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A Model for ACOs

April 4, 2011
by Karen van Wagner and John Gorman
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Applying best practices from an IPA’s Medicare risk business to ACOs

Lately, there has been a great deal of attention paid to Accountable Care Organizations (ACOs). And for good reason: the health care industry’s strides toward adopting the ACO model are being driven by the desire to reduce Medicare costs by improving coordination and continuity of care. Applying the ACO model can help improve the quality of care for a specific population of patients while reducing costs over time. This trend may eventually help push the Centers for Medicare and Medicaid Services (CMS) and its providers a step closer to value-based purchasing of healthcare.

However, achieving ACO status is a large undertaking, and the right organization design must be implemented to ensure success. A good model can be found in independent practice associations (IPAs), and particularly those who manage Medicare risk populations. IPAs offer best practices and lessons learned from their long history of managed care contracting and its affiliation of independent practices, which operate as a virtual network. As healthcare organizations across the U.S. plan their ACOs, examining working models for coordinating care and managing quality—such as the one in place at North Texas Specialty Physicians (NTSP), a 600-physician IPA headquartered in Fort Worth—can reveal critical areas where investments must be made.

NTSP faced challenges managing its at-risk managed care population due to physicians’ reliance on a paper-based claims reporting system for viewing a member’s health history. Recognizing the inefficiencies in this reporting system, NTSP committed to transforming its model of patient care by providing its physicians with electronic health record (EHR) systems connected to a community-wide health information exchange (HIE). This connected system now enables the independent practices of NTSP to share patients’ health information, access evidence-based care guidelines adopted throughout the IPA, and, therefore, proactively manage the care of their patients.

Improving Quality of Care Through an ACO
Health provider organizations working toward ACO status will have challenges similar to those faced by NTSP in the management of its risk-based managed care business. Physicians need a clear picture of the defined patient population they are managing in order to provide the highest-quality of care. They must be able to view a patient’s full medical and treatment history across all settings at the point of care. Physicians must be proactive in how they manage these patients because the risk adjustment process begins even before the patient steps into their office.

However, achieving substantial improvement in health outcomes in the current highly fragmented healthcare system is not a simple task. Even though the federal and state governments are promoting the adoption of EHRs, physicians are often limited to the data in their own EHR system, which is only one piece of the patient’s history.

What physicians need in order to truly transform their model of patient care is the ability to access the patient’s longitudinal health record through an HIE-enabled EHR system. This system architecture enables care providers to see a broader, more complete picture of a patient’s health record. With this type of complete system, physicians can see the discharge reports from a recent hospital stay, which allows them access to critical information at the time and point of care. When a primary care physician is able to view diagnosis and medications prescribed from a patient’s recent visit to their cardiologist, clinical decision making is improved.

Continuity of care also depends on physicians who can share, discuss, and monitor the diagnoses and treatments of their patients across a now interconnected network. This care management model is anchored by close relationships among physicians, who can coordinate care efficiently and achieve quality targets using advanced HIE technologies. To assist its physicians in identifying and treating those patients with gaps in care more quickly and efficiently, NTSP developed a point of care quality application that is driven by the rich clinical content of their HIE. For example, the application highlights specific patients who have failed to have a mammogram at the recommended interval, allowing providers to track adherence to recommended care at the point of care or in an automated fashion prior to the point of care.