Optimizing health care delivery by integrating workplaces, homes, and communities: how occupational and environmental medicine can serve as a vital connecting link between accountable care organizations and the patient-centered medical home

In recent years, the health care reform discussion in the United States has focused increasingly on the dual goals of cost-effective delivery and better patient outcomes. A number of new conceptual models for health care have been advanced to achieve these goals, including two that are well along in terms of practical development and implementation-the patient-centered medical home (PCMH) and accountable care organizations (ACOs). At the core of these two emerging concepts is a new emphasis on encouraging physicians, hospitals, and other health care stakeholders to work more closely together to better coordinate patient care through integrated goals and data sharing and to create team-based approaches that give a greater role to patients in health care decision-making. This approach aims to achieve better health outcomes at lower cost. The PCMH model emphasizes the central role of primary care and facilitation of partnerships between patient, physician, family, and other caregivers, and integrates this care along a spectrum that includes hospitals, specialty care, and nursing homes. Accountable care organizations make physicians and hospitals more accountable in the care system, emphasizing organizational integration and efficiencies coupled with outcome-oriented, performance-based medical strategies to improve the health of populations. The ACO model is meant to improve the value of health care services, controlling costs while improving quality as defined by outcomes, safety, and patient experience. This document urges adoption of the PCMH model and ACOs, but argues that in order for these new paradigms to succeed in the long term, all sectors with a stake in health care will need to become better aligned with them-including the employer community, which remains heavily invested in the health outcomes of millions of Americans. At present, ACOs are largely being developed as a part of the Medicare and Medicaid systems, and the PCMH model is still gathering momentum and evolving among physicians. But, the potential exists for implementation of both of these concepts across a much broader community of patients. By extending the well-conceived integrative concepts of the PCMH model and ACOs into the workforce via occupational and environmental medicine (OEM) physicians, the power of these concepts would be significantly enhanced. Occupational and environmental medicine provides a well-established infrastructure and parallel strategies that could serve as a force multiplier in achieving the fundamental goals of the PCMH model and ACOs. In this paradigm, the workplace-where millions of Americans spend a major portion of their daily lives-becomes an essential element, next to communities and homes, in an integrated system of health anchored by the PCMH and ACO concepts. To be successful, OEM physicians will need to think and work innovatively about how they can provide today's employer health services-ranging from primary care and preventive care to workers' compensation and disability management-within tomorrow's PCMH and ACO models.     

Interpretations of Integration in Early Accountable Care Organizations

Context

It is widely hoped that accountable care organizations (ACOs) will improve health care quality and reduce costs by fostering integration among diverse provider groups. But how do implementers actually envision integration, and what will integration mean in terms of managing the many social identities that ACOs bring together?

Methods

Using the lens of the social identity approach, this qualitative study examined how four nascent ACOs engaged with the concept of integration. During multiday site visits, we conducted interviews (114 managers and physicians), observations, and document reviews.

Findings

In no case was the ACO interpreted as a new, overarching entity uniting disparate groups; rather, each site offered a unique interpretation that flowed from its existing strategies for social-identity management: An independent practice association preserved members’ cherished value of autonomy by emphasizing coordination, not “integration”; a medical group promoted integration within its employed core, but not with affiliates; a hospital, engaging community physicians who mistrusted integrated systems, reimagined integration as an equal partnership; an integrated delivery system advanced its careful journey towards intergroup consensus by presenting the ACO as a cultural, not structural, change.

Conclusions

The ACO appears to be a model flexible enough to work in synchrony with whatever social strategies are most context appropriate, with the potential to promote alignment and functional integration without demanding common identification with a superordinate group. “Soft integration” may be a promising alternative to the vertically integrated model that, though widely assumed to be ideal, has remained unattainable for most organizations.     

The March to Accountable Care Organizations—How Will Rural Fare?

