Accountable care is, broadly defined, a set of clinical and payment reforms that tie provider reimbursements to quality metrics and reductions in the overall costs of care. Under accountable care, groups of care providers coordinate their efforts to treat patient populations and may be at financial risk for the quality and efficiency of the care provided.
As Tripathi points out, numerous models are springing up both in the government and commercial sectors under the ACO guise. In his state, for example, Blue Cross Blue Shield of Massachusetts began in 2009 paying participating health care provider groups under the "Alternative Quality Contract," instead of traditional fee-for-service payments. In this arrangement, providers receive fixed payments for patient care, plus rewards based on savings generated and clinical performance targets reached.
At the federal level, Medicare has launched several similar models, each of which is designed to reimburse based on outcomes, not sheer productivity. Tripathi-and many others in the industry-wonder if these various models will align and if providers can realistically embrace the financial risk involved.
One thing is clear: For any model to succeed, it will need to facilitate data sharing across diverse, and often, disconnected care settings. The chronic communication disconnects among inpatient, ambulatory, long-term and hospice settings, as well as communication breakdowns between insurers and providers, have stymied the best efforts of the industry to provide the care needed at affordable levels.
And the inability to coordinate efforts has providers bleeding red ink treating a relatively small but incredibly expensive patient population. Robert Berenson, M.D., contends that rising costs can be largely attributed to treating patients with multiple chronic conditions. "Nineteen percent of Medicare beneficiaries account for 77 percent of spending," says Berenson, a fellow in the Urban Institute, a Washington, D.C. think tank. "You have people seeing 14 physicians a year with 100 prescriptions. All sorts of things fall through the cracks. There's redundancy and inconsistency. A crucial aspect of the ACO is having somebody to reconcile all this for doctors who are doing their best-but doing it in isolation."
The many flavors of ACOs-including the patient centered medical home, bundled payment arrangements, and shared savings-attempt to facilitate that very kind of coordination. No doubt, there will be a substantial role for health I.T. in these models, as electronic health records, health information exchanges and perhaps even personal health records are prerequisites to success.
But many question marks loom around the proper role and responsibility of patients as the industry begins the shift away from productivity-based payment. In addition, there's the open question of who's going to lead the transition to accountable care. For Berenson, the natural-if not best suited-leaders would be physicians. "A hospital-oriented ACO will be challenged," he says. "They want to keep beds full and do procedures. Physicians like the status quo and they're feeling threatened. But you need somebody in charge."
In the Northern Adirondack Region Medical Home Project, that "somebody" is a primary care physician. Launched two years ago in rural upstate New York, the effort has two key purposes, says Karen Ashline, director of one of the multiple initiatives under the widely dispersed effort. First is recruiting primary care physicians to an underserved area. Second: improve outcomes and reduce costs-the cornerstones of accountable care.
Based in Plattsburgh, N.Y., the project spans 26 small group practices, five hospitals and nine commercial and government payers. The payers have chipped in extra reimbursement, which the group distributes to practices based on meeting certain financial/clinical criteria.
The initial criteria, Ashline says, was attaining certification from the National Committee for Quality Assurance (NCQA) as a medical home (29 of 31 have attained Level 3, the highest). Later, payments will focus will meeting certain quality thresholds, adds Heidi Moore, M.D., a participating pediatrician serving on the effort's executive board. In the medical home model, a primary care physician keeps tabs on a patient, serving as the central coordinator of care across specialties as needed, says Moore, one of four physicians practicing at Mountain View Pediatrics, also in Plattsburgh.
Two I.T. components are vital-an EHR and a data exchange, Moore adds. The participating primary care practices all run ambulatory EHRs-seven different products in total-and are connecting to a statewide regional data exchange. Through the data exchange, physicians can download hospital discharge summaries, see a record of emergency department visits, and access medication lists, Moore says. Practices also use their EHRs to initiate lab orders, view results, and prescribe medications.
Electronic transactions around medications are a big safety boost, Moore adds. "Medication errors are a cause of readmission. The EHR makes the medication list easier to coordinate between the hospitalization, the ED visit and the primary care office."
For Moore, the EHR's ability to trap quality metrics so clinicians can act on shortcomings in their treatment efforts is the critical first step toward accountable care. In essence, before the medical home practice can serve as conductor for other providers, it must get its own house in order. "I can sit down and look at the quality reports with other physicians," she says. "I can say, 'Look, either you're not asking about smoking cessation or you're not documenting it.'"
