Health care is the most complex, knowledge-driven industry in the world, representing one of our most significant economic challenges. While the transition to a system of more accountable care will be evolutionary, real challenges exist in building successful accountable care organizations or supporting ACO-like operations. One core challenge will be the diversity of forms of ACOs; the Centers for Medicare & Medicaid Services definition will be one of many.
What lies ahead is the reorientation of decades of organizational processes and structures that long have supported fee-for-service payments, competition among providers and strained relationships with payers. We are embarking on a transformation of epic proportions, one that requires the industry to come together with a common purpose. We need a laser focus on care coordination, quality improvement and cost reduction.
A key tenet of accountable care is to improve integration. ACOs are expected to implement a wide range of managerial, legal, clinical and other leadership structures. The goal is to ensure that the health and wellness of the population is managed, the most cost-effective care is provided, clinical processes are streamlined and follow the best evidence, the necessary reporting is in place, and the payments and reimbursement are appropriate.
Last but not least, the ACO must demonstrate, in a variety of ways, its commitment to being patient-centered and to engaging patients in managing their care and overall health.
Shifting Perspectives and New Competencies
Accountable care will require industry perspectives and health care delivery practices to shift:
- from care providers working independently to collaborative teams of providers;
- from treating individuals when they get sick to keeping groups of people healthy;
- from emphasizing volumes to emphasizing outcomes;
- from maximizing the use of resources and assets to applying appropriate levels of care at the right place;
- from offering care at centralized facilities to providing care at sites convenient to patients;
- from treating all patients the same to customizing health care for each patient;
- from avoiding the sickest, chronically ill patients to providing special chronic care services;
- from being responsible for those who seek services to being responsible for the needs of the community;
- from putting forth best efforts to becoming high-reliability organizations.
Additionally, accountability will bring new performance and utilization risks to providers, as the focus shifts from optimizing business unit performance to optimizing network performance. At the same time, instead of maximizing the profitability of care, organizations will increase the volume of desired bundled episodes while controlling costs.
As providers assess their risk tolerance, they must also strengthen their ability to manage several core processes in an accountable care environment. These core processes include:
Identifying, assessing, stratifying and selecting target populations. It will become imperative for providers to store, access, maintain, derive and update population data and categories (stratification) from multiple sources. Additionally, within target populations, providers will select cohorts for specific programs based on predefined metrics (cost, utilization, outcomes).
Providing care management interventions for individuals and populations. This includes patient-centered management and coordination of care events and activities in multiple care settings by one or more providers (e.g., identifying care gaps and situations requiring additional interventions, as well as managing care transitions). The aim is to manage the most complex patients through the health care system, taking their preferences and overall situation into consideration. In addition, managing the overall health of a select population (diabetics, elderly, well, etc.) will require proactive care, communication, education and outreach.
Providing high-quality care across the continuum. While this is an obvious goal for all providers, ACOs must facilitate cross-continuum medical management for active episodes and acute disease processes or for any patient outside of the defined goals of a target population. It also includes fine-tuning coordination among care team members, transition of care planning, targeting venues of care, establishing patient and family engagement initiatives, and monitoring and improving clinical performance.
Managing contracts and financial performance. With new payment models (bundled, shared savings) emerging, proactively understanding patient coverage and financial responsibility will be critical. Financial teams must have a solid handle on estimating reimbursement and associated payment distributions, carrying out predictive modeling for reimbursement contracts, measuring performance against contracts and predicting profitability, as well as integrating with other key processes to share information.
Monitoring, predicting and improving performance. With payment so tightly linked to quality and outcomes, tracking and measuring system performance in key areas become paramount in an accountable care environment. Under value-based purchasing programs, there will be real ramifications for poor care and rewards for improved care. Providers can work with their quality and clinical staff to adapt processes accordingly. In a value-based purchasing model, even low-performing areas can qualify for high payments if they demonstrate year-over-year improvement.
Across the risk spectrum, these accountable care processes will require a range of IT components and capabilities, some of which will introduce new competencies for many providers.
IT Building Blocks to Support Accountable Care
Several application systems will be essential for responding effectively to accountable care and new payment models. In addition to an electronic health record that spans the continuum of care, the following six key technologies will enable the core accountable care processes:
1. A revenue cycle and contracts management application that evolves to span the continuum of care. One could argue that the revenue cycle system forms the foundation of a provider's response to accountable care and payment reform. As the reimbursement environment becomes more complex, revenue cycle systems must evolve to support payments based on quality and performance, requiring new capabilities such as:
- aggregating charges to form bundles and episodes, with the aggregation logic enabling different groupings for different payers;
- managing the distribution of payment for a bundle to the physicians, hospitals and non-acute facilities that delivered the care;
- streamlining transitions between disparate reimbursement methodologies and contracts when billing and collecting;
- providing tools for retrospective analysis of clinical and administrative data to identify areas for improving the quality of care and reducing the cost of care delivered.
