ACO Coalition Web Session: Despite Need, Challenges Confront Value-Based Healthcare

PLAINSBORO, N.J. — Converting to a healthcare system that rewards value will be challenging and require strong leadership, according to those who addressed the ACO and Emerging Healthcare Delivery Coalition during a recent Web-based meeting.

The Affordable Care Act created accountable care organizations, or ACOs, which seek the so-called “triple aim” of improved health for populations, better patient experiences, and lower cost of care. The ACO Coalition, organized by The American Journal of Managed Care, now includes 70 stakeholders from across the healthcare spectrum: payers, providers, accountable care organizations, integrated delivery networks, pharmaceutical manufacturers, and specialty and retail pharmacy representatives. Coalition members are engaged in transitioning from a fee-for-service reimbursement model to one that rewards value.

ACO Coalition presenters said making this transition may be difficult because a key stakeholder group, the employer, may not be ready to embrace the value-based model. Presenter Leonard Fromer, MD, executive medical director, Group Practice Forum, and assistant clinical professor, Department of Family Medicine, University of California at Los Angeles, shared results from a two-year effort with the National Business Group on Health. Dr. Fromer’s research group engaged human resources executives from 10 large self-insured employers on accountable care issues. All were intrigued by the concepts of value-based care, but at the end of the project only one approached its third-party administrator about a reimbursement model that rewarded providers based on value.

“Real change is very painful,” Dr. Fromer said. “There are derailers and obstacles and challenges everywhere you look.”

Despite the awareness that the fee-for-service model rewards volume instead of value, he said, when value-based care is implemented, “we bang head-on into the reasons why we have this chicken-and-egg conundrum for a lot of providers,” he said. Right now, providers are investing a lot of money into systems to provide value-based care, such as electronic health records, and many have not yet seen “the tipping point” at which those investments are paying for themselves.

In response to a question, Dr. Fromer said it’s critical that employers harness their power to change the status quo. In his discussions with the large employers, many did not recognize that as self-insured entities, they had the power to force change if they chose to use it. Providers, Dr. Fromer said, have to carry the value message to employers. “That is what has worked the most,” he said.

ACO Coalition Co-Chair Anthony Slonim, MD, CEO of Renown Health, agreed that no single actor in the healthcare system would bring change. “Changing a belief system is a real tricky task. We need leadership at all levels.”

Even ACOs that are performing well in healthcare delivery can still fall short on shared savings, as Summit Medical Group learned. Kimberley Kauffman, vice president for Value-Based Care, outlined how the ACO uses a series of tools to track high-risk patients after discharge from the hospital to avoid readmissions, which is one of the criteria Medicare now tracks closely.

Using a metric that Summit calls “LACED,” for length of stay, acuity, comorbidity, history of ER use, and drugs prescribed, the ACO particularly targets patients on multiple medications or blood thinners and ensures follow-up within two business days of discharge to schedule visits with a primary care physician a week to two weeks after leaving the hospital.

Summit has made use of disease registries to closely track high-risk patients with congestive heart failure or chronic obstructive pulmonary disorder. Care navigators cull lists first, then hand off patients who need to be checked to care coordinators, who get a list of 10 patients and have two weeks to check on them. This sentence is confusing, maybe: Care navigators cull lists first, then provide care coordinators with a list of 10 patients who need to checked. Follow-ups for these patients are then completed within two weeks. Summit has also had success in lowering glycated hemoglobin (A1C) rates for its highest-risk diabetes patients, and produced a total weight loss of 167 pounds among a group of 17 patients in a healthy lifestyles initiative.

A “scorecard” used to evaluate individual practices was popular among the Web session participants, and Kauffman said it is well-received among the ACO practice groups, too.

Presenter Brian Powers, MA, of Harvard Medical School, discussed a paper he recently co-authored for The American Journal of Accountable Care, which reviewed recent studies on new ways by which patients should select a specialist. Conventional methods, such as asking friends or a primary care physician, may fail to address five key criteria that help patients determine if the physician’s values and practice methods align with their own.

Powers said those criteria are: communication and decision-making, therapeutic approach, social and cultural awareness, cost and value, and practice environment.

Dr. Slonim asked if the ACO model limits the patient’s ability to choose a physician who aligns with his or her values and practice preferences. Powers said that while narrow networks could present some challenges, the focus of ACOs on “linking patients to physicians” could make the model better than it might appear in value alignment.

The next Web-based session of the ACO Coalition will be August 18, 2014, and the next live meeting will be October 16-17, 2014, in Miami, Florida.

About the Coalition

As ACOs and other emerging delivery and payment models evolve and move away from traditional fee-for-service system models toward cost-effective and value-based care, the need to understand how these models will evolve is critical to building long-term strategic solutions. The mission of the Coalition is to bring together a diverse group of key stakeholders, including ACO providers and leaders, payers, IDNs, specialty pharmacy, and pharmaceutical manufacturers to work collaboratively to build value and improve the quality and overall outcomes of patient care. Coalition members share ideas and best practices through live meetings, Web-based interactive sessions and conference calls. Distinguishing features are the Coalition’s access to leading experts and its small workshops that allow creative problem-solving. To learn more, click here.