Purpose: This article describes a strategy for rural providers, communities, and policy makers to support or establish accountable care organizations (ACOs). Methods: ACOs represent a new health care delivery and provider payment system designed to improve clinical quality and control costs. The Patient Protection and Affordable Care Act (ACA) makes contracts with ACOs a permanent option under Medicare. This article explores ACA implications, using the literature to describe successful integrated health care organizations that will likely become the first ACOs. Previous research studying rural managed care organizations found rural success stories that can inform the ACO discussion. Findings: Preconditions for success as ACOs include enrolling a minimum number of patients to manage financial risk and implementing medical care policies and programs to improve quality. Rural managed care organizations succeeded because of care management experience, nonprofit status, and strong local leadership focused on improving the health of the population served. Conclusions: Rural provider participation in ACOs will require collaboration among rural providers and with larger, often urban, health care systems. Rural providers should strengthen their negotiation capacities by developing rural provider networks, understanding large health system motivations, and adopting best practices in clinical management. Rural communities should generate programs that motivate their populations to achieve and maintain optimum health status. Policy makers should develop rural‐relevant ACO‐performance measures and provide necessary technical assistance to rural providers and organizations.     

The promise and peril of accountable care for vulnerable populations: a framework for overcoming obstacles

Accountable care organizations (ACOs) are a promising payment model aimed at reducing costs while also improving the quality of care. However, there is a risk that vulnerable populations may not be fully incorporated into this new model. We define two distinct vulnerable populations, clinically at-risk and socially disadvantaged, and we discuss how ACOs may benefit each group. We provide a framework to use in considering challenges for both vulnerable patients and health systems on the path to accountable care. We identify policies that can help overcome these obstacles: strategies that support ACO formation in diverse settings and that monitor, measure, and reward the performance of providers that reach all patients, including vulnerable populations.     

Accountable Communities for Health: Moving From Providing Accountable Care to Creating Health

Lessons from community-oriented primary care in the United States can offer insights into how we could improve population health by integrating the public health, social service, and health care sectors to form accountable communities for health (ACHs). Unlike traditional accountable care organizations (ACOs) that address population health from a health care perspective, ACHs address health from a community perspective and consider the total investment in health across all sectors. The approach embeds the ACO in a community context where multiple stakeholders come together to share responsibility for tackling multiple determinants of health. ACOs using the ACH model provide a roadmap for embedding health care in communities in a way that uniquely addresses local social determinants of health.     

Analysis & commentary: The accountable care organization: whatever its growing pains, the concept is too vitally important to fail

The success of health reform efforts will depend, in part, on creating new and better ways to organize, deliver, and pay for health care. Increasingly central to this idea is the accountable care organization model proposed for Medicare and a slightly different model for commercial health care. But these new health care delivery and payment models face considerable skepticism. Can Medicare succeed with accountable care organizations if physicians can't determine whether patients are in the organization or not? Will commercial hospitals use their clout to create accountable care organizations, leaving physician practices in a weaker position? This article answers those and other criticisms of the developing accountable care organization movement. If the concept fails, the nation may face indiscriminate cuts to health care payments, with resulting reductions in access, service, and quality.     

The ACO paradox impacting physicians

Accountable care organizations (ACOs) would hold care providers jointly accountable for the quality and costs of care, allow consumers the freedom to choose their providers, and involve physicians and consumers in their shared decision-making. Even though the ACO model proposes physician empowerment, it also poses significant financial and change-management challenges for physicians. Furthermore, the "patient-centered" ACOs that have been established to safeguard consumer sovereignty pose the risks of concentrating healthcare markets further and exacerbating the existing disparities in healthcare. We conducted a survey study to understand physicians' perspectives of ACOs by seeking their first-hand feedback. The survey results suggest that there are significant communication gaps between physicians and healthcare administrators; and efficient communication can help improve physician-administrator alignment and help them identify opportunities that would be critical to the success of ACOs.     

