Everywhere I turn, I hear about accountable care organizations, especially during provider-focused forums. Nearly everyone is excited about their ACO (and medical home) initiatives, but I’ve also met with quite a few skeptics who believe that the concept is nothing new and has been tried many times—and failed--in various forms. Interesting!

To be honest, I haven’t delved deeply into the complexities of the initiatives (but am doing a lot of research to come to grips with it) hence my blog today will be more of an invitation for comments rather than an opinionated monologue.

Based on all the discussions I’ve heard, I think I can break down the concept into three major components. Might be too simplistic a representation, but I guess that’s the limit of my current knowledge of the topic:

  • A network of care providers that can cover almost all aspects of care dissemination
  • A collaborative model for exchange of clinical data
  • Performance-based reimbursements

So, let’s assume that my categorization is correct and let’s then analyze each of these three points separately.
Network of Care Providers:  Since the advent of HMOs, we always had had a collection of care providers that we called an in-plan network, so assembling a set of care providers working together to resolve patients’ disease conditions is not a new concept. But a collection of people working toward a common end goal but maintaining potentially divergent self-interest is not exactly the same as a collection of people whose self-interests are intricately tied together.

The ACOs goes much farther than HMO networks because everybody has to work together to get the desired reimbursements. Not to mention the fact that there is a central coordinator who carries the burden of care planning rather than the poor patient who is already struggling with the disease condition. The performance-based incentives rather than the fee-for- service model helps too.

Exchange of clinical data: This is where the critics talk about having already tried the EHRs/PHRs/HIEs and them not working so successfully at all. To be honest this is one point where I believe the critics are closest to having a very sound argument. We know how difficult it is to set up a real good HIE platform, not only from a technological perspective but also from an operational perspective.

However, with the advent of a collective-neck-on-the-line concept, I would propose that a lot of the challenges faced by HIEs will be eliminated. If one looks carefully, one could deduce that majority of the ills associated with past implementations of HIE platforms were due to resistance to data sharing rather than technological obstacles. Where a fee-for-service model and ‘no-impact-on-me’ attitude prevailed, resistance was understandable. But now with the shared compensation and metrics based on common sharable incentives, one would think twice before asking for a redundant radiology test rather than depending upon the perfectly fine report from a test conducted a few days ago.

Performance-based reimbursements: Here again, I hear people snickering about all those P4P initiatives that were launched with plenty of fanfare but for the vast majority of providers turned out to be pretty damp squibs. Once again the counter to that is the collective nature of the reimbursement.  The “collective” variant is what carries the day.

A provider working in the P4P environment still had plenty of loopholes to enable them to punt the total-spend or overall quality-of-care issue to a third party. Why did ‘X’ have a re-admittance? Well, nothing to do with my care. It must have been the drugs or some allergic reaction to the radiological dye that was used, or … you get the gist. Whereas under the ACO scenario, there is no third party to begin with, so who does the blame shift to? This structure will force the provider group to invent new clinical pathways that are not only effective but are significantly cheaper. Building a cost and quality conscious attitude in the provider community: now that’s a novel concept, isn’t it?

In a nutshell, I believe that though the overall ACO concept is nothing more than a combination of three existing concepts, with a few variants thrown in to spice things up, the collective nature of the concept has the potential to bring about a sea-change in the health care industry. So, at least for now, I’m saying “Go ACO, Go!”

Rajiv Sabharwal is the chief solution architect in the Healthcare and Life Sciences unit at Infosys Technologies LTD. He can be reached at Rajiv_Sabharwal01@infosys.com.

 

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