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Payer Action in the ACO Market: Part 2

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Claims based data is flowing, but when will clinical data be the norm?

In a look at what payers are doing to shake up the ACO market, I blogged on Friday about how Cigna was collaborating with its medical group partners to reduce unnecessary medical costs. In this blog I want to point out some other recent acquisitions in the space that might be setting the stage for more to come, as well as share some interesting perspectives from those watching this space carefully.

A big piece of the Cigna ACO that I reported on Friday was to employ a new nursing position, the embedded care coordinator, to close healthcare gaps. The care coordinator makes transition of care calls to reduce readmissions, identifies chronic disease patients to engage to reduce hospital admissions, and perform monthly gaps in care analysis and reach out to those patients.

I’m curious about the future of this care coordinator position. As I reported earlier this year, Gary Austin, principal and co-founder, TranzformHealth (a Las Vegas-based healthcare consultancy), predicted in his article “ACOs: A Call to Arms for Payers?” that by 2014 most payers will be shedding “care management operations” within their walls as a core competency, and paying a kicker to their provider network to assume that responsibility. “Operationally, that may play out as the delivery entity hiring its own care management personnel, or the payer placing payer personnel directly into the delivery entity,” he wrote. “Real-time analytics will make this service far more valuable at the point of care rather than as an afterthought.”

It makes more sense for care management operations to be housed within the walls of the provider network, whose job it is to care for patients, rather than be employed by payers where conflicts of interest could arise.

Jeffrey Rose, M.D., vice president of clinical excellence of informatics at Ascension Health,  who was participant on the “ACOs: Policy, Strategic, and IT Issues” panel at the HCI Executive Summit, said he was dubious about the role of payers in accountable care development, and said they present a “cognitive dissonance” in their focus to pay doctors faster for their efforts to save money and reduce unnecessary testing. The focus, Rose said, should be on managing the health of the population and preventing readmissions, in addition to reducing unnecessary testing. “The payers are never going to be able to intervene at the point-of-care with good clinical data to help you do the right thing as a provider, based on the population you’re taking care of,” he said.

Austin mentioned some recent acquisitions that pointed to the growth of ACOs. One was DaVita, an operator of kidney dialysis clinics throughout the United States, which Austin said that in order to keep from being marginalized, agreed to buy HealthCare Partners that has huge ACO presence in three states for $4.4 billion. Another acquisition in the space was Wellpoint acquiring 1800 Contacts, a consumer brand, to likely expand that into eye insurance and health insurance as a delivery platform, Austin said. In the next few years Austin predicted that we’d see more of these types of transitions to expand into ACO world.

Also, the Center for Medicare & Medicaid Innovation (CMMI) announced on June 7 memorandums of understanding with six payers—Aetna, Capital District Physicians' Health Plan, Empire Blue Cross, Hudson Health Plan, MVP Health Care, Teamsters Multi-Employer Taft Hartley Funds—in the Capital District-Hudson Valley Region. The CPC initiative, or CPCi, is an effort to align payers—public and private—to reimburse medical practices for comprehensive primary care. Nationally, 45 commercial, federal and state insurers in seven markets have agreed to participate.

“I think the one thing that seems pretty constant out there is the folks that think they’re going to sit this one out are probably destined to lose,” said Austin. Austin recommended for payers to be proactive in approaching delivery partners to “play in the ACO sandbox,” and when the organizations are culturally ready to engage, the conversation can be continued. He also suggested participants spread ACO health IT costs across all the players, including all payers. You need to invest in health IT on behalf of your delivery partners for everyone to be successful, he added.