Accountable Care Organizations Facing New Competency Challenges: The “8 Habits” Required of US Health Systems
Published Online: December 12, 2013
Daniel K. Zismer, PhD
The US health system has undergone notable transformations over the last 2 decades. Independent community hospitals haveconsolidated horizontally with others to form hospital healthcare systems, with many of the larger ones covering wide-ranging geographies, generating billions of dollars in operating revenues. Hospitals and physicians have consolidated their businesses through vertical integrations, stemming from hospital acquisition of private medical practice assets forming various models of integrated health systems. Integrated health systems are extending clinical programming beyond acute care to create a broader reach along the continuum of care and are standardizing clinical service line models and methods across sites and geographies.1
The next transformation is to accountable care, and while definitions may differ, the foundation of the accountable care organization (ACO) is its ability to assume the responsibility for the health of attributed populations, over time, for known allocations of funding (financial risk transfer).
ACO structural designs exist on a continuum from “less integrated” to “fully integrated,” with fully integrated defined here as all clinicians and related staff working for the same organization. The lesser integrated ACO is often aggregations of independent parties (eg, community hospitals and private practice physicians) holding stakes in a legal entity formed as the contracting mechanism between a third party payer (governmental or commercial insurer or other financial intermediary) and the participating providers.
With this transformation the business relationship between provider and payer changes fundamentally, as do related financial incentives. Systems of healthcare delivery are transformed from manufacturers of units of service sold to sick people on a per unit basis to systems of healthcare accountable for the health status of a population and all related current and future health services needed. This includes provision of preventive healthcare and care for the acutely ill. The principal difference in the financial model is the nature of the incentives: “more is better” shifts to “more is more costly to the provider.”
Over the last few years, I have been examining the implications of such organizational transformations through studies funded by MedPac2 and through unfunded work, including interviews with a number of leaders of larger, integrated health systems. What follows is a summary of that work expressed as a list of organizational competency challenges. These competency challenges represent the “where we need to go as an organization” thinking of health-system leaders.
Competency #1: Public Health Practice
Embedded or contracted competencies in the areas of: the epidemiology of attributed populations, including health cost risk profiles with evidence-based best practices applied; total costs of care for specific care episodes and for cohorts with chronic illnesses; health behavior intervention methods and models for specific populations at risk; and effective application of social media as a health behaviors management tool for specific, attributed populations. Many health-system leaders believe it is time for the convergence of principles of public health management with principles of health-system management.3
Competency #2: Interprofessional Team Care and Care Management
Given that skilled healthcare professionals are likely to remain in short supply for the foreseeable future, provider supply will be constrained, requiring more effective “leverage models,” meaning the applications of interprofessional team care. Our study of this area shows a number of important observations: (1) many of the more integrated health systems are experimenting with models for primary and specialty care and interprofessional team care, (2) “best practices” in this regard are not likely to emerge for wide pread industry consumption anytime soon, (3) many of the models in operation are designed to optimize productivity of physicians in a fee-for-service environment, and (4) what passes as interprofessional team care is often times physicians and physician extenders doing much the same work (especially for primary care).
Competency #3: Physician Compensation Design
Many of the compensation designs for integrated health systems (those that employ physicians) are productivity based with a compensable unit of effort the work relative value unit (RVU). The number of work RVUs produced by a physician multiplied by an internally derived value equals the cash compensation paid. The model is typically indifferent to type of patient seen, type of work performed, or whether the health system is paid for the work done. The raw incentive at play is the production of “more” work RVUs. The more integrated health systems are working on the options with the goal of paying market compensation for clinical productivity that aligns the incentives of the providers and their organization with those derivative of the types of financial agreements (risk contracts) executed with the payers. Health systems that have a history of salary-based compensation plans may have an easier time with this challenge.4
Competency #4: Facility Asset Investments and Utilization
Integrated health systems are principally in the outpatient business; ie, most of revenue earned and clinical activity delivered is not from the acute care setting. The size, design, layout, and functionality of larger, clinically sophisticated ambulatory healthcare facilities are a fast-moving area of health-systems asset planning, development, and financing.5 Many health-system leaders admit they are “behind the curve” with what is a new science for facilities design and application. Based upon examination of balance sheets of larger health systems there is a sizable latent demand for investments in ambulatory facility assets that serve the needs of changing health services delivery models.
Competency #5: Performance Metrics, Benchmarks, and ACO Performance Evaluations
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