Enabling Healthy Decisions

While my other post talked about the IT priorities of the ACO, I believe that a large part of the ACO (Accountable Care Organization) effort driven by CMS is about creating a provider-centric approach to care management. While medicine certainly began as a provider to patient relationship, that has changed over the years to a managed care driven relationship. This peaked years ago with the HMO backlash that led to the revised system that most of us have grown accustomed to operating within.

Then, with the discussions around exchanges, Medicare, and the individual market, we’ve seen a shift to a more patient-centric approach to healthcare focused on the patient experience and understanding their behavior. Is anyone necessarily wrong – no. But, there needs to be a balance. I personally think that the ACO approach is trying to build some of that with a Kaiser type of framework. Physicians would be at the heart of the solution with technology, process, and financial support from managed care companies and medical management companies. And, they would have to partner with the patient to really affect behavior and ultimately health outcomes.

Will it work? Who knows. There have been a lot of smart people who have spent a lot of time and energy trying to figure out health outcomes and cost with limited effect in any scalable way.

There have been a few initial articles about ACO success:

• Norton and Humana pilot
• CalPERS pilot
• Cigna pilots

There have also been a few people talking about ACO 3.0 and the future of how ACOs will evolve from what we know today.

• ACO version 2.0
• ACO Unicorn

Of course, most of this is focused on the CMS ACO model while others are using the “ACO” moniker as a framework for pay-for-performance (P4P) within the physician world.

[To see more about our physician directed Accountable Care Solutions at inVentiv Medical Management, click here. Or contact me if you’re interested in how we’re applying these to support ACO and “ACO-like” organizations in their efforts to engage consumers and drive health outcomes.]

Right now, it’s a little bit of the Wild West in terms of building Accountable Care Solutions (ACS’s)…which is not necessarily bad.

You have physicians building ACOs. You have hospitals building ACOs. You have managed care companies buying physician groups to have ACOs. You have managed care companies providing technology to providers to have ACOs. You have consultants helping design ACOs. You have technology companies building components of ACOs. Eventually, my prediction is that you’ll end up with some type of franchise model on ACOs that providers can leverage. Perhaps it’ll be like the Medicine Shoppe model for pharmacies.

But, as I read through all the literature and try to have opinions on this space, there are a few core things I keep coming back to:

• Leveraging Evidence-Based Medicine (EBM) guidelines
• Consumer engagement and behavior change
• Quality tracking and reporting
• Technology enablement
  • Patient registries to collectively manage similar patients
  • Gaps-in-care identification
  • Risk modeling
• Coordination of data and care across PCP, specialists, hospitals, pharmacy, clinics, and labs
• “Care coordinator” role (probably a blend of human and automation)
• Sharing value and risk

While traditional providers have been focused on actual diagnosis and care, they haven’t focused on most of this. This is a fundamentally different business (at least at the individual physician level). Even the one that most naturally fits with the practice of medicine – Evidence Based Medicine – is a challenge given the pace of change and information. Plenty of studies have documented this challenge.

So, while everyone is now using this term that our team started using last year, the reality is that ACS’s are complex solutions that take a holistic view of the patient and their care and manage using EBM with an integrated solution that blends technology and face-to-face care with a focus on specific health outcomes.

• Aetna on Accountable Care Solutions
• United Healthcare on Accountable Care Solutions
• Insanity Workout Review

To borrow from Ernst & Young, here’s a framework they propose on their website about Accountable Care:

[To see more about our physician directed Accountable Care Solutions at inVentiv Medical Management, click here. Or contact me if you’re interested in how we’re applying these to support ACO and “ACO-like” organizations in their efforts to engage consumers and drive health outcomes.]

The Advisory Board out of Washington DC has jumped headfirst into the pool around ACOs. They have some great information on their website and like any other consultants, provide some great frameworks to leverage.

One that I found helpful lays out the 5 critical IT components for developing an ACO (see image below):

1. Network Interconnectivity (Practice Management System and Electronic Medical Record integrations in my words)
2. Clinical Knowledge Management (Evidence-Based Medicine in my words)
3. Patient Activation (or Engagement)
4. Financial Operations
5. Population Risk Management (or Medical Management or Population Health Management)

I think this is a good starting point for understanding what technology you need to provide an ACO (and theoretically make money doing it).

[To see more about our physician directed Accountable Care Solutions at inVentiv Medical Management, click here. Or contact me if you’re interested in how we’re applying these to support ACO and “ACO-like” organizations in their efforts to engage consumers and drive health outcomes.]