Better Integration to Improve Care Outcomes Highlighted at AJMC’s ACO Coalition

Coverage from the 2016 Spring Live Meeting of the ACO & Emerging Healthcare Delivery Coalition on April 28-29, 2016, in Scottsdale, Arizona.
Published Online: June 21, 2016
Laura Joszt, MA
Finding the right way to address a patient’s condition before it worsens will ultimately lower the cost of healthcare—and it seems like the healthcare industry is now getting on board with that notion. “You do the right thing, at the right time, at the right dose with the right patient … and the total cost of care goes down, not up,” said Leonard M. Fromer, MD, FAAFP, from Group Practice Forum. “Even if the cost of the treatment might be a lot of money.” Over the course of 2 days, attendees at the spring live meeting of the ACO & Emerging Healthcare Delivery Coalition, presented by The American Journal of Managed Care, not only heard case studies, panel discussions, and presentations that highlighted how better integration and more coordinated care can improve quality of care while lowering costs, but also shared their own best practices.

Integrating Behavioral Health

With ACOs accountable for both the health and the cost of the population they serve, integrating the behavioral and medical components of health is a necessity. “Unless you address both the medical and behavioral, you’ll have poor outcomes,” said Roger G. Kathol, MD, CPE, of Cartesian Solutions, Inc, and the University of Minnesota. Only 25% of people with behavioral health problems are seen in the behavioral health sector, which means that 75% never have access to evidence-based care. The vast majority of patients seen in the primary care setting receive either no treatment or ineffective treatment, he explained, which provides a tremendous opportunity to better address the needs of those with behavioral health issues seen in the medical setting.

For ACOs, there are a few options for how to handle behavioral health: do nothing and eat the cost when patients have poor outcomes, buy traditional services that people are proven to not use, or build behavioral health services inside the ACO. In his workshop, John Santopietro, MD, outlined the virtual care model being used by Carolinas HealthCare System. Instead of co-locating 1 social worker in each practice, the system adapted the model by deconstructing what the provider does and recreating that as a virtual team of providers that includes the call center clinician, a care manager, a behavioral health coach, a pharmacist, a therapist, and a psychiatrist. “If you do it that way, you can deploy [the team] much more effectively,” Dr Santopietro said.

The early results from the program have found a decrease in depression and anxiety scores, and a decrease in glycated hemoglobin, total cholesterol, and low-density lipoprotein cholesterol. The biggest hurdle to getting the program off the ground was not hesitation on the part of the patient, but that from psychiatrists.

“But we’re getting out of the world where psychiatrists were concerned and didn’t want to do it,” Dr Santopietro said. “More and more, they are getting trained in telepsychiatry.”

Precision Medicine and ACOs

During his keynote presentation, Dr Fromer explained that precision medicine is a fundamental piece of the accountable care movement. The benefit of precision medicine is that caring for patients LAURA JOSZT, MA Coverage from the 2016 Spring Live Meeting of the ACO & Emerging Healthcare Delivery Coalition™ held April 28-29, 2016, in Scottsdale, Arizona. ajmc.com 6.16 / 63 becomes less expensive when healthcare zooms into classes of patients, he said. Medications may be more expensive, but “the big picture cost” plummets only by improving the health of the individual and keeping them well.

Oncology is the biggest and earliest adapter, and stakeholders in that space have begun to create nomograms that use an alpha-numeric code to describe something unique about the patient: genetic makeup, tumor makeup, comorbidities, social environment, etc. “To know which drug will work best first, and not hunt and peck, that’s where you save money—a lot of money,” Dr Fromer said.

Where this all ties into ACOs is through the idea of being proactive with the population being cared for. Dr Fromer added that he expects to begin seeing quality measures move precision medicine forward. “Precision medicine quality measures—they’re coming,” he said. “It will follow, not lead. It will be there because it will be a natural output from aligning the payment model in general.”

