The ABC`s of ACO`s

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The ABC’s of ACO’s
Cindy Dullea, RN, MBA, BC, CHAM
SrVP Marketing
SCI Solutions
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Agenda
 Accountable Care Organizations
 What, Why, Where, How?
 Care Management
 Want Role Will Access Management have?
 Questions
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What is an Accountable Care Organization?
 An ACO is a network of doctors and hospitals that shares
responsibility for providing care to patients.
 Under the new law, ACOs would agree to manage all of
the health care needs of a minimum of 5,000 Medicare
beneficiaries for at least three years.
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When will ACOs begin operating?
 The ACO initiative is scheduled to launch in January 2012,
but the race to form ACOs has already begun.
 Hospitals, physician practices and insurers across the
country, from New Hampshire to Arizona, are announcing
their plans to form ACOs
 Not only for Medicare beneficiaries but for patients with
private insurance as well.
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Why did Congress include ACOs in the law?
 As lawmakers search for ways to reduce the national deficit, Medicare
is a prime target. With baby boomers entering retirement age, the
costs of the program for elderly and disabled Americans are expected
to soar.
 ACOs would make providers jointly accountable for the health of their
patients, giving them strong incentives to cooperate and save money
by avoiding unnecessary tests and procedures.
 For ACOs to work they’d have to seamlessly share information. Those
that save money while also meeting quality targets would keep a
portion of the savings.
 The Congressional Budget Office estimates that ACOs could save
Medicare at least $4.9 billion through 2019.
 That’s less than one percent of Medicare spending during that period,
but if the program is successful it might be expanded by Health and
Human Services
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How would ACOs be paid?
In Medicare’s traditional fee-for-service payment system, doctors and hospitals
generally are paid more when they give patients more tests and do more
procedures. That drives up costs.
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ACOs wouldn’t do away with fee for service but would create savings
incentives by offering bonuses when providers keep costs down and meet
specific quality benchmarks, focusing on prevention and carefully managing
patients with chronic diseases.
 In other words, providers would get paid more for keeping their patients
healthy and out of the hospital.
 We might see bundled payments (global) for specific “episodes of care.”
If an ACO is not able to save money, it would be stuck with the costs of
investments made to improve care, such as adding new nurse care managers,
but would still get to keep the standard Medicare fees.
The law also gives regulators the ability to devise other payment methods,
which would likely ask ACOs to bear more risk.
 For example, an ACO could be paid a flat fee for each patient it cares for.
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How will an ACO be different for patients?
 Patients may not even know that they are part of an ACO.
 Although doctors will want to refer patients to hospitals
and specialists within the ACO network, patients will still
be free to see doctors of their choice outside the network.
 ACOs also will be under pressure to provide high quality
care because if they don’t meet standards, they won’t
receive savings bonuses – and could lose their contracts.
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Who's in charge —hospitals, doctors or insurers?
Hospitals, doctors and insurers are all vying to run ACOs. This question was left
purposely vague in the law in order to be flexible.
 Some regions of the country, including parts of California, already have large
multi-specialty physician groups that may become an ACO on their own, likely
by networking with neighboring hospitals. This may mean a dusting off of the
existing health care structures they had in place" which we knew as capitation
or PHO’s
 In other regions, large hospital systems are scrambling to buy up physician
practices with the goal of becoming ACOs that directly employ the majority of
their providers.
 Because hospitals usually have access to capital, they may have an
easier time than doctors in financing the initial investment required by an
ACO.
 Some of the largest health insurers in the country, including Humana, United
Healthcare and Cigna, already have announced plans to form their own
ACOs.
 Insurers say they can play an important role in ACOs because they track
and collect data on patients, which is critical for coordinating care and
reporting on the results.
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Lots of Different Approaches
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If patients don't like HMOs, why consider an ACO?
 ACOs may sound a lot like health maintenance
organizations. Some consider an ACOs to be an HMOs
(or a PHO) in drag.
 But there are some critical differences – notably, an ACO
patient is not required to stay in the network.
 ACOs aim to replicate "the performance of an HMO" in
holding down the cost of care while avoiding "the structural
features that give the HMO control over [patient] referral
patterns," which limited patient options and created a
consumer backlash in the 1990s.
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What can go wrong?
 History has shown that the health industry tends to operate with "kind
of a herd behavior," rushing to implement an idea "without working
through the detailed business questions of how they'll work.
 ACOs could become the three-letter health acronym of the year, if
not the decade just like PHOs were in the 90s.
 Many health care economists fear that the race to form ACOs could
have a significant downside: hospital mergers and provider
consolidation.
 As hospitals position themselves to become integrated systems, many
are joining forces and purchasing physician practices, leaving fewer
independent hospitals and doctors.
 Greater market share gives these health systems more leverage in
negotiations with insurers, which can drive up health costs.
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Are there any possible legal concerns?
 Doctors, hospitals and others in the health care industry
have raised concerns that ACOs could run afoul of
antitrust and anti-fraud laws, which try to limit market
power that drives up prices and stifles competition.
 One concern is that ACOs, particularly those in rural
markets, could grow so large that they would employ the
majority of providers in a region. In other words – they are
the only game in town.
