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I appreciated all the dialogue that my recent post on KevinMD’s blog, “The emergency department in an ACO world,” has generated over the past week or so – the number of comments is a great indicator that ED physicians are not just letting this topic go by. I’ve compiled the following post to address as many as I can:
In the era of accountable care, you’ll notice that many hospitals and health systems are already driving towards more collaborative workflow. The integrated delivery network (IDN) is changing significantly, and for the better. But in high-acuity care areas, like the emergency department (ED), the challenge of treating patients more holistically in what is already a fast-paced environment is concerning for physicians evaluating the pay-for-performance model.
In today’s ED, patients may enter with a chronic condition that could be better managed by a primary care physician (PCP), but because ED physicians are incented to treat sick people in a fee-for-service model, they continue to take these patients on instead of referring them outside the ED walls. If instead both ED and primary care physicians operate as part of a team of care givers that are incented to ensure patients stay healthy and avoid hospital admissions and readmissions, they are headed in the same direction in terms of focusing on better patient outcomes vs. reimbursement dollars.
For this week’s guest post we welcome back Joel C. Hoffman, Senior Vice President with OptumInsight Payer Solutions.
Evaluating and managing population risk has traditionally been the payer’s role in the health care system. But as providers become increasingly accountable for populations, they will need to be equipped with many of the same competencies that payers have been relying on for years. This includes the right technology to capture both clinical and claims data, but also the ability to analyze and transform these data into actionable information that affords the delivery of high quality, efficient health care and ultimately real population health — that’s where actuarial services come in.
There’s a reason why actuaries are known for incessant number crunching, data collection and manipulation (along with the occasional pocket protector) — it’s a complicated field that first requires extensive training and then plenty of experience to practice effectively. Our team of over 175 actuaries, who are engaged on a daily basis to do this work, are hearing excitement, but also understandable caution from providers looking to assess and understand both the risk and the financial benefits of setting up any of a variety of accountable care models. Many providers — including some already approved for the more advanced CMS Pioneer ACO — just don’t know where to begin, so we’ve pulled together these tips for how to wear the “payer hat” when evaluating populations and assessing risk:
It’s been one busy week! As director of the newly launched Optum Institute for Sustainable Health, I’ve been presenting our first set of findings at the The World Congress 2nd Annual Leadership Summit on Accountable Care Organizations (ACOs) in San Diego, flying all over the country to meet with providers, and on the phone with health care reporters who’ve been interested in our study – everyone from HealthLeaders to Healthcare Finance News to USA Today. Who needs sleep, right??
In my more than 20 years in health care, the Optum Institute is the most exciting organization I’ve been lucky enough to lead. As someone with a true passion for health care, I’m like a kid in a candy store. Our job is to be an authoritative source of information on trends in the marketplace – especially new collaborative care models – and a resource for folks who are working to make healthcare sustainable. We’ll do that by conducting research, monitoring trends, working with leading experts around the industry to keep a finger on the pulse of all things accountable care, evaluating what works and what doesn’t, and helping develop best practices to propel our industry forward in the development of Sustainable Health Communities.
To kick things off right, we went big, surveying 1,000 US-based physicians, 400 hospital executives, and 2,000 health care consumers to get a sense for how each group views this inevitable evolution of care, and to identify the most immediate opportunities for positive change. Some of the results surprised us and others were in line with our expectations, but here my favorite highlights:
Like many folks in the healthcare industry, the “light reading” that has graced my nightstand over this past week or two has consisted of 700 pages of the Department of Health and Human Services’ Final Rule on Medicare Accountable Care Organizations (ACOs). Overall, the changes from the draft proposal, aimed at nudging providers away from a fee-for-service model and into one of shared savings and risk, are both substantial and encouraging, with a number of key improvements in three key areas:
The rise of various accountable or collaborative care models across the country is already driving new demand for the right technologies to support them. These technologies are especially critical for those aiming to achieve Sustainable Health Communities, where all parties are connected, intelligent and aligned. While hospitals and health networks are already familiar with electronic medical records (EMRs) and health information exchanges (HIEs), they will need to become comfortable with a group of new solutions — some that the payer community has relied on for years and others that will put the data from EMRs and HIEs to the test.
While many things remain undefined when it comes to the industry’s move to pay for performance, one thing is certain – one size does not fit all. Encouraged by the regulations around Medicare’s CMS-based ACO, providers, physicians and payers are teaming up in a variety of ways to create new models of collaborative care. Although the CMS-defined ACO model has the lowest downside and many health systems will need to adopt it due to competitive pressures, the following models allow for the ability to scale to various-sized populations and design customized shared savings arrangements tailored to the needs and demographics of each community:
What a difference a year makes! I am amazed how mindsets are changing in an industry that typically takes its sweet time to make any changes of significance.
In a sense, the whole debate around healthcare reform — both before and after it was enacted — shocked those who were not happy with the proposed models into starting their own initiatives around new models of care. We have entered a new era of collaborative care and provider transformation and, whether you believe in state-sponsored health insurance exchanges and ACO’s or not, one fact holds true: the lines between payer and provider are becoming blurred. Take the recent controlling interest that Pittsburgh insurer Highmark Inc. took in West Penn Allegheny Health System as an example. Hospitals, which are the core of this new wave of accountable, integrated care, are moving to models where they will take on more risk, and they are in dire need of new expertise and tools to help them manage populations rather than care episodes. This is something that payers have done for over 50 years, and they are now jumping in to help hospitals get there.
This week’s post comes from John Nackel, Ph.D., Chief 
Executive Officer at OptumInsight Consulting and Executive Vice President, OptumInsight (previously known as Ingenix). With more than 30 years of experience advising health care organizations, entrepreneurs and emerging businesses, John discusses his vision for Accountable Care Organizations.
The proposed CMS regulations on Accountable Care Organizations (ACOs) took the first step in promoting discussions about lowering costs, but how to align these costs between each healthcare stakeholder is still an issue and obstacle, leaving most of us to wonder — how will this all actually work? Confusion around how to develop the legal and financial framework that is an ACO, coupled with the complexity of aligning each constituency and enabling the model to continue to work effectively long-term — which we define as a Sustainable Health Community — may be driven by the provider. For some, this new model will mean huge opportunity and for others, significant risk.
This week’s guest post comes from Justin Chang, M.D., chief of emergency services, Kaiser Permanente, Colorado, and medical director, Exempla St. Joseph Hospital Emergency Department. A proponent of collaboration and enhanced coordination of care, Dr. Chang makes the case for a new model of healthcare delivery as defined March 31 by the Centers for Medicare & Medicaid Services (CMS) in its proposed ruling on Accountable Care Organizations (ACOs).
I think we can all agree — physician, payer, provider, patient, etc. — that the ultimate goal of regulations and reform should be to improve the delivery of healthcare, lowering costs and ultimately, making patients healthier and more satisfied. Coupled with driving toward the results defined by CMS, this requires some fairly significant changes in how healthcare providers operate — changes which may rightfully make some providers uneasy. But what many of us may not realize is that hospitals, physicians and payers across the country are already becoming advocates for the types of changes ACOs will require, supporting a shift away from the fee-for-service and silo-type models, even before the regulations go into effect.
