ACO Advice: Culture Must Precede Measures

Attempting to launch an accountable care organization before building a culture around physician and hospital collaboration won't work.

That was the message given by Mark Shields, M.D., senior medical director at Advocate Physician Partners during a presentation at the Medical Group Management Association annual meeting, held in Las Vegas this week. Shields described Advocate's steady development of what he called "clinical integration," a model of facilitating collaboration across multi-specialty physicians via shared managed care contracts, which include pay-for-performance bonuses.

Advocate's 3,900-member physician-hospital organization includes some 900 physicians employed by the 12-hospital delivery system serving Chicagoland. Beyond that group, the bulk of the membership practice is in small, independent groups, Shields noted.

One of the key challenges of building an ACO is that the large multi-specialty group practices that would be ideally situated to coordinate care are in short supply, he noted. "About 90 percent of patients get their care in small groups."

Advocate in 2004 began an effort to promote and reward best practices among its PHO members. An underpinning of the effort is a data warehouse holding lab and test results from the hospitals, plus claims data from payers. Advocate started small with its clinical integration model--implementing about 30 individual performance measures at the beginning. As the program grew, that number has expanded to nearly 150.

But Shields cautioned the audience to not start their ACO with a series of measures. It is far more important, he asserted, to create awareness among physicians of the collective impact of their work on patient outcomes. "Don't start with measures, start with culture, then governance," he said, noting that Advocates' physicians are responsible for choosing performance measures, bonus thresholds, and credentialing standards for their peers.

Advocate issues quarterly report cards derived from the warehouse, which rank individuals and their local PHOs on measures including utilization of I.T., patient satisfaction and specific clinical indicators. At the end of each year, Advocate aggregates the data, using it to drive the distribution of performance bonuses to physicians, money which is earmarked from the various payer contracts.

Advocate uses its own set of criteria in negotiations with payers, thus sidestepping the difficulty of trying to comply with varying criteria given by individual health plans. That makes membership in the PHO attractive, Shields said.

On the I.T. front, Advocate physicians access the data warehouse via a Web-based, customized disease registry, whose usage is mandatory for participation in the bonus pool. The disease registry helps physicians identify which patients may be lacking treatments and thus avoid costlier hospitalizations down the line. After deploying an EHR for its employed physicians, Advocate launched e-prescribing in 2007. Last year the health system began rolling out an ambulatory EHR to its independent practices. 

Health Data Management will host a Web seminar Thursday, Oct. 27 at 2 p.m. to break down the final ACO rule. To register for the free event, click here.