Looking at the title of this post, you are probably asking yourself what this 1970 Jack Nicholson film could possibly have to do with healthcare. The answer, simply put, is nothing – but it is a great film, and since I’m going to write about five questions that physicians must keep in mind about Accountable Care Organizations (ACOs) to help them prepare for what’s coming (or already here), I am going to borrow the movie’s simple and perfectly descriptive title.
So, without further ado, The Top 5 Things Physicians Need to Keep in Mind About ACO's:
- How much does it cost?
- Where is all the data?
- How do we all stay connected?
- Is there really evidence that this will work?
- How do we keep patients out of the hospital?
I can say with certainty from my own experience that doctors aren’t taught very much (that’s zip, zero, zilch, etc.) about finance or economics during medical school, their internship, or their residency. What we are taught is to take the best possible care of each and every patient regardless of what a test or procedure costs. But just because doctors might not be focused on cost, doesn’t mean that anyone else isn’t.
The ACO model was created to give a better understanding of what high quality and high value healthcare should look like, and to make sure that it is delivered to the patients in the most cost-effective way. In the ACO model, physicians aren’t forced to be “gatekeepers” as they were in old HMOs. But they do remain a key component of the process, whereby patients are better monitored to keep them healthier in the first place, and their chronic diseases are managed as soon as they are identified to minimize the extent and progression of the illness where possible. Ergo, costs go down while quality and value go up.
The first step in decreasing cost and improving quality measures is having a better understanding about what’s going on with your patients. The more data available to the provider, the more engaged he or she can be with the patient throughout the process. This includes diagnostic data from the laboratory or radiology department, scheduling data, outcomes data, etc.
If an ACO is going to be successful, it needs to have as complete a picture of the patient’s healthcare journey as possible. For example, knowing when and why a patient goes outside the health system network for care, creating a gap in the care continuum, is a crucial piece of data. In addition, even transitions from location to location within the health system offer multiple opportunities for “dropping the ball”. Furthermore, patients that are confused about their medication or discharge instructions, or are lost to follow-up, will negatively impact the ACO’s success. Providing the right information to the right person in the right place at the right time is critical to delivering high quality care.
One of the key ways that ACOs will flourish in the new world order will be by ensuring that everyone on the provider team contributes to the process. Schedulers, lab techs, nurses, doctors, physical therapists, etc., all need to have access to the information about each patient throughout the process, keeping the whole team engaged in ways that contribute to better outcomes for the patient. Nothing can “slip through the cracks”, and patients can’t be “lost to follow-up” if the ACO is going to be truly “accountable” for the care of its patients.
In the final rules for ACOs, CMS clearly states that “procedures and processes to promote evidence-based medicine, beneficiary engagement and coordination of care” should be in place. These guidelines are developed for physicians to follow so that unsuccessful or unnecessary clinical variation can be eliminated. As outcomes data is accumulated from patients who have been treated by particular clinical pathways or guidelines, future patients will benefit from this experience. This is exactly what evidence-based medicine is all about.
Patients and doctors share some of the responsibility for the high number of avoidable emergency room (ER) visits each year that put a strain on a hospital’s resources. From the patient perspective, it is often difficult to get in to see a physician on short notice, so the ER seems like the best option. Doctors, on the other hand, are often unable or unwilling to see patients on the same day so their only recourse is to send the patient to the ER instead.
If providers want this tedious pattern to change, basic adjustments need to be made. For example, hospitals and physicians need to embrace technologies that will help them better engage and understand their patients before they are even admitted to the hospital. In addition, they will need to communicate with them often, and in greater detail, with the goal of keeping them well. This will sometimes even necessitate offering them same-day office visits, which is becoming a much more common practice.
These are just a few basic questions physicians need to be aware of to succeed in the age of ACOs. As I’ve suggested above, what’s truly needed is better communication and cooperation between all parties – hospitals, doctors, and yes, even patients and their families. There may not be an “Easy Button” to make it work magically from day one, but if healthcare follows even some of the strategies found in the playbooks of other industry giants, patient satisfaction, quality and value are bound to improve while costs go down.