Modeling and designing health care payment innovations for medical imaging

Payment innovations that better align incentives in health care are a promising approach to reduce health care costs and improve quality of care. Designing effective payment systems, however, is challenging due to the complexity of the health care system with its many stakeholders and their often conflicting objectives. There is a lack of mathematical models that can comprehensively capture and efficiently analyze the complex, multi-level interactions and thereby predict the effect of new payment systems on stakeholder decisions and system-wide outcomes. To address the need for multi-level health care models, we apply multiscale decision theory (MSDT) and build upon its recent advances. In this paper, we specifically study the Medicare Shared Savings Program (MSSP) for Accountable Care Organizations (ACOs) and determine how this incentive program affects computed tomography (CT) use, and how it could be redesigned to minimize unnecessary CT scans. The model captures the multi-level interactions, decisions and outcomes for the key stakeholders, i.e., the payer, ACO, hospital, primary care physicians, radiologists and patients. Their interdependent decisions are analyzed game theoretically, and equilibrium solutions - which represent stakeholders’ normative decision responses - are derived. Our results provide decision-making insights for the payer on how to improve MSSP, for ACOs on how to distribute MSSP incentives among their members, and for hospitals on whether to invest in new CT imaging systems.     

The Economics of Medicare Accountable Care Organizations

Background

Accountable care organizations (ACOs) have been created to improve patient care, enhance population health, and reduce costs. Medicare in particular has focused on ACOs as a primary device to improve quality and reduce costs.

Objective

To examine whether the current Medicare ACOs are likely to be successful.

Discussion

Patients receiving care in ACOs have little incentive to use low-cost quality providers. Furthermore, the start-up costs of ACOs for providers are high, contributing to the minimal financial success of ACOs. We review issues such as reducing readmissions, palliative care, and the difficulty in coordinating care, which are major cost drivers. There are mixed incentives facing hospital-controlled ACOs, whereas physician-controlled ACOs could play hospitals against each other to obtain high quality and cost reductions. This discussion also considers whether the current structure of ACOs is likely to be successful.

Conclusion

The question remains whether Medicare ACOs can achieve the Triple Aim of “improving the experience of care, improving the health of populations, and reducing per capita costs of health care.” Care coordination in ACOs and information technology are proving more complicated and expensive to implement than anticipated. Even if ACOs can decrease healthcare costs and increase quality, it is unclear if the current incentives system can achieve these objectives. A better public policy may be to implement a system that encompasses the best practices of successful private integrated systems rather than promoting ACOs.     

Salary and Quality Compensation for Physician Practices Participating in Accountable Care Organizations

BACKGROUNDThe accountable care organization (ACO) is a new organizational form to manage patients across the continuum of care. There are numerous questions about how ACOs should be optimally structured, including compensation arrangements with primary care physicians.METHODSUsing data from a national survey of physician practices, we compared primary care physicians’ compensation between practices in ACOs and practices that varied in their financial risk for primary care costs using 3 groups: practices not participating in a Medicare ACO and with no substantial risk for primary care costs; practices not participating in an ACO but with substantial risk for primary care costs; and practices participating in an ACO regardless of their risk for primary care costs. We measured physicians’ compensation as the percentage of compensation based on salary, productivity, clinical quality or patient experience, and other factors. Regression models estimated physician compensation as a function of ACO participation and risk for primary care costs while controlling for other practice characteristics.RESULTSPhysicians in ACO and non-ACO practices with no substantial risk for costs on average received nearly one-half of their compensation from salary, slightly less from productivity, and about 5% from quality and other factors. Physicians not in ACOs but with substantial risk for primary care costs received two-thirds of their compensation from salary, nearly one-third from productivity, and slightly more than 1% from quality and other factors. Participation in ACOs was associated with significantly higher physician compensation for quality; however, participation was not significantly associated with compensation from salary, whereas financial risk was associated with much greater compensation from salary.CONCLUSIONAlthough practices in ACOs provide higher compensation for quality, compared with practices at large, they provide a similar mix of compensation based on productivity and salary. Incentives for ACOs may not be sufficiently strong to encourage practices to change physician compensation policies for better patient experience, improved population health, and lower per capita costs.     

