An editorial in response to the editor in chief’s December 2021 letter discusses alignment of specialist physicians with value-based care initiatives.
Am J Accountable Care. 2022;10(3):5-6. https://doi.org/10.37765/ajac.2022.89230
In the December 2021 issue of The American Journal of Accountable Care® (AJAC), Editor in Chief Dennis P. Scanlon, PhD, authored a letter calling on health systems to innovate and learn in real time with the goal of delivering patient-centered care. He then invited organizational leaders to respond in editorials of their own, which are being published in AJAC throughout 2022.
In his December 2021 letter, The American Journal of Accountable Care® Editor in Chief Dennis P. Scanlon, PhD, highlighted the need for the application of systems science to make health care delivery more patient-centric and of higher value. It will take more than just systems science. Health care is too expensive, its quality is too variable, and customer service is frequently lacking. I agree with Dr Scanlon that better systems are important, but what’s essential is more courageous leadership from health care executives with power to change the status quo even when doing so is uncomfortable for their organizations.
Accountable care is an important pathway to a more patient-centered, value-based health care system. But accountable care organizations (ACOs) are neither a silver bullet nor monolithic. Historically, many of the highest-performing ACOs have been physician-led organizations that don’t own or operate health care facilities. The performance of large health system ACOs has been mixed. In these systems, the ACO or population health departments make valuable contributions but frequently don’t get the resources or authority they need to transform care across their parent organizations. Specialists and facilities generate the bulk of systems’ revenue and therefore control the flow of resources. Most large health systems are still addicted to fee-for-service payment, and ACO initiatives that endanger their cash flow are viewed as a threat.
For the past decade, ACOs have focused much of their work on enhancing primary care. Among ACO leaders, there is a perception that most medical specialists are either unaware of or perhaps not particularly interested in the work of the ACO. Taking accountable care to the next level will require alignment of specialist physicians with value-based care initiatives. That will require an enhanced focus by specialist physicians on the whole patient, more careful assessment of the appropriateness of both routine and high-cost services, increased collaboration with primary care providers (PCPs), and organized efforts to reduce use of low-value services.
So how can ACOs effectively align with specialist physicians? Many are considering strategies that include the following elements: (1) education on value-based care, (2) performance measurement and reporting, (3) systems designed to catalyze PCP-specialist collaboration, and (4) steering referrals to preferred specialists.
Specialist education and outreach. The goal of educational outreach is to establish a dialogue between ACO leaders and prospective specialist partners. This can be challenging. According to a recent anecdote from an ACO medical director, 2000 specialist physicians were invited to a virtual meeting with ACO leadership—only 40 opened the email and only 18 showed up. It may be that ACOs have not paid attention to specialists, or that specialists have ignored ACOs. The truth is probably somewhere in between. But the goal is to start a conversation about value-based care and find areas of common ground. ACOs won’t make progress with every specialist, but they will find some who care deeply about improving value. These individuals will be the first wave of specialist champions for change.
Performance measurement and reporting. ACOs are rewarded based on how well they manage the total cost of care (TCOC) for beneficiaries who are attributed to their participating providers. Many specialists do not provide the types of evaluation and management services that are used to attribute patients to ACOs and therefore TCOC measures aren’t relevant. Instead, organizations need episode-of-care analytics to measure specialist efficiency. More ACOs are turning to vendors that can help them compare specialists using episode-of-care tools. Measuring quality is a bigger challenge, however. ACOs can look at event rates such as surgical infections or readmissions, but these measures aren’t good enough. Specialty societies need to show more leadership in defining, measuring, and reporting quality of care, and especially taking a hard look at high-revenue services that provide only marginal benefit to patients. Plans and policy makers also need to invest more resources in advancing patient-reported outcomes.
Enhancing PCP-specialist collaboration. The most effective way to treat seriously ill patients is through comanagement within multidisciplinary care teams. Sometimes the specialist needs to be the quarterback and other times it’s the PCP. But the patient is best served when there is coordination and continuity rather than a bevy of disparate clinicians working in silos with nobody responsible for the whole patient. Doing so is easier in organizations in which everyone uses the same electronic health record. This allows data sharing and timely communication across everyone responsible for a patient, especially when they work in different locations.
How can ACOs encourage coordination and comanagement? Some ACOs are establishing systems in which PCPs cannot make certain types of referrals without documenting that they’ve discussed the case with a specialist first. Some of these ACOs are organizing the conversations with their own employed specialists, whereas others are using virtual curbside specialty consults (from companies that offer outsourced services) to help PCPs manage more care themselves and ensure that their referrals are appropriate. These arrangements are a source of high satisfaction, especially when a medical issue can be resolved quickly, and the patient avoids the stress of a long wait for a specialist appointment and additional co-payments.
Steering referrals to preferred specialists. Some ACOs aspire to recreate the employed multispecialty group practice model either physically or virtually, emphasizing collegiality, collaboration, and a focus on what’s best for the patient. Such a model is more challenging when ACOs rely
on specialists from outside their organizations, especially when the providers work on medical record systems that aren’t interoperable. In most ACOs, more than two-thirds of patients receive specialist care outside of the ACO’s provider network. Therefore, ACOs have becoming increasingly interested in curating preferred networks of specialist physicians, following in the footsteps of health plans. ACOs will adopt more aggressive referral management policies in the coming years to the benefit of specialists who communicate effectively with PCPs, provide great patient service, and deliver efficient high-value care.
The movement to better integrate specialists into ACOs should be viewed as a win-win opportunity. Clinicians will benefit from the collegiality of working in well-functioning teams. Specialists will benefit from PCPs who refer appropriately so that they can focus their time on patients who need their expertise. Specialists who demonstrate efficiency, value, and collaboration will be rewarded with additional referrals, and patient care will be better. However, specialists who don’t want to play will eventually see referral volume decline.
The work ahead will not be easy. To really advance care transformation, ACOs and health systems need leaders capable of building a value-based culture, information systems that enable effective communication and data sharing, and aligned financial incentives. They also need health plans to offer TCOC contracts including full-risk capitation to medical groups and health systems that want them. The focus on ensuring better value from specialist care is going to pick up steam. If the value movement continues to grow, as is the goal of the Biden administration, the specialist community would be well advised to get on the bandwagon.
Author Affiliation: Institute for Accountable Care and Brandeis University, Waltham, MA.
Source of Funding: Arnold Ventures.
Author Disclosures: Mr Mechanic is employed as the executive director of the Institute for Accountable Care, a nonprofit group that receives some funding from the National Association of ACOs and from providing analytic services to accountable care organizations and health systems; he has also received a grant from Arnold Ventures to study specialist engagement with accountable care organizations.
Authorship Information: Concept and design; drafting of the manuscript; and critical revision of the manuscript for important intellectual content.
Send Correspondence to: Robert Mechanic, MBA, BS, Institute for Accountable Care and Brandeis University, Waltham, MA. Email: email@example.com.