The Future of Healthcare

Clifford Goodman, PhD, of The Lewin Group, moderated a panel discussion between Michael E. Chernew, PhD, of Harvard Medical School; Patricia Salber, MD, MBA, of The Doctor Weighs In; and Bruce Sherman, MD, FCCP, FACOEM, of Buck Consultants, A Xerox Company. They discussed the future of healthcare in the United States, including the sustainability of the Affordable Care Act (ACA), the impact of the presidential election on healthcare delivery, employer coverage, and maintaining cost of care in the era of innovation.

The panel kicked off with a discussion on Medicaid expansion. Dr Salber noted that it is difficult to separate the decision to expand the program from the politics and she added that since the implementation of the ACA, resistance to expanding the program has begun to deteriorate. She also expects to see more and more states agree to expand Medicaid. Dr Chernew echoed this sentiment, explaining that the ACA was designed to have very strong incentives for states to agree to expand.

“I think that if the election moves in a direction that it looks like the ACA will not be repealed at the federal level, you will see a lot of states move to [expand Medicaid],” he said. “If it looks like it’s really here to stay, you’ll see more states expanding.”

According to Dr Sherman, from an employer standpoint, expanding Medicaid has been a good thing. After all, if people have the money to pay for healthcare, the employer stands to benefit. Expanding Medicaid potentially helps to mitigate some of the disproportionate share of costs that employers cover because of charity care, he added. One of the biggest challenges to the ACA may not even be the politics and the threat of a Republican president repealing the law. Healthcare spending continues to grow, and if the United States cannot get the healthcare delivery system working in a more sustainable way, then the ACA may collapse under its own weight when the country can no longer afford the level of subsidies included in the law, explained Dr Chernew.

Dr Salber then shifted the conversation over to drug pricing. Although there has been development of life-saving, life-altering therapies, they come with huge price tags that the health system hasn’t figured out how to deal with just yet. She expects to continue to see innovative drugs and the pharmaceutical industry continuing to increase the cost of those treatments. Nevertheless, how those drugs are handled in the insurance benefit design could have huge ramifications, she added.

“If all of those things end up fourth tier with huge coinsurance or huge deductibles, there will be a situation where if you have money you can survive, but if you don’t, you will get chemotherapy instead of targeted therapy,” Dr Salber said. “In that part of healthcare we could see a widening disparity.”

Dr Chernew pointed out that regardless of the public sentiment around drug pricing, it has been well established that there is a relationship between profitability and innovation. And while it can be debated whether that relationship should be there, it is. “I think that the fundamental challenge that healthcare faces is that innovation is universally considered good, but it’s something we continue to struggle to finance,” Dr Chernew said.

Telementoring in Oregon

In Oregon, there are some unique innovations taking place regarding healthcare delivery. The state is home to coordinated care organizations (CCOs), which are essentially ACOs, but specifically for Medicaid. These CCOs are charged with the responsibility of ensuring that healthcare delivery change is driven by providers and to improve quality of care. In order to do so, Health Share of Oregon has invested in Project ECHO, a telementoring program that connects specialists with primary care providers.

The basic idea of Project ECHO is to “demonopolize the specialist’s knowledge,” explained Mark Lovgren, director of telehealth services at Oregon Health & Science University. The program runs for 40 weeks and includes 15- to 20-minute didactic presentations delivered by specialists and real-time case-based presentations from primary care providers who are struggling with specific situations. The expert team of specialists are able to provide recommendations to the primary care provider who is struggling with how to care for a specific patient.

“The idea is that through repeated exposure to these difficult cases, everyone participating will feel more comfortable with them,” Lovgren explained.

It does take a few weeks for providers to feel comfortable when participating in the program to open up and share a case, he added. After all, when a provider shares a case, he or she is asking for help, which isn’t always easy for them to do.

“The secret sauce is your facilitator and team,” explained Christine Bernsten, senior manager of delivery system transformation for Health Share of Oregon. “You can get the cookbook to implement [Project ECHO], but you need the facilitators who are good teachers and they are kind and supportive of the providers participating in [the program].”

Voluntary ACO Accreditation

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