As part of its mission to bring together stakeholders engaged in implementing the Affordable Care Act, The American Journal of Managed Care created the ACO and Emerging Healthcare Delivery Coalition, which gives participants opportunities to share best practices in using new reimbursement models. The final panel of "Patient-Centered Diabetes Care: Putting Theory Into Practice" invited ACO Coalition members to present insights on diabetes care.
Dennis Scanlon, PharmD, opened by describing the ACO, or accountable care organization, as “the hottest 3-letter word in healthcare.” He noted, of course, that in the 1990s there had been a different 3-letter word that was going to change everything: HMO, or health maintenance organization. Scanlon asked Scott Hines, MD, to define the term ACO.
Hines said his group is a physician-owned multi-specialty group, which includes 2 important features. “We decided in around 2010 that the direction of healthcare was toward valuebased care and the accountable care organization,” he said.
“Value-based care is really a philosophy of how we should be treating patients” that is centered on the Triple Aim of better health, better healthcare, and lower costs. “An accountable care organization,” Hines continued, “is the structure that can deliver that care.”
Diabetes as an Example of Value-Based Care
Diabetes presents a key opportunity to deliver value-based care. Crystal Run began a practice called “virtual rounds,” involving an endocrinologist, 4 to 5 primary care physicians, a care manager, and a nutritionist. The process covered patients with glycated hemoglobin (A1C) in excess of 9.25. Patients who had been lost to followup were contacted, and recommendations were made for others.
In many cases, the patients were contacted but did not have to come in. “By doing that, we reduced the percentage of patients who had A1Cs greater than 9 from 18% to about 12%,” he said.
A variation reduction program began to chart patients on a graph and confront physicians with the data, showing them that, contrary to their assumption, their outliers were not the sickest patients. Then, the program deployed best practice guidelines to standardize care in diabetes. In doing so, not only did the sickest patients get better, but the patients at control who were coming in every 3 months were able to come in less frequently, thus creating room in the schedule.
“Just through that transparent data sharing and that conversation, over 6 months we reduced the cost of care for diabetes by 9%, or about $400,000. Over 2 years, we reduced the cost of care by 17%, or about $850,000,” he said. “We basically created a capacity of an extra physician without having to hire an extra physician. That allowed more patients who needed to be seen to be able to come in and be seen.”
“So, we’ve used this program, we’ve expanded it to many other diagnoses but that’s kind of the cornerstone of the work that we’ve been doing,” Hines said.
Breaking Down Silos
Next, Scanlon asked Katherine Schneider, MD, MPhil, FAAFP, to talk about creating more collaborative environments, which he described as an essential part of the ACO movement.
Schneider, a family physician with population health training, said her company provides software that helps solve specific problems of accountability. For example, understanding the fundamentals of diabetes—aka the ABCs, for A1C, blood pressure, and cholesterol—can help reduce the number of days a patient with diabetes
is hospitalized if he is admitted for a problem unrelated to diabetes.
Having good data and metrics is fine, Schneider said, but doesn’t replace good care. “Having a good organization where you manage governance and standardized hand-offs and all that, that’s important,” too, she said. “But you’re not going to succeed without the ‘C’ in the ACO.” Otherwise, she noted, it’s just “a new board and a new layer of bureaucracy.”
Next, Scanlon asked Meaghan Kim, BS, RN, CDE, of AtlantiCare to discuss the challenges of health information technology (HIT) and the implementation of electronic health records (EHRs), especially in relation to diabetes. Kim said AtlantiCare, which has a relationship with Joslin Diabetes Center, identified gaps in services and designed a plan to fill them in. AtlantiCare used EHR to risk-stratify patients, by provider and practice, and to identify those patients with A1C above 9. Then, AtlantiCare could see where additional certified diabeteseducators (CDEs) could be placed for greatest benefit. “Two years ago we started with 1 [American Diabetes Association-] recognized site within the AtlantiCare system, and today we have 9,” she said.
Diabetes education services are expanded and also decentralized, so CDEs work collaboratively with the primary care physicians. AtlantiCare is working on improving transitions of care, Kim said, and it has identified EHR capacity as a new challenge—specifically, the system must identify which patients need A1C checks at 3-month and which at 6-month intervals.
Success at Geisinger Over Long Haul
Integrated Delivery Networks (IDNs) are associated with Geisinger in Pennsylvania, Scanlon said. He asked Michael Evans, RPh, to describe the ambulatory clinical pharmacy program in place within the healthcare system.
“We’ve had an electronic health record for 20 years,” Evans said. “Twenty-two years ago we started our anticoagulation service at Geisinger, pharmacist-run.” Collaborative models, with pharmacists playing significant roles in diabetes care, are clearly not new. Nor is the idea of Evans being able to log onto a computer and ask,
“How many patients have an A1C over 9? How many haven’t had an A1C in 3 months? In 6 months? What are their current medication regimens?”
In the beginning, Geisinger pushed much of the workload back on physicians, but that has changed with physician shortages. Today, physicians handle the diagnosis; aftercare is the responsibility of mid-level providers. According to Evans, the process works. And care is stratified: patients with A1C currently above 9, or above 8 for more than a year, are referred to a pharmacist; those with A1C at 8 for less than a year see a CDE.
“For metabolic disease, 71% of patients are getting to goal, and we’re maintaining that goal,” Evans said. Their efforts to maintain adherence to medication have succeeded, and Geisinger’s results reach 80%, far higher than those of most other American health plans.
When patients reach Geisinger with an A1C of 8 or 9, “They’ve essentially failed everyone before they come to us.” But, Evans clarified, “It’s not the patient that’s failed; it’s typically the system that’s failed the patient.”
Sometimes, success is a matter of picking the right therapy—one the patient can stick with. “If they’re adherent to 1 therapy, it’s better than being not adherent to any therapy,” he said.
In response to a question, Evans repeated advice given earlier: it’s important to coordinate outreach so the patient hears from only 1 or 2 regular contact persons, so strong relationships are developed. Geisinger serves patients over a huge geographic area, with some patients living up to 100 miles from the nearest clinic. That
makes developing a rapport especially important.
Future of ACOs?
Scanlon noted that some observers do not see a bright future for ACOs. For instance, “Regina Herzlinger from Harvard [Business School] has said thatACOs will implode just as capitated HMOs imploded in the 1990s.” Others, however, predict “That won’t happen because we have better data now,” Scanlon said.
Schneider said the practices that succeed under the ACO model will be those that view it as a full-time commitment, not as a “project” to do on the side. Hines agreed.
“If ACOs don’t succeed,” he said, “what is the alternative? The status quo is not an alternative.”