The Advent of Accountable Care Organizations: A Shift in the Managed Care Paradigm

In a presentation entitled "Accountable Care Organizations: 2013 and Beyond," 4 managed care experts shared their insights and thoughts on the ongoing paradigm shift in managed care towards accountable care organizations, elaborating on current trends, unmet needs, and the future direction of the managed care landscape.

In an educational session on healthcare reform entitled "Accountable Care Organizations: 2013 and Beyond," Robert W. Dubois, MD, PhD, the chief science officer of the National Pharmaceutical Council began by indicating that the success of accountable care organizations (ACOs) is contingent upon many factors, such as pharmaceuticals, patient education, and quality measures. A significant contributor to a model's success is the role and utilization of medications throughout the continuum of patient care delivery. Dubois continued by saying that while ACOs accomplish some functions fairly well, such as high rates of transmitting prescriptions electronically, identifying medication profile disparities and interactions, unifying medical and pharmacy data into a singular system, and encouraging the use of generics in formulary, there are also many facets of ACOs that require further improvement. These areas, he noted, include components of care protocols, such as those for the identification or prevention of duplicate medications or polypharmacy, as well as patient and provider engagement initiatives.

Taking the podium next was Kristina Lunner of Leavitt Partners, who defined accountable care as an "entity that directly influences the provision of care and bears financial risk for the measured health outcomes of a defined population." ACOs can be categorized by different structures, models (eg, insurer, insurer-provider, multiple provider, single provider), and sponsor types (eg, community-based, physician group, hospital system, insurer). Discussing the current trends of ACOs in today's managed market environment, Lunner pointed out that, in comparison to the 45 ACOs at the end of the fourth quarter in 2010, the end of the first quarter in 2013 witnessed 428 ACOs, with marked growth within various regions throughout the United States. Furthermore, Lunner continued, there continues to be an active push for legislative and policy changes to instill ACOs in the United States. In comparison to the previous managed care structure of capitated payment, care management via payer, and cost management incentives, ACOs are currently operating by a shared savings payment model, with physicians regulating care management, and incentives driven by population health management. As risk-bearing entities, ACOs are incentivized to optimize patient outcomes to minimize healthcare expenditures, thereby keeping patient care at the forefront. However, as noted by Dubois earlier, there are still many areas that require further improvement to optimize the form and function of ACOs, and according to Leavitt Partners, current areas of unmet needs include data management, care management infrastructure, physician alignment, and network development.

Marissa Schlaifer, MS, RPh, echoed Lunner, stating that the clinical role of ACOs is to ensure that "the best care is provided in the most economical setting for ACO patients." Responsibilities to achieve that goal may entail the establishment of care coordination guidelines, the review and dissemination of best practices and management guidelines, and clinical practice improvement. Pharmacists play a substantial role in the optimal function of ACOs, Schlaifer continued, such as the implementation of quality measures that are directed at 1 or more of the 33 CMS quality measures. Other functions include advising prescribers about the relative clinical efficacy and value of a drug regimen, accepting greater responsibility and role in medication therapy management and outcomes measurement, and ensuring efficient and consistent pharmacotherapy across the patient care continuum to help ACOs achieve quality benchmarks and financial targets. Various companies and groups have already implemented pharmacists to help achieve organizational goals, and current trends demonstrate that the role of pharmacists is continuing to expand towards further integration.

The last speaker at the program was Mark Shinmoto, PharmD, the director of pharmacy services are HealthCare Partners, an organization that employs pharmacists who are involved in integrated clinical and medical management activities. The organization's vision, he said, is to become the "role model for integrated and coordinated care" by improving outcomes and eliminating waste through 4 strategic initiatives: clinical excellence, patient satisfaction, technological support to clinicians, and growth. Shinmoto pointed out that higher healthcare spending does not equate to better quality, referencing a chart where Louisiana was ranked last for overall quality, despite spending the most healthcare dollars (over $8,000) per beneficiary. Using his organization as an example, Shinmoto noted that current initiatives at HealthCare Partners to achieve the vision of collaborative care include improved patient identification and communication strategies, risk stratification, care management programs, pharmacy support centers, medication reconciliation, and increased generic utilization. He concluded his presentation by stating that the key components to success were robust data systems, an infrastructure that facilitates communication between the stakeholders, and the alignment of incentives. He emphasized that pharmacy is an essential component of total care management, but as the movement is still in its early stages, there are many areas for further improvement and introspection.