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The Soft Underbelly of ACO Development: PCP Office Processes?

November 21, 2015
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A recent AMCJ article points out some of the operational challenges ACO leaders face around PCP participation

It was very engaging to read a recent blog posted in the American Managed Care Journal online. The Nov. 14 article, written by the publication’s assistant managing editor, Laura Joszt, and entitled, “Using the MSSP Model to Become Involved in Alternative Payments,” covered some relatively familiar ground, but also underscored how many gaps primary care physicians have, as they start down the path of accountable care.

Joszt was reporting on a recent conference session.  As she wrote, “The Medicare Shared Savings Program (MSSP) is providing a way for physicians to get involved in alternative payments as Medicare moves to replace fee-for-service, explained Hymin Zucker, M.D., chief medical officer of the Triple Aim Development Group.   The move away from fee-for-service means physicians will now have to move from ‘providing the minimal amount of service’ to more comprehensive care, Dr. Zucker said during his session at the Fall Managed Care Forum presented by the NAMCP Medical Directors Institute, the American Association of Integrated Healthcare Delivery Systems, and the American Association of Managed Care Nurses and held in Las Vegas, Nevada.”

As Joszt reported, “Dr Zucker shared lessons learned from being hired to go into accountable care organizations (ACOs) that aren’t making money to determine if they should continue and how they can make money moving forward.   Unfortunately, the transition to value-based care doesn’t work well if the physicians aren’t on board. However, the benefit of the MSSP is based on improvement over previous performance.   ‘There is no better way to get into an alternative payment model for a primary care doctor than to join into the MSSP, specifically in an accountable care organization,’ Dr Zucker said. ‘However, the message is very difficult to deliver.’”

Joszt further quoted Dr. Zucker as saying, “The truth really is, once you understand fee-for-service is dead, and you want to know, you have a little bit of leeway to learn this [new model of care] and a good student can learn this.” He noted that there are several key areas that primary care physicians must address, in order to begin to be successful in an ACO environment. Specifically, he cited beneficiary retention, patient access, workflow/office operations, quality/outcomes, cost and utilization management, and patient experience/engagement.

And guess what? Every single one of those elements is an area of endeavor that involves intensive process and IT work to optimize. For example, as Joszt wrote, describing Dr. Zucker’s presentation, “Looking at emergency room (ER) data afterwards, the physicians who weren’t open on Friday and didn’t answer the phone at night had much higher ER visits, he added. All it takes is making a change, but physicians continuously do the same thing even though it’s not working.”

And these are exactly the kinds of problems that integrated health systems face as they guide their affiliated physicians into accountable care organization work. For example, referencing the survey Dr. Zucker had conducted prior to his presentation, Joszt reports, “As part of the survey, he gauges existing ACO practice patterns and has found that 40 percent of PCPs didn’t know what an ACO was and the same proportion had answering machines directing patients to the ER if there was an emergency. Furthermore, 60 percent of PCPs only worked four days a week. Afterwards, 40 percent of PCPs had increased their same-day appointments and worked five days a week, and 45 percent had improved their current on-call process so that a PCP answered the phone during non-office hours. The result was decreased ER visits, increased patient retention, and increased quality metrics.”

So this really