Foundations for a Successful
Patient-Centered ACO:
First Steps
Frank E. Belsito, DO, MMM
and
James J. Dearing, DO, FAAFP, FACOFP
Evolving Healthcare
Moving from a
“Sick Care” system
to a
“Health Care”
system
A Time for Change
• Health care is being
delivered in a fragmented
process
• Lack of communication
• Lack of coordination
Payor Paradigm
System paid by what we do, not
the outcome of what we did
Transformation from
Fee-for-Service to
Value-Based Payment:
The Integrated
Delivery System Perspective
Value-Based Strategy
Physician Alignment
Delivering Value
Demonstrating Value
Value-Based Contracting
Accountable Care Organization
Anatomy refers to the
Structure of the ACO
ACO is not itself an entity, but rather it
is a contractual relationship dealing with
delivery and financial strategies and
tactics between an Organized Delivery
System and CMS-Medicare. It is also used
to expand the relationship to other
payors such as BCBS, etc.
We must first construct the ACO
structure, creating the anatomy of the
delivery system.
Creating an ACO and the payment systems to
support them may well have the greatest
potential for improving quality and
controlling costs.
There is no single formula
for a successful ACO…..
so different approaches are encouraged
Integrating Hospitals and
Medical Groups
Hospitals & PO
+
Operate in a manner of a
multispecialty group practice
Governance Structure:
All Parties at the Table
Assure that all parties are at the
table from the beginning:
• Hospital Administration
• Physicians engaged in the ACO
development
• Others?
Physician Buy In
• Be sure that all physicians understand
what you are trying to accomplish,
primary care first and then specialists.
• Primary Care Physicians (PCPs) will
use the patient centered medical
home model.
(Physicians must understand and
identify with how the ACO will help
their patients, accountability for care
of the patient population.)
Patient Centered Medical
Home (PCMH)
Seven Principles
1. Personal physician for each patient
2. Physician directed medical practice
3. Whole person orientation
4. Care is coordinated and/or integrated
5. Quality and safety is ensured
6. Enhanced access to care
7. Payment reflects the value of care
Patient Centered Medical
Neighborhood (PCMN)
• Explain the differences between a
PCMH and a PCMN. . .
(Integration of specialist,
hospital, home care teams,
visiting nurses, and all other
entities that go into managing
the assigned patient population.)
Recruitment of Physicians:
the Best and the Brightest
• You need to recruit physicians
whose quality parameters and
patient satisfaction scores are
high. Your ACO quality stats will
be reviewed by employers,
patients, and payors.
Recruitment of Physicians:
Cultural Fit
• It is critical to recruit physicians not just for
their quality of care parameters but also for
their ability to fit the specific culture of the
ACO and the goals that you are trying to
reach.
– Make the group better by coming up with
ideas from a potentially different angle.
• The challenge is selling individualists on
thinking as a team member and making
decisions based on the “whole”.
Success will depend on:
1) Complete and timely information about
patients and the services they are
receiving
2) Technology and skills for population
management and coordination of care
3) Culture of teamwork among staff
4) Coordinated relationships with
Specialists
5) Ability to measure and report on the
quality of care
Implementation of an
Electronic Medical Record
• All facilities need to be able to
share patients’ medical records.
Develop Accountability of the
Group and Assign a Leader
The leader should have great
quality parameters but will have to
accept accountability for the team,
not just his/her own stats.
Use Dashboards for
Accountability
• Every physician has a dashboard. Give them
meaningful data: patient reports,
productivity reports, and physician reports.
• The brightest and the smartest will use that
information to push your group in the right
direction and make your ACO the most
successful organization it can be.
• There are a number of vendors to provide
data.
Care Coordination
Case Management Coordinator
Disease Registry
PCMH
Health Coaches
Wellness Program
Care Transition Coordinator
Infrastructure Issues:
Integrated Care
• Coordination of both primary
care and specialist doctors
around the patient population
(PCMH and Chronic Care Model)
• List all patients in a registry by
disease state and by all payors.
Infrastructure Issues (cont’d)
• Integrate patient registry with an
electronic health record for both
primary care and specialty
facilities to enable exchange of
info on patient real time.
• Care managers embedded into
practice sites to help manage
chronic diseases/patients/issues
in real time.
Infrastructure Issues (Cont’d)
• Discharged hospital patients are
seen by within 24-48 hours of
discharge by their Primary Care
Physician.
Payment Systems
• In an ACO fee-for-service does
not work. Under the Value-based
strategy you have to deliver
quality. There is a transition
timeframe involved in switching.
The question is how do you
weather the transition?
Payment Systems (cont’d)
• Create a payment system that
incentivizes team activities. All
players should work to the
highest level of their degree.
• Put the work at the least
common denominator degree.
• Provide daily dashboards with the
most information possible.
Clinical Integration is the
Core Initiative
Hospitals and Physician are
turning to Clinical Integration to
increase QUALITY and
EFFICIENCY in care delivery.
Transforming care to
significantly improve outcomes
and resource utilization is
MORE difficult than achieving
“clinical integration”!
Negotiating with Payers
• Don’t try to cut deals with payers
until you have your act and data
ready for the negotiation.
• Don’t just accept the payer’s data
unless you can compare to your
real data.
• Questions/Comments?