Accountable care and integration: A challenge for credentialing and risk management

Healthcare reform efforts have resulted in expanded creation of integrated organizations such as accountable care organizations. These ACOs, however, create additional risk management issues for organizations in terms of antitrust compliance, fraud and abuse, and medical liability issues. While much has been written on the formation of such organizations, the postformation risks have not been explored adequately. This article summarizes some of the risk‐management challenges that ACOs and other integrated organizations may face.     

ACO final rule cuts provider burden

The Centers for Medicare and Medicaid Services (CMS) made significant changes in the final rule for creating accountable care organizations (ACOs) to coordinate care across healthcare settings. CMS made changes in how ACOs will share savings based on input from the industry. ACOs are one way the healthcare field is recognizing the value of care coordination. The number of quality measures on which ACOs report has been reduced from 65 to 33.     

Are ACOs the Answer to High-Value Healthcare?

Background

The Patient Protection and Affordable Care Act required the Secretary of the Department of Health and Human Services to establish the Medicare Shared Savings Program (MSSP) by January 1, 2012. The MSSP is intended to encourage physicians, hospitals, and other providers and suppliers to form accountable care organizations (ACOs) to provide cost-effective, coordinated care to Medicare beneficiaries. Under the MSSP, ACOs can qualify for additional payments by meeting specific savings benchmarks and quality measures.

Objectives

To review the anticipated changes in the role and responsibilities of ACOs and to evaluate the challenges and opportunities that various healthcare stakeholders, including patients, providers, and payers, will encounter with the launching of the new MSSP.

Discussion

ACOs assume responsibility for overall care, cost, and quality of patient care. The MSSP will provide ACOs additional payments for meeting cost-savings and quality benchmarks. The extra savings will be shared with participating providers based on different risk-sharing options. As the MSSP and new ACOs launch, stakeholders will be impacted differently. This article is based, in part, on responses of approximately 100 payers to a survey conducted in June 2011 by Xcenda. Each stakeholder group, including providers, payers, patients, and manufacturers, must monitor the reactions and relationships between all players in the care continuum. Providers will have to achieve a greater level of coordination and collaboration than typically exists today. Government and commercial payers will have a role in determining how quickly they will adopt accountable care models. Patients are expected to become more engaged and participatory in their care to achieve optimal outcomes, and manufacturers will be required to prove the value of their products given the clinical value proposition embedded in accountable care models.

Conclusion

Whether ACOs are the answer to providing higher-quality healthcare at lower costs remains unclear. All signs, however, point toward a systemic change in an effort to improve patient care and contain healthcare costs. It will be important for all healthcare stakeholders to understand the roles that ACOs will play in ensuring access to care and quality of care.Section 3022 of the Patient Protection and Affordable Care Act of 2010 (ACA) calls for the Department of Health and Human Services to create the Medicare Shared Savings Program (MSSP) and other pilot programs to reduce healthcare costs while improving the quality of care.1 The ACA requires the Centers for Medicare & Medicaid Services (CMS) to launch the MSSP by January 1, 2012.2Accountable care organizations (ACOs)—an arrangement among healthcare providers “who collectively agree to accept accountability for the cost and quality of care delivered to a specific set of patients”3—were envisioned by the ACA as a vehicle for physicians, hospitals, and other providers to provide cost-effective, coordinated care to Medicare beneficiaries. The MSSP will create for healthcare professionals a framework for sharing risk, which, in turn, will supply financial incentives for integrated care.CMS released its proposed rule on ACOs and the MSSP on March 31, 2011, and subsequently, the Center for Medicare & Medicaid Innovation (CMMI) announced an alternative, non–MSSP-affiliated pathway to establishing ACOs called the Pioneer ACO Model.4 After the initial proposed rule received strong criticism across the healthcare community, CMS released its final ruling on ACOs and the MSSP on October 20, 2011, which included significant changes aimed at making participation in ACOs more attractive to providers.2 Under the MSSP and the Pioneer program, providers in ACOs will continue to receive fee-for-service (FFS) payments from Medicare for their individual services.4 However, providers will have the opportunity to receive additional bonus payments if their ACOs meet savings benchmarks and quality measures set by CMS.2

