One of the hottest topics of debate on the health care blogosphere is the Medicare pilot program creating accountable care organizations (ACOs)—19 of them—throughout the country.
Models for ACOs vary and can be expected to morph further as the new concept is tested and refined. ACO delivery systems can include five different models of organizing structures:
- integrated delivery system models (Geisinger, Group Health, Kaiser);
- multispecialty group practices (Cleveland Clinic, Mayo, Marshfield, Virginia Mason);
- physician-hospital organizations (Advocate Health, CaroMont Health, Middlesex Hospital, Tri-State Child Health Services/Cincinnati Children's Hospital);
- independent practice associations (Atrius Health, Hill Physicians Group, Monarch HealthCare); and
- virtual physician organizations (Community Care of North Carolina, North Dakota Cooperative Network).
One example of a Medicare ACO could include a hospital, primary care physicians, specialists and other health care providers that work together in a more cohesive way to address patient care. Services would still be fee for service, but the ACO participants would coordinate care for their Medicare patients to meet cost and quality benchmarks. Because ACO providers are held collectively accountable for this care, they would share in any savings from quality improvement.
Under the ACO concept, Medicare would contract with these provider networks in a way that holds them jointly accountable for quality improvement and cost reduction. The idea is to motivate providers to work together in more collegial, coordinated and cost-effective ways to improve the quality of health care services while reducing the overall cost of care for a defined patient population. Delivering accountable care requires better communication between providers, more attention to anticipative care coordination, and higher levels of patient engagement and self-care. Providers must ensure that all required services are delivered without duplicative or unnecessary services.
A Sound Role for Integrative Health Care
ACO providers will need to invest resources not only in lower-cost care—including home, ambulatory and sub-acute care—but also in effective complementary care and other lower-cost modalities that improve healing, promote self-care and prevent admissions. As ACO providers reallocate inpatient resources toward primary and home-based care, and fine-tune IT infrastructure to manage relevant information about each patient in a centralized medical record, they must also look at gaps in care delivery.
To be more specific, as the care focus becomes more proactive rather than reactive, ACO providers will need to develop new competencies and resources to focus on prevention and health promotion. The right level of care, in the right place, at the right time, with the right amount of shared accountability (including patient self-care) will be the right equation—and the new mantra—for achieving truly accountable care.
Here is how integrative health care or complementary and alternative medicine (CAM) therapies can play a role:
The Medicare population exhibits widespread prevalence of chronic illness that in most cases does not have a "cure." Even so, there are a multitude of proven therapies that can alleviate symptoms, improve quality of life, reduce unnecessary visits to the physician's office and prevent admissions to the hospital.
For example, two studies of integrative medicine in the United States and Ireland showed significant patient health benefits and lower cost of care when patients were offered CAM therapies, including holistic nursing, acupuncture, chiropractic therapy and osteopathy along with their conventional health care services. In the U.S. study, clinical and cost utilization over a seven-year period showed a 60.2 percent reduction in hospital admissions, 59 percent reduction in hospital days, 62 percent decrease in outpatient surgeries and procedures, and 85 percent reduction in pharmaceutical costs when compared with conventional medicine alone.
The National Institutes of Health also has research demonstrating that acupuncture works for treating pain (both acute and chronic), and large, randomized, placebo-controlled, comparative studies have shown that acupuncture is almost twice as effective as conventional treatments for chronic pain conditions such as headache, back and neck pain, and arthritis—conditions that exist among Medicare patient populations.
Promoting Patient Engagement and Self-Care
Educating seniors about disease-specific conditions and training them to engage in self-care techniques increases their ability to self-monitor and self-manage chronic conditions. Diabetes management is one example in which nutrition, exercise, self-monitoring and self-management can have a significant influence on related disabilities like blindness and vascular disease. Helping patients manage blood sugar and lifestyle changes can often be accomplished through outpatient and group support programs that involve fewer physician visits.
Chronic diseases are often lifestyle-related, so managing them requires modifying behavior and providing personal support systems that educate, motivate, reinforce, reward and renew long-term personal commitment and resilience. While this skill set is underdeveloped in traditional medical practice, it will be critical to achieving the goals of accountable care. As ACOs experiment with new delivery models, there is timely opportunity to learn from integrative approaches to health care that include lower-cost options involving higher levels of patient engagement and self-care.
Beyond the bottom-line benefit of reducing avoidable admissions, effective self-care can improve quality of life, give a sense of personal control and improve patient outcomes. Encouraging healthful behaviors throughout the aging process can stimulate the body's own healing capacity, improving health outcomes. In addition, the initiative associated with self-care competency can lessen dependency-related depression and improve the overall sense of well-being.
Medicare patients in ACOs can also benefit from therapies such as massage, which can improve circulation, reduce pain and provide the all-important human touch. Stress reduction is another important approach, as stress is a major facilitator of chronic illness and contributes to high health care costs. Inducing the relaxation response through various techniques such as mindfulness meditation, yoga, tai chi, breathing training, imagery and various other approaches has been shown to directly counter the genetic and physiological stress response and improve health and well-being.
ACOs are just one maneuver in the game of reinventing health care delivery to achieve better cost, quality, outcomes and value. A clear underpinning of ACOs is to better manage the health of a defined population—in this case, a minimum of 5,000 Medicare patients per ACO.
As we make conscientious efforts to test new structures, design more proactive patient-centered care models and create more cohesive care coordination, we will miss a great opportunity if we don't make efforts to incorporate proven complementary therapies and expertise from integrative health care approaches. As the health care delivery game changes, so must the team of players—and integrative health holds the promise of significant additional bench strength.
Sita Ananth, M.H.A., is the director of knowledge services at the Samueli Institute in Alexandria, Va. She is also a regular contributor to H&HN Weekly. Mary Hassett is a principal at Integrations in Greenville, S.C.
The opinions expressed by authors do not necessarily reflect the policy of Health Forum Inc. or the American Hospital Association.