"There are many keys to a successful accountable care organization (ACO); however, most important will be the coordination of care and the clinical outcomes of the people we serve," says Terri Schieder, RN, MSN, MBA, vice president for clinical development and integration, AtlantiCare, the largest regional healthcare system in southeastern New Jersey.
Two more keys to accountable care:
All that said, Schieder advises health systems that are moving toward accountable care to put the patient experience at the forefront of their goals. "If the people you serve are not in the center of your framework, you will not be successful," she says. "Payers, providers, and partners are all part of the equation, but the driver of future success will be the population we serve."
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AtlantiCare is participating in a national, multi-health system collaborative to develop and implement an ACO structure, which will be created as a legal entity later this year. The health system expects the ACO to contract with the federal government through the Medicare Shared Savings Program, and it intends to contract with private insurers as well.
However, Katherine A. Schneider, MD, MPhil, vice president of health engagement, says the transformation at hand is focused more on delivering accountable care than setting up an ACO.
"Accountable care is not a project, and it's not an entity," she says. "It's moving from transactions within our health delivery system to relationships with members of our community and being accountable for patient outcomes over time and at the population level. That's what we have our eye on here."
AtlantiCare started moving to population-level health management four years ago when it created the AtlantiCare Special Care Center for patients with heart disease, diabetes, hypertension, and other chronic illnesses. Developed in conjunction with a hotel and restaurant employees union, the center uses a patient-centered medical home model. Health coaches, social workers, and dietitians help patients stay on track with physician orders (see the sidebar below).
Based on AtlantiCare's experience to date, Schneider shares a lesson learned: Starting a medical home practice from scratch is probably easier than trying to transform an existing primary care clinic because it allows care delivery and payment systems to be redesigned simultaneously.
Instead of fee-for-service payments, self-insured employers-including a large casino and the AtlantiCare system itself-pay a monthly fee for each employee enrolled in the Special Care Center.
The center, which has 1,300 members, has served as AtlantiCare's learning lab for replacing a transactional model of care with a longitudinal relationship. "The work processes are totally different, and the skill sets are very different from what you would see in a typical primary care practice," says Schneider. "The incentives are very different, and the outcomes, frankly, have been very different as well."
The model-AtlantiCare uses the term "advanced primary care"-has proven that better care translates into improved outcomes for patients with high blood pressure, diabetes, and heart and lung disease (see the exhibit below).
The model is also linked to fewer hospital admissions and emergency department (ED) visits. An analysis by Harvard Medical School researchers found that Special Care Center participants had 41 percent fewer inpatient admissions and 48 percent fewer ED visits than a control group during a one-year period starting September 2008, according to AtlantiCare.
Achieving these results has required a number of innovative changes. For one thing, benefit designs financially incentivize patients to take good care of their health. No Special Care Center patients have copayments for office visits, and some patients (such as those with diabetes) get free prescriptions-while all patients have lower drug copayments than most traditional insurance plans. For another, patients have phone access to a caregiver around the clock, which helps eliminate unnecessary ED visits.
Proactive planning is built into the care delivery model. "The first hour of every workday, the whole team comes together in a huddle to review which patients have outstanding issues, who was in the ED or hospital over the past 24 hours, and what we are going to do about it," says Schneider. "It is really designed around helping all those people overcome their barriers to take better care of themselves."
AtlantiCare opened its second Special Care Center in February 2011 in a medical office building in Galloway, N.J.
"Right now, patient experience is important mainly around growth and market share, and how good your brand is and how loyal your patients are. In a few years, patient satisfaction will also drive how much we get paid," says Schneider, referring to the Centers for Medicare & Medicaid Services' Value-Based Purchasing Program. When this program goes into effect on October 1, 2012, hospital reimbursement will be tied to a weighted combination of clinical quality scores and patient experience scores, as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems survey, commonly known as HCAHPS.
That is why AtlantiCare has used focus groups and surveys to seek patient input to create its ACO. Schneider says patients have identified specific areas for improvement: patient communication with caregivers, navigation of services and care, education and information, and accessibility of services.
"Our challenge will be to monitor our effectiveness in meeting these needs across the entire care delivery system, not merely in the acute care setting," she says.
That's where Bush Bell, corporate director for customer service at AtlantiCare, comes in. He is developing a new approach to monitoring AtlantiCare's success at coordinating care across the continuum.
For starters, the system is creating a formal Patient Advisory Board that will be charged with providing feedback on AtlantiCare's care delivery changes. Additionally, the system is beginning to ask patients about care coordination. "We're starting off very slowly," says Bell. "We added a common question to most of our surveys that asks how well we coordinated the patient's care."
For example, at the end of an inpatient visit, a patient will be asked if care has been coordinated (for example, follow-up physician appointments scheduled, prescriptions filled, and home medical equipment or services ordered).
Over time, care coordination will be monitored through a broader survey methodology that asks patients to think about their care over the last six or 12 months. Questions will probe about how difficult it was to get an appointment with a specialist, whether the specialist was knowledgeable about the patient's background and care history, and whether the patient had to re-answer a lot of questions.
"That's the kind of stuff that we know patients will remember," he says, and AtlantiCare can use the information to see how well it is accomplishing its care coordination goals.
AtlantiCare's move to an ACO model will require that all physician members standardize the collection of patient experience data. The system currently measures satisfaction of patients treated by its approximately 100 employed physicians/providers. But most of the roughly 500 independent physicians/providers measure patient satisfaction in a haphazard way.
"Some are doing it using a variety of scales or using a home-grown paper survey, but they're going to have to really up their game," says Schneider. "And we're there to help them do that so that we're all being transparent and accountable around the same metrics."
Standardized patient experience metrics will be one way AtlantiCare monitors whether its physician partners are delivering accountable care.
"If a patient can't get access, does not understand the physician's instructions, or is falling through the cracks, quality outcomes are going to suffer, and those outcomes are going to be important to how we all get paid."
Like other hospitals and health systems across the nation, AtlantiCare recognizes that patient satisfaction, efficiency, and quality outcomes will be important factors influencing reimbursement as health care moves toward greater accountability and transparency. "This triple aim approach to reimbursement will help our industry move away from volume-based reimbursement toward value-based reimbursement," says Schneider.
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