KEY POINTS

• ▸ The Medicare Shared Savings Program (MSSP) that will take effect in January 2012 is intended to complement the formation of accountable care organizations (ACOs).
• ▸ ACOs rely on increased stakeholder collaboration, which should help improve care quality and bring overall costs down.
• ▸ Based on a June 2011 survey of nearly 100 payer decision makers representing more than 200 million covered members, 61% of payers are already contracting with ACOs or are planning to do so in the near future.
• ▸ Under the MSSP, providers will continue to receive fee-for-service payments from Medicare, but will have opportunities to get additional payments if their ACO meets savings benchmarks.
• ▸ Patients will be empowered with access to competitive networks of providers offering quality healthcare at relatively lower costs; this is likely to foster competition among ACOs and drive performance up.
• ▸ Private payers are expected to test different methods of payments to ACOs and may also join independent, non–MSSP-affiliated ACOs.
• ▸ The first-year costs for starting an ACO are estimated at $1.75 million.

Even before CMS released its final MSSP-related ACO regulation, the move toward accountable and more integrated care—with the concept of shared savings between payers and providers—began gaining momentum. Hospitals, physicians, and health plans have already formed or are contracting with ACOs.5In June 2011, Xcenda''s payer market research platform, the Managed Care Network (MCN), conducted a survey of its panel members, consisting of nearly 100 payer decision makers representing more than 200 million covered members.5 They were asked to identify whether their organizations were contracting with ACOs, planning to contract, or not planning to contract ACOs within the next 12 months. Based on the MCN panel responses to this survey, 61% of payers are already contracting with ACOs or are planning to contract with them within the next year (Figure 1).5Open in a separate windowFigure 1Payers'' Plans to Contract with ACOsACOs indicates accountable care organizations.NOTE: These data reflect responses to a June 2011 survey of nearly 100 payers responsible for >200 million covered members.5With the formation of ACOs, payers and providers are creating a new healthcare delivery model that will test value-based and quality-based reimbursement mechanisms. The growth of ACOs, along with a focus on the delivery of increased quality of care at lower costs, will require each sector of healthcare to understand how ACOs will affect all stakeholders, including patients, providers, payers, and manufacturers. This article focuses on the implications for these stakeholders of implementing ACOs and the imminent launch of the MSSP.     

Swiss experiment shows physicians, consumers want significant compensation to embrace coordinated care

Policy makers in several industrial countries are seeking to limit the rise in health care cost growth by supporting coordinated or integrated care programs, which differ from most prevailing forms of medical organization in how physicians are paid and how they work in groups. However, as long as fee-for-service payment systems remain an option, general practitioners will be reluctant to embrace coordinated care because it would give them less autonomy in how they practice. A study in Switzerland indicates that general practitioners will require a pay increase of up to 40 percent before they are willing to accept coordinated care, and a similar study found that Swiss consumers wanted a substantial reduction in premiums to accept it. These findings suggest that provisions of US health care reform designed to encourage the growth of coordinated care--such as accountable care organizations and medical homes--may face a challenging future.     

