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The American Journal of Accountable Care June 2014
Patient-Centered Physician Selection: A Necessary First Step for Accountable Care
Brian Powers, BA and Sachin H. Jain MD, MBA
Patient-Centered Medical Home Recognized Practices Provide a Strong Front-Line for Accountable Care Organizations
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Patient-Centered Outcome Assessment May Lead to Different Conclusions and Different Treatment Decisions
Robert M. Kaplan, PhD, chief science officer, Agency for Healthcare Research and Quality
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Krista Drobac, executive director, Alliance for Connected Care, and Clif Gaus, president and CEO, National Association of ACOs
How We Did It: How One Physician-Owned ACO Earned Shared Savings
Kelly Conroy, executive director, Palm Beach Accountable Care Organization, CEO Triple Aim Advisory Group
Study: Health Recovery Solutions Uses Tablets to Reduce Cardiac Readmissions
Judith Kutzleb, DNP; and Joan Shea, MBA, JD
A Transitional Care Model for Patients With Acute Coronary Syndrome
Sherry Bumpus*, PhD, FNP-BC; Barbara L. Brush*, PhD, ANP- BC, FAAN; Susan J. Pressler*, PhD, RN, FAAN; Jack Wheeler, PhD; Kim A. Eagle*, MD; and Melvyn Rubenfire*, MD *These authors contributed equall
AHIP: 2014 National Health Policy and Health Insurance Exchanges Forum Event Highlights
Katie Sullivan
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AJMC's ACO and Emerging Healthcare Delivery Coalition: First Live Meeting Coverage
Katie Sullivan

AJMC's ACO and Emerging Healthcare Delivery Coalition: First Live Meeting Coverage

Katie Sullivan
Accountable and patient-centered care delivery models were at the forefront of discussions among coalition members.
The American Journal of Managed Care hosted its very first ACO and Emerging Healthcare Delivery Coalition meeting in Baltimore, Maryland, on April 17-18, 2014. The 2-day event engaged coalition members as they discussed important issues surrounding accountable and patient-centered care delivery models.

Marketplace Overview and Real-World Perspectives 

The opening session was presented by Ira Klein, MD, MBA, FACP, chief of staff, office of the chief medical officer, national accounts clinical sales & strategy, Aetna, Inc, and Anthony D. Slonim, MD, DrPH, CPE, FACPE, executive vice president and chief medical officer, Barnabas Health, and executive director, Barnabas Health ACO North and Central Jersey ACO.

Dr Klein opened with a discussion that analyzed the findings of a survey performed by The American Journal of Managed Care and Health Research & Analytics (HRA), both part of Intellisphere, LLC. The brief survey was sent to 41 ACO Coalition members, including Johnson & Johnson, Aetna, Walgreens, and the National Pharmaceutical Council. Findings centered on everything from the challenges they faced with collaboration to some of the innovative solutions they have implemented within their ACOs.

Dr Klein suggested to audience members that the survey was used as a “map” by which speakers could guide the conversation on topics that audience members had the most interest in. The poll asked Coalition members to rank, on a scale of 1 through 5, the most important topics in 4 categories:

 Patient Experience—Patient engagement was ranked as the most important aspect to “progress collaboration in activating patient interest to engaging them long term” (2.6/5). Patient satisfaction was ranked least important in this category by survey takers (0/5).

 Quality—Survey takers ranked “quality metrics” (2.7/5), followed by “enhancing care management” (2.2/5) as the top 2 important under quality topic discussions.

 Cost/Financial—Contracting was deemed to be the most important for members (5/5), but cost-effectiveness (2.6/5) and value-based reimbursement (2.9/5) were not far behind.

 Data Technology—The most significant results here were what was found to be not important by survey takers. This included “tracking measures” (4.2/5). Dr Klein noted that most survey takers seemed not to care about sharing data as much as they did about sharing information.

Overall, Dr Klein determined that one of the most crucial and beneficial aspects of the Coalition and of the meeting was that every life cycle of the ACO presents a variety of opportunities and challenges. With such a diverse group of members from organizations such as ACOs, pharmacies, and insurers, members are able to share their unique experiences and learn from one another.

ACOs and the Evolving Healthcare Marketplace 

Anthony D. Slonim, MD, DrPH, CPE, FACPE, Barnabas Health, provided a very thorough analysis of ACOs and how they function. With an estimated one-third of care offering little to no value, Dr Slonim said that many want to know what the value proposition of an ACO is, and what it will mean for patients. The value proposition says that value is subject to quality as it relates to total costs of care. To increase value, one must improve quality or lower costs. Value decreases when quality is reduced or costs increase.

Dr Slonim explained that current care models can be chaotic in non-hospital settings. To improve managed care settings, beyond controlling costs, organizational processes must be reengineered and health- system employee roles must be clearly defined. ACO models have been perceived as a potential solution to ensuring that doctors practice better, specifically when dealing with a panel of patients.

ACOs also offer a variety of payment/reimbursement models, including shared savings (both 1-sided and 2-sided risk models), bundled payments, partial capitation, and global payments. An ACO’s structured network can allow physicians to take risks with payment models where they might not otherwise be able to do so in other care delivery settings.