These new capabilities must complement routine activities such as registering patients, scheduling appointments and administering patient billing.
2. Care management systems that span the continuum for individuals and populations. Care management systems support proactive, preventive and cost-effective care for individuals and populations. Specific capabilities include care venue transition management, care coordination (utilization and case management), disease management, population management and wellness management.
These care approaches focus on preventing unwarranted emergency department visits and avoiding acute episodes. Additionally, disease registries will enable providers to identify cohorts of patients with focused care needs, review summary data sets and make necessary interventions when care is not up to standard.
3. Rules engines, workflow engines and intelligent displays of data that enable intelligent processes across the continuum, defined by best practices. Processes that are efficient, predictable and robust enable an organization to thrive in an accountable care environment. Workflow and rules engines can monitor process performance, alerting staff to missed steps, sequence issues or delays.
Workflow engines specialize in executing a business process, not just decisions made at a discrete point in time. The technology can assist greatly in clinical decision-making by not only presenting clinicians with alerts and reminders, like a rules engine, but also by encouraging teamwork in clinical decisions, assisting with the time management and task allocation in process delivery, stating changes in patient or operational conditions, and creating behind-the-scenes automation of process steps.
4. Sophisticated business intelligence and analytics. Analytics will facilitate proactive management of key performance metrics. For example, there will be a greater need to assess care quality and costs, examine variations in practice, and compare outcomes. As such, the application of business intelligence in health care will become the platform upon which the organization not only monitors performance, but also makes critical decisions to uncover new revenue opportunities, reduce costs, reallocate resources, and improve care quality and operational efficiency.
However, the industry lacks experience with the tools and techniques associated with advanced data analysis. Thus, enhancing an organization's competency in data management and business intelligence will become an essential requirement for internal purposes as well as for external reporting requirements.
5. Systems that enable interoperability between affiliated providers. Having information available is critical to the success of accountable care. A health information exchange platform will become increasingly important to enable the secure flow of data about patients and can, for example, facilitate access to information needed for:
- performance metrics, such as care cost and quality;
- patient events monitoring, such as a visit to the ED or a failure to show up for an appointment;
- patient status, as in a hospitalization in a member hospital with a specific discharge destination;
- ensuring that the care team has a comprehensive view of a patient's status and the care delivered by all members of the patient's care team.
While there has been some success in the regional HIE movement, much of the focus now is on HIE capabilities at the integrated delivery system or ACO level. This enables providers to obtain a composite clinical picture of the patient regardless of where that patient was seen. In time, a provider will be able to request data about a patient from any other provider in the region, perhaps even in the country.
6. Technologies that support the engagement of patients. In addition to providing high-quality, effective care at the best possible cost, providers need to engage patients in staying well and managing their health. A system that allows patients to communicate with caregivers, perform self-care activities and participate in health screenings, for example, can improve quality of care and outcomes, especially for patients with chronic diseases.
While few are taking advantage of patient portals and personal health records, organizations are using other approaches to engage patients in their care, including texting and social media channels. Such engagement efforts will increase over time, and we will use these technologies in a variety of ways, such as:
- providing patients with access to their data so they understand their current health status;
- allowing patients to communicate with their care providers (ask questions, discuss symptoms, renew medications, requests appointments, and so forth);
- enabling patients to enter their own data (ranging from correcting a medication list to entering data about their symptoms, particularly if there's been a change in treatment pattern);
- providing patients access to health information and management tools (education, discussion forums with other patients who have conditions similar to theirs, and so forth).
Aligned, Focused and Moving Forward
A more accountable system of care supported by aligned incentives long is overdue in this country. Such a system creates shared accountability and incentives for managing a patient's health — a much different health care system than the one in place today. Accountability will require that care be accessible to the community and that providers deliver a high-quality experience focused on keeping patients healthy and engaged in their own care.
New payment models will be disruptive, and parts of the journey will be chaotic. Additionally, the long-term success of this transformation relies largely on building the robust, secure IT infrastructure to support the far-reaching goals of accountable care. However, thanks to a well-crafted federal health information technology agenda, which lays the foundation for payment and structural reform — a reform that encourages widespread meaningful use of interoperable EHRs — the industry is aligned, focused and moving forward.
Savvy providers will use the meaningful use mandates to help prioritize and plan for IT investments that also enable the core processes associated with accountable care. Even for providers that may not be participating in an ACO, building the organizational and IT competencies to support accountable care is critical to staying competitive. Organizations that fail to develop and demonstrate accountable care capabilities may not fulfill their obligations to the community they serve — in fact, they may not survive.
John Glaser, Ph.D., is the CEO of health services at Siemens Healthcare in Malvern, Pa. He is also a regular contributor to H&HN Daily.