A patient-centered medical home is the engine of an accountable care organization--and the core duties of the home are not as complex as may be envisioned. But changing behaviors of providers and patients is the tricky part.

Those are insights that a participating federally qualified health center shared during the ACO Symposium at HIMSS14. The core duties of a medical home, said Raymond Fusco, COO at Manatee County Rural Health Services in Florida, are to improve the patient experience, improve the health of specific populations and reduce per capita cost of care. 

The organization was among 54 of 114 Medicare Advantage ACOs that saved costs during their first year, but Manatee was $180,000 shy of the mark needed to share savings.

The organization started with 5,000 patients served by four clinics, and now has 10,000 in 18 clinics in the program. Lessons from previous changes in Medicare reimbursement are applicable today as accountable care expands, Fusco said.

He recalled the good old days when providers were reimbursed for their cost plus 15 percent before Diagnosis Related Groups came in with fixed costs for procedures. Under DRG, labs and imaging centers that were revenue generators became cost centers, and some organizations created utilization nurses to monitor appropriate use of resources in various departments. Now, those skills are again needed under the ACO shared savings model. Remembering the early days of DRGs will help an organization in its early days of using the ACO model, Fusco emphasized. “We know this is the model of the future, so you need to learn the new rules, just like when DRGs came in.”

The Medicare Advantage ACO that Manatee County participates in covers a nine-county region. One of the challenges is that many hospitals haven’t accepted the ACO model and prefer admitting patients over keeping them in an observation status if appropriate, so finding hospital partners can be tough. Medicare plans also initially did not provide much usable information to ACO participants to help them understand their performance, Fusco says. The plans would tell an organization that its medical loss ratio was too high but give no details on where it was high and why. Now, the plans can offer such information, including identifying providers running up bills so ACO members can avoid them.

As for providers in ACOs, they need to change behavior and that change needs to be monitored, Fusco warned. Many physicians like to refer out to specialists, letting a cardiologist or neurologist take the lead in managing certain populations. Now, the primary care physician must become the manager and know what the specialists are doing and whether they also are using new processes to better manage population health. And physicians have to stop routinely admitting patients to the hospital from the ED, a behavior that can take up to six months to change, Fusco said. Physicians in ACOs also must work on changing patient behavior. The ACO started with 33 quality measures and the first seven measures focused on patients becoming more engaged in their care.

Hospitals participating in an ACO have a big change to make, one that gives an indication of how important new ways of thinking will become, Fusco said. “You can’t advertise 15-minute wait times in your ED and then complain when low income patients flock to your ED.”

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