As an ACO matures, its priorities will change, as will the opportunities within the industry. Dr Slonim suggested that many within ACOs simply are “learning as they go.” Additionally, he recommended that the doctor-patient relationship remain front and center in all that ACOs do. As the healthcare landscape evolves, conversations amongst health professionals such as those at the ACO Coalition meeting will be needed to determine the best path to successful ACO management.

Healthcare Delivery Implementation Strategies 

Ed Cohen, PharmD, FAPhA, Walgreens, presented a session that focused on WellTransitions, a Walgreens program which “bridges gaps in care by supporting patient recovery through several hospital-to-home transition steps.” These steps aim to reduce patient readmissions, increase patient satisfaction, and lower the costs of overall care.

Patients who participated in the program were:

 46% less likely to have an unplanned readmission

 26% less likely to be readmitted with non-CMS–targeted con- ditions, while those with CMS–targeted conditions were 55% less likely to be readmitted

 44% less likely to be readmitted under age 65 years, while those age 65 years or older were 48% less likely to be readmitted.

Dr Cohen provided a study which took place at DeKalb Medical Group, which partnered with Walgreen pharmacists to increase patient education about their medication following a hospital admission. The collaborative pharmacist-hospital relationship enabled DeKalb to improve its Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) score, which monitors patient satisfaction, just 90 days after it was initiated. In fact, they reported a 26% relative increase in HCAHPS domain score. Dr Cohen stressed that Walgreens functions not as a vendor at DeKalb, but as a department of hospital system operations.

“We don’t want to be looked at as an outside vendor, we want to be looked at as another department in the hospital, so we work really hard to integrate, we have our staff go through all of the orientation as though they were an employee at the hospital, so we are really proud about that,” said Dr Cohen.

With nearly 1 in 3 patients nonadherent to the medications that manage their disease, health systems require treatment programs supported by a collaborative team to ensure patient wellness and healthy outcomes.

ACOs: Key Functions & PCMH Support 

Paige Cooke, National Committee for Quality Assurance, defined an ACO as a provider-based governing body responsible for the provision of resources to meet the triple aim. It is supported by stakeholders that include payers, purchasers, pharmacy, and ambulatory care sites. The foundation of building any strong ACO model, she said, is the patient-centered medical home (PCMH).

She provided 2 testimonials that described the ACO experience. The first group was Bon Secours Virginia Medical Group. Bon Secours achieved savings in the first year of participation in the CMS Medicare Shared Savings Program, with enterprise-wide electronic medical record use, early adoption of the medical home model, and other patient engagement initiatives.

She also shared the example of the Montefiore Medical Center in New York, a group which also integrated patient engagement as well as implementing “innovative nurse-driven interventions that supported patient outcomes and experience.”

Ms Cooke noted that the PCMH model is the fastest growing delivery system innovation in the United States. As of March 2014, there were 7118 PCMH sites throughout the country. The National Committee for Quality Assurance (NCQA) ranks several PCMH quality standards on a score-based scale. PCMHs can help:

• Enhance access and continuity

 Encourage team-based care

 Identify and manage patient populations

 Plan and manage care

 Track and coordinate care

 Highlight performance measurement and quality improvement.

In 2014, there were various quality-standard updates to team-based care, behavioral health, and measuring costs. Ms Cooke noted that ACOs can provide valuable resources to support the delivery of patient-centered primary care including access and coordination of patient management.

“One of the most important concepts that ACOs need to embrace is that the patient-centered medical home model is an evolutionary one, it’s one that is designed to align with the growth and evolution of what is happening in health reform,” said Ms Cooke. She praised NCQA’s PCMH Recognition Program, which provides accolades to those ACOs and PCMHs which demonstrate success with implementing evidence-based practices within their health systems.

Real-World Best Practices: Financial Structures, Quality Measurement, Medication Management 

Kelly Conroy, Palm Beach Accountable Care Organization (PBA- CO), LLC, provided insight into experience with managing patients at the PBACO. CMS accepted the group on July 1, 2012. As with other accountable care models, PBACO focuses on a triple aim of care, which includes improving the patient experience, improving population health, and decreasing per capita healthcare costs. Additionally, as a member of CMS’s Medicare Shared Savings Program, they are able to be rewarded for achieving specific quality and cost-saving benchmarks.

Ms Conroy noted that initial implementation was difficult. They had to put pressure on the community stakeholders, like hospitals,to buy into the accountable care model. It was difficult to convince providers and doctors that transitioning from the fee-for-service model to and ACO was not only possible, but the financially responsible and logical choice. It was important to reach out to physicians and let them know that their contributions were making a difference once they agreed to join PBACO’s efforts.

“We created this outside component of competition with our community stakeholders pushing on the doctors, and eventually, the doctors started answering the phones, and then eventually, the doctors started to appoint a point of contact in their office to get it,” said Ms Conroy. “And then, after they made $22 million or saved $22 million, then they got really interested in doing things.”

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