 To help providers avoid legal problems, the Federal Trade
Commission says it is trying to clarify antitrust guidelines
for ACOs, and the U.S. Justice Department's antitrust
division has offered to provide an expedited antitrust
review process for ACOs.
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Understanding the Four – C’s
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Complexity
Coordinate
Collective
Community – Based Care
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Complexity
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Health care systems growing
More IT … more data…more data sources
Aging population with chronic diseases
Genomics and phenomics in relation to clinical care
Greater number of healthcare providers involved in care
management
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Coordinate
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Communication
Information sharing
Care team workflow
IT infrastructure supporting connectivity
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Collective
 Reimbursement tied to care delivery
 Focused on wellness and supports the aging with “Care
Anywhere”
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Community Based Care
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Medical Device and mobile technology
Shift from volume driven to value driven
Health Management Tools
Primary Care is integral – this could be an issue given
there are not enough. Also the law says the PCP can
belong to only one ACO, but specialists can belong to
many
 Increase in Medical Home Programs may occur
 Strong Case Management needed.
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Payment for Care
 ACOs will need to comply with a kitchen sink of 65 clinical
measures that are meant to produce efficiencies
 reducing infections or ensuring that patients take their
medications after hospital discharge.
 If care at an ACO costs less than Medicare predicts it will
cost under the status quo, then the ACO will receive a
share of the savings as a bonus payment.
 The rule also includes financial penalties if an ACO misses
its targets.
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The Role of Patient Access
 Patient Access will play a pivotal role in the support of
care coordination.
 Patient Access must develop new skills and creative
approaches for providing clinical services while managing
front-end revenue cycle processes
 Most importantly, the front-door patient experience.
 But First – know your customer!
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Veteran’s
 Born prior to 1945 (Age 63+)
 Core Values
 Advanced education a dream
 Silent and Traditional
 Respect Authority
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Communication With The Veteran
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May be Technology Phobic – or NOT!
May write a memo before calling – very paper oriented
Not afraid of challenges
Do better in smaller one on one conversations
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Baby Boomers
 Born between 1946 and 1964 (Age 45 to 63)
 Core Values
 Strong commitments
 First Baby Boomer reached Medicare eligible this year
 A record 2.8 million will qualify in 2011, rising to 4.2 million a
year by 2030
 Communication diverse
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Communication With The Baby Boomer
 Unpredictable
 You’ll need to relate to their generation
 They look for products and services that speak to deeper
values. They expect customer service
 Communication aimed at their self image – how they view
their health.
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How can Access Management play in an ACO
environment?
 Ease of Obtaining Care
 Build your Physician Community
 Make the process of orders for services easy
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Orders to the hospitals in the ACO
Orders from PCP to Specialty Care
Orders from Case Management for Discharge Planning
Medical Necessity
ED Deployment – to gatekeep care in the network
EMR Integration to your owned/community MD’s
Order and Medication reconciliation
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How can Access Management play in an ACO
environment?
 Enterprise Wide scheduling
 Intelligent scheduling/multi location functionality
 Tight integration to Registration
 Worklist and Front End Revenue functionality
(authorizations, medical necessity)
 Inpatient Transfer Center
 Reminders (support of predictive and preventative care)
 Order Compliance
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How can Access Management play in an ACO
environment?
 Self-Service Modules
 Patient- Facing Technologies
 Portals for online appointment scheduling
 Reduction of administrative costs through self service
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Bottom Line
“Self-service is a clear and present trend in many other
industries and will be embraced more enthusiastically by
the Healthcare Delivery Organizations during 2011. As
time goes on, patients will view patient self-service as a
market differentiator. There is a real need to improve the
patient experience, to better coordinate care, to become
more operationally efficient and to improve the quality of
patient information. As part of the IT infrastructure
underlying the Real Time Healthcare System, patient selfservice (kiosks) offer a way of contributing to these goals.”
Source: Gartner Group – “Three Good Reasons for Deploying Patient Self-Service Kiosks” © 2011
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Healthcare Needs Self-Service
Every Other Major Industry
Has Adopted Self-Service Options
ATM / Cash Machines
Online Travel Websites
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Pay-at-the-Pump
Self Check-out Registers
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Lets Improve Our Service
 Even better, let’s have all major transactions be Self
Service:
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Physician offices self order and self schedule
Patient self-register and self schedule
Improve customer satisfaction
Baby Boomers will expect this!
Portals and Kiosks
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The Menu of Access Options is the Key
Menu of Access Options
for Referring Physician Offices
If your office is connected to the Internet:
Pick one or more; change your mind anytime
Send e-Order via EMR/Web
(hospital will call patient to schedule)
Menu of Access Options
for Patients/Consumers
Scheduling Options
Self-schedule appointment
Self-schedule appointment
Call centralized scheduling
(with e-Order sent in same flow)
Receive call from hospital
If you prefer the personal touch:
Call centralized scheduling
(you can fax or send the order later)
If you really want simple, low-tech:
Fax your order to hospital
(hospital will call patient to schedule)
(based on hospital getting order)
Pre-Registration (to save time when you arrive)
Pre-Register online
Receive call from hospital
(can be scheduled for convenience)
Arrival Options
Regardless of how you refer patients to the
hospital, you or your staff can check the status
of the appt/order online at any time, from
anywhere you can get to the Internet
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Quick Check-In with Staff
Check-In at Kiosk
Questions
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