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The Year of the ACO
By Fauzia Khan, MD, FCAP

Holding the person or people responsible for an individual’s care accountable for the outcomes of that care seems like a reasonable progression in today’s healthcare landscape. What remains to be seen, and is still a serious point of contention, is how to best execute that care.

Accountable care organizations (ACOs) have emerged to reduce overwhelming Medicare and Medicaid costs and are destined to change the healthcare structure. ACOs have captured the industry’s attention, but what will be their true influence this year?

The healthcare industry will experience firsthand the change that may occur thanks to proposed cuts to Medicare and Medicaid that are being debated in Congress this election year. The challenge is finding an objective voice with the patient’s best interest in mind. Binding ACOs to cuts in Medicare spending along with American citizen taxation implications focuses the conversation on an economic discussion rather than patient care.

For the ACO model to remain effective, quality must continue to be its focus, with improved patient care as the end result. Incentives need to be united with providers’ and payers’ needs to achieve what is best for the patient and to push the system toward a providing-care model rather than a fee-for-service model. Additionally, the patient must also be engaged in his or her care at all times. Educating and engaging the patient can empower him or her to assist in making the most prudent and economical choices.

The final rule on ACOs was issued by the Centers for Medicare & Medicaid Services in late 2011, and the shared savings program begins during the first half of this year. Organizations in the pilot program that have been established as risk-bearing providers for many years demonstrate that it is possible to facilitate seamless and coordinated care. For organizations just getting started on the path toward connectivity and accountable care, the revised final rule makes it easier and more lucrative to get involved now rather than wait for years to see others’ long-term success rate.

While there does still seem to be concern regarding the expense and the risk of entering into an ACO, the overall benefits of increased reimbursement for meeting the quality measures, the improvement in patient care, the reduction in overall healthcare costs, and the mechanism to analyze clinical outcomes based on actual data and improve measures accordingly will likely be worth the up-front investment.

The healthcare entities that encompass an ACO must have open communication to meet the ultimate goal of improving care while trimming costs. Sharing data, open communication in a secure environment, and recommending financial arrangements that emphasize risk sharing with providers all require connectivity across facilities and stakeholders in the continuum of care. An EMR or health information exchange alone traditionally cannot accomplish this. Additional HIT resources are required to connect beyond the encounter to assign roles across the legal entity of the ACO.

An ACO will also require detailed analytics based on clinical and financial data. It will need to benchmark and track the performance of care providers and the financial performance based on the organization’s predetermined goals. As a collective, the healthcare industry must forge ahead with strategies and solutions that highlight how clinical decision support and analytics can help standardize healthcare delivery.

Under this model, providers will rely more heavily on clinical decision support to help them manage risk and optimize their payments while also improving patient outcomes. What must remain at the forefront of discussions and legislation is the patient. Historically, physicians have been leery of patients self-educating via online resources. However, it is now time for physicians to embrace these resources and provide their own resources for education at the point of care. An educated patient will be more likely to comply with his or her prescribed treatment plan, thereby helping to improve the outcomes on which the physician will be measured. If all these elements of technology, patient engagement, and open communication across multiple stakeholders can come together, this new model of healthcare may prove to be one of the best medicine options yet.

In the past, HIT vendors have been tasked with simply reporting on quality and efficiencies. Now vendors are going to be required to actually improve quality and efficiencies. The challenges, from a vendor’s perspective, in doing so are multipronged: There are issues with interoperability and integration within existing systems; language, vocabularies, and coding must be standardized across systems to facilitate communications; and shifts in stakeholders’ mindsets are needed to allow for open communication among the payer, patient, provider, and government. Improving quality and efficiency, rather than just reporting on it, places a heavy reliance on the ACO-wide sharing of clinical and cost data. Modernizing processes will enable healthcare organizations to provide efficient workflows throughout the system while also providing a higher quality of patient care.

In the future, it is apparent ACOs will rely heavily on clinical HIT solutions to provide the pipelines for communication and actionable healthcare data to all. Clinical decision support in the form of multiparameter alerts or recommendations based on all known patient data from preencounter, encounter, and postencounter will be an integral piece for managing and improving the standard of care. A single platform with one view into the complete patient data can also minimize duplication of work in managing data, reducing errors, ensuring consistent data is delivered when it’s needed, and easing the issues that often arise during transitions of care. It can also establish an infrastructure that will help support many medical home concepts with minimal politics and workflow incentives that are often found with the establishment of a medical home.

— Fauzia Khan, MD, FCAP, is cofounder and chief medical officer of DiagnosisOne, author of the Guide to Diagnostic Medicine, and a diplomat of the American Academy of Pathology and Anatomic and Clinical Pathology.