The description of Accountable Care Organizations in the Patient Protection and Accountable Care Act of 2009 has caught the attention of physician groups, hospitals, and integrated care organizations across the nation. By January, 2012, the Department of Health Services will engage providers in ACO demonstration projects to evaluate alternative ACO structures and to identify what works and what doesn’t work in promoting the goals of health reform.
As providers weigh in on their decision to establish an ACO, many questions need answering:
First and foremost, what is an Accountable Care Organization?
Under the Affordable Care Act, an ACO is limited to Medicare Fee-For-Service beneficiaries with the goal of lowering per capita costs through care coordination across the continuum of care. CMS will share a portion of those savings with the providers as a reward for their care coordination efforts.
However, there are many other permutations that ACOs can voluntarily establish. The size and scope of a voluntary ACO is limited only by one’s creativity. It may involve commercial payers and alternative payment schemes; it may focus only on chronic disease(s); it may be limited to primary care or include the full spectrum of care; or it may be any combination that meets the organization’s vision, mission, and goals.
What is care coordination and what is meant by the continuum of care?
To be a successful ACO, providers need to migrate to a “patient centered medical home” model of care whose purpose is three-fold:
- Keep healthy patients healthy through prevention, screening, early diagnosis and early intervention
- Case manage patients with chronic and complex conditions and engage patients by educating them on ways to cost-effectively self-manage their health conditions
- Establish interdisciplinary care teams to address the full range of physical health, mental health, and social needs of patients across the continuum of care settings
The continuum of care includes physician offices, mental health counselors, specialty consults, hospital care, skilled nursing care, home health, hospice, nutritionists, social workers, and care givers. Data is shared across care settings to assure that the transition from one care setting to another is seamless.
What are the risks of ACO's?
There are many risks in forming an ACO just as there are with starting any new business.
- There are financial risks in that most ACOs will have some capitated payment schemes either through global budgets, bundled payments, or shared savings.
- There are performance risks if providers and/or staff are unable to adopt new care delivery models or meet target quality measures.
- There are quality control risks for providers who contract with the ACO rather than participate as an ACO member
- There are infrastructure risks around the secure sharing of protected patient data across care settings.
How do organizations mitigate those risks?
- Realistically assess one’s ability to succeed as an ACO before moving forward
- Carefully select your partners and decide whether it’s best for them to be in the ACO or participate on a contractual basis
- Invest in significant up-front planning and organizational development
- Create an implementation strategy that
- matches available financial resources
- addresses providers’ and staff timetables to train on new care delivery models
- allows time to build needed infrastructure for data management and quality improvement
How can CareSync Consulting help?
Whether your Accountable Care Organization is structured around physicians, hospitals, or an integrated delivery system, CareSync Consulting is there to support you through the three phases of ACO development:
- Readiness AssessmentBusiness
- Planning and Organizational Design
- Implementation and Activation
What Is Your ACO Vision?
Every Accountable Care Organization will be structured differently depending upon how each one answers the following questions. There are no right or wrong answers. Each organization will have to respond to each question in a way that reflects their business strategy.
1. An ACO focuses on integrated and interdisciplinary care teams.
- How will you migrate your providers and staff to a patient centered medical home care delivery model?
- How will you infuse an organizational culture that emphasizes prevention, screening, outreach and early intervention among providers, staff, and patients?
- How will you increase case management services to improve the quality of life for patients with chronic and complex conditions?
- How will you establish interdisciplinary teams that include a broad spectrum of physician specialties, social workers, mental health counselors, nutritionists, etc. to holistically treat patients?
2. An ACO depends upon primary care providers to coordinate patient care across the continuum of care.
- How are you going to change the dynamics of traditional provider autonomy in clinical decision making and information sharing across the continuum of care, including specialists, hospitals, and skilled nursing facilities?
- How will you structure governance and administration among diverse stakeholders within the ACO?
- How are you going to monitor compliance with new communication requirements, data sharing and reporting requirements, quality measures, and cost performance across the continuum of care?
- How will you share risk across the continuum of care?
3. An ACO is data driven.
- How will you deploy evidence-based medical protocols across the organization that succeed in minimizing unnecessary variation in cost and quality metrics?
- How will you monitor organizational benchmarks and incentive targets?
- How will support secure and seamless information sharing across the continuum of care?
- How will you communicate financial, quality, and productivity results to ACO stakeholders?
- How will you account for population-based goals on quality improvement and per capita cost reductions?
4. An ACO promotes individual responsibility for one’s health.
- How will you engage and monitor patient self-management of their health?
- How will you connect with non-health care workers to holistically address each patient’s needs in ways that promote a healthy lifestyle?
5. ACO providers are remunerated based on value and quality rather than volume of services delivered.
- How are you going to incentivize providers to manage their patients’ health over time rather than only treat episodic illnesses and injuries?
- How are you going compensate providers to “do the right thing?”
- What are you going to do with noncompliant providers?
- How are you going administratively manage a variety of payment schemes?
- Do you have the infrastructure in place to manage new payment schemes?
- Do you have the policies and procedures in place to accurately manage and monitor new payment schemes?
- Is your staff trained to manage new payment schemes?
CareSync Consulting Services for Accountable Care Organization Startup
CareSync Consulting advocates a three step approach for planning and implementing an ACO. The steps include 1) Readiness Assessmnent; 2) Business Planning and Organizational Design; and 3) Implementation. CareSync consultants can assist with any or all three steps.
1. Readiness Assessment: ACO ReadyTM is a proprietary tool developed by CareSync Consulting that measures how well your organization and those with whom you may partner are ready to organize as an ACO. CareSync Consulting delivers a strategic analysis of what your ACO needs to have in place to be successful. We supply a customized action plan and we facilitate Go/No-Go decisions with your administrative team and Board of Directors. Through a series of administrative and staff interviews, CareSync Consulting examines ten domains through application of the ACO ReadyTM tool:
- Governance
- Clinical Integration & Care Model Design
- Quality Improvement
- Technical Infrastructure
- Financial & Administrative Capabilities
- Leadership
- Care Management & Coordination
- Cultural Alignment
- Population-based Management Capabilities
- Regulatory Requirements & Risk Management
2. Business Planning and Organizational Design Solutions include:
- ACO Structural Design covering legal and governance issues
- ACO Operating Policies, Procedures, Staffing, and Administration
- Financial Terms: Revenue and cost sharing arrangements, compensation formulas, and incentives
- Care Delivery Redesign: Interactive planning and design of patient centered medical homes, care coordination, and interdisciplinary care teams
- Data Management: Data sharing protocols, data compilation mechanisms, and data communication processes across the continuum of care
- Information technology planning and design for system interfaces and interoperability
- Risk Mitigation and Contingency Planning
3. ACO Implementation and Activation services include:
- Cultural Change and Sustainability Mechanisms involving
- Patient centered medical home training for providers and staff
- Continuous quality improvement woven into integrated care delivery models
- Provider and staff training on application of evidence based medical protocols