Federal health care reform has generated immense interest in Accountable Care Organizations (ACOs). In theory, improved quality and reduced cost will be gleaned by bundled payment of a health system and the physician. To attain this, however, and to improve quality and reduce cost, there will have to be good communication and a strong relationship, with an open medical staff having well defined objectives and measures.
That communication must also be extended to the patient and other parties as well. For an ACO to be effective, there is not only a shift in culture to be managed but a change in the tools available to both hospitals and physician to manage care and effectively communicate across multiple “Communispheres.” Clinician to clinician; clinician to hospital; clinician to patient; hospital to patient; and all of the above to payers is a matrix of vast communication and data challenges. There is significant detail to be worked out that will manifest itself in things as obvious as a consolidated bill to patient and payers, and well as longitudinal availability of a clinical record both a priori and a posteriori to a hospital stay. Also an element of public health will, I suspect, play an important part in overall quality improvements. Can someone say, ‘advanced clinical and collaborative care’?
Collaborative care and the level of communication inherent in the process demand information technology tools – most of which are not fully cooked nor, I venture to say, fully conceived. Over the past few months, vendors and health systems both seem to believe that buying a health exchange product is all they need to power an ACO, but that model is like Wile E. Coyote rocketing into a brick wall. The recent acquisitions of Medicity and Axolotl seem to validate the recognition for better tools to enable collaborative care, however it is not enough. I believe that an HIE is only part of the solution. Surely, if done right, it is an engine to power physician alignment and, with the proper analytics, can help build a base to define the effectiveness of disease management activity. But other elements are imperative. There have to be performance measures, data warehousing, disease registries, alerts and notifications, a personal health record, an MPI or patient locator service, semantic egalitarianism i.e. (standard nomenclature) and workflow tools that support clinical modeling and evidence-based care. That is a tall order, and I am unaware of a product that has all of these elements in place within a secure environment.
Not only is an integrated technology a challenge but other elements are also imperative for an ACO to be an effective tool to improve quality and reduce cost. The governance, legal issues, and payment reform inherent in an ACO are not insignificant. All of these need to be addressed and tools identified to manage these issues. They must all be put in place when structuring an effective operation.
A governance model needs to be based on identified measures and predefined methodologies for analyzing data. Establishing targets and means of computing performance and compliance should be an early requirement, and tools to help all parties monitor progress must be simple and streamlined. A simple dash board would meet the need, but it has to be real time and based on clinical performance, not claims data. The few tools that exist today tend to be proprietary and live mostly with payers. They rarely have a real-time component. Both physicians and health systems need to have a real-time equivalent of progress to evidenced-based metrics in place as part of proper care modeling.
Legal concerns such as anti-trust issues, the Stark law on physician self-referrals, and anti-kickback laws – all of which were based on fighting fraud and abuse – have to be carefully negotiated and managed as well. Often state and federal law clash on these items and will need to be re-defined. Payment models have to be determined with all parties.
Systems to accomplish this, provide documentation and monitor shared savings will be a requirement to meet this challenge and, to my knowledge, are not available on the market in any real way. The governance and legal issues will require documentation, financial systems and patient tracking tools of significant power and flexibility that I have yet to see. That does not mean they are not available, but they are not in the mainstream of vendor products and, as such, will require some effort to find and integrate into our clinical and financial environments.
The lack of obvious integrated products to meet the needs of an ACO may force us into cobbling together a set of solutions, which historically has not been easy or optimal. An ACO requires a new level of software, and we need to call on our vendors to think beyond the data sharing and look to the functions and performance we need for success. I am a strong supporter of the ACO concept, but the success and effectiveness of this model will require new software tools and cultural changes. Systems have to be identified, implemented and managed that address the advanced communication, documentation, and collaborative integration requirements which will validate improved quality and reduced cost.
In a world of declining reimbursement, this is imperative and needs to be addressed early in the process. Adding a HIE to a hospital EHR and connecting to physician EMRs is not the way to create an effective ACO. There is more work to be done both in product development and education. A new level of integration and collaboration has to be tied into the cultural changes an ACO represents to deliver the higher quality and lower cost for which we all yearn. If we do not broaden our perspective, we will be rocketing into a brick wall like our coyote friend on an ACME rocket of incomplete tools and poorly defined objectives. If any vendor out there has a complete solution, please let us know.