwarding test results, accommodating late-notice appointments, referring patients to other providers, etc.
• Additional responsibilities. Staff members within the ACO need to take on extra population management tasks, including patient outreach and monitoring, Lopez says. "Beginning to think about how you manage a population of patients outside of the exam room on a team basis is very important."
• New roles. Ideally, ACO participants have the means to hire new employees to conduct patient outreach, Salmon says. Or, a less expensive option is to hire individuals with non-healthcare related degrees to telephone patients about follow-up care, says Lopez.
3. Patients as partners
Practices that fail to engage patients as full partners in their care are going to have difficulty reaching quality and cost targets. That's because many of the quality targets have as much to do with patient behavior (diet and medication adherence, for example) as with any service performed by the doctor.
As a result, patient engagement is a "crucial issue," says Lopez. He suggests ACO providers implement a patient portal in which patients can request prescriptions and appointments; and view lab results, immunization history, problem lists, and family medical history. "This is a way to sink in with a growing part of the population that is e-connected and get them to engage in their healthcare," he says.
Another way to improve patient engagement, at lower cost, is by making patients aware that they are an integral part of this new model of care. "Patients want to do what their doctors want them to do," Dunn says. "If we don't communicate to our patients that we're changing, then we can't expect them to step up."
4. Money challenges
It's impossible to predict whether ACO participation will pay off for your practice until the checks start flowing in (or out), but there are some options to consider that could help minimize the upfront costs of participating.
If a hospital is part of an ACO, it might help the smaller participants by providing them with staff members to help manage their patient populations. Or, it might provide funding to help them acquire suitable EHRs, Lopez says. Community resources such as the local VA hospital might also assist with keeping tabs on patients.
Practices participating in ACOs also need to ensure they receive a fair portion of the shared savings. "If there's a place for a physician to sit on the board or to represent the practice or his or her colleagues out there, they need to do that," Dunn says. "They have to be knowledgeable and work together with their operational leaders so that they are well represented in the agreement."
If your practice is on the fence about ACO participation, think realistically about whether it will be financially lucrative for you, especially if you're already performing well for quality and cost, Stream says. "Practices really need to evaluate from a financial standpoint, [whether] this is a program that really makes sense for this particular group in this particular market or not."
Aubrey Westgate is an associate editor for Physicians Practice. She can be reached at email@example.com.
This article originally appeared in the February 2012 issue of Physicians Practice.