Legal Mechanisms Supporting Accountable Care Principles

Public health and private providers and facilities may shape the future of the US health system by engaging in new ways to deliver care to patients.“Accountable care” contracts allow private health care and public health providers and facilities to collaboratively serve defined populations. Accountable care frameworks emphasize health care quality and cost savings, among other goals.In this article, I explore the legal context for accountable care, including the mechanisms by which providers, facilities, and public health coordinate activities, avoid inefficiencies, and improve health outcomes. I highlight ongoing evaluations of the impact of accountable care on public health outcomes.As the US health system undergoes transformation, public health departments are engaging in new ways to deliver health care with private entities. One such method is “accountable care,” the coordinated provision of patient services by health care and public health providers and facilities with the goals of improving outcomes and avoiding inefficiencies.1 The core tenets of accountable care are prevention, health care quality, patient satisfaction for the population served, and cost savings to the health care system.1 Accountable care frameworks are based on risk and reward, with providers and facilities agreeing to collectively share the financial risk for a population in return for the opportunity to access rewards for attaining preestablished health care goals.Entities that seek to engage in accountable care are formed according to legal principles governing businesses and contracts, but federal and state laws2 specifically incentivize the formation and success of these entities by establishing antitrust waivers, fraud and abuse protections, and mandates to coordinate care. Although much has been written on the legal basis for establishing accountable care entities, with this article, I seek to inform public health practitioners of the relationship between the laws that recognize accountable care principles and the public health goals of improving patient care, impacting quality and outcomes, and measuring population health.In this article, I discuss 3 mechanisms by which providers, facilities, and public health may contract together to maintain legal entities that implement accountable care principles. First, health care providers and payers have pursued private contracts to provide accountable care to improve outcomes in their patient populations.3 Second, the Centers for Medicare and Medicaid Services authorizes Medicare reimbursements for legal entities certified as accountable care organizations (ACOs) through traditional fee-for-service and other payments upon meeting benchmark cost and quality standards.4 Third, state laws incorporate accountable care mechanisms into Medicaid provisions, permitting state programs to reimburse accountable care entities that serve vulnerable populations.5 Finally, I offer suggestions for evaluating the impacts of accountable care on public health outcomes.     

Accountable Care Organizations: roles and opportunities for hospitals

Federal health reform has established Medicare Accountable Care Organizations (ACOs) as a new program, and some states and private payers have been independently developing ACO pilot projects. The objective is to hold provider groups accountable for the quality and cost of care to a population. The financial models for providers generally build off of shared savings between the payers and providers or some type of global payment that includes the possibility of partial or full capitation. For ACOs to achieve the same outcomes with lower costs or, better yet, improved outcomes with the same or lower costs, the delivery system will need to become more oriented toward primary care and care coordination than is currently the case. Providers of clinical services, in order to be more effective, efficient, and coordinated, will need to be supported by a variety of shared services, such as off-hours care, easy access to specialties, and information exchanges. These services can be organized by an ACO as a medical neighborhood or community. Hospitals, because they have a management structure, history of developing programs and services, and accessibility 24/7/365, are logical leaders of this enhancement of health care delivery for populations and other providers.     

The Case for Enrolling High-Cost Patients in an ACO

Though accountable care organizations (ACOs) are increasingly important to American healthcare, ethical inquiry into ACOs remains in its nascent stages. Several articles have raised the concern that ACOs have an incentive to avoid enrolling high-cost patients and, thereby, have an incentive to deny care to those who need it the most. This concern is borne out by the reports of consultants working with newly formed ACOs. This paper argues that, contra initial appearances, there is no financial incentive for ACOs to avoid enrolling high-cost patients.     

Accountable Care Organizations: Roles and Opportunities for Hospitals

Abstract

Federal health reform has established Medicare Accountable Care Organizations (ACOs) as a new program, and some states and private payers have been independently developing ACO pilot projects. The objective is to hold provider groups accountable for the quality and cost of care to a population. The financial models for providers generally build off of shared savings between the payers and providers or some type of global payment that includes the possibility of partial or full capitation. For ACOs to achieve the same outcomes with lower costs or, better yet, improved outcomes with the same or lower costs, the delivery system will need to become more oriented toward primary care and care coordination than is currently the case. Providers of clinical services, in order to be more effective, efficient, and coordinated, will need to be supported by a variety of shared services, such as off-hours care, easy access to specialties, and information exchanges. These services can be organized by an ACO as a medical neighborhood or community. Hospitals, because they have a management structure, history of developing programs and services, and accessibility 24/7/365, are logical leaders of this enhancement of health care delivery for populations and other providers.     

Getting up to speed. Execs detail IT needs, investments required to support an ACO

The push for accountable care organizations means a push for more information technology that allows the sharing of data. So hospitals and other providers that are forming ACOs are feeling new urgency to ramp up their IT improvements. At Banner Health it means figuring out how to deal with independent physicians' "mishmash" of systems. "There has been an acceleration of interest," says Dr. John Hensing, left, Banner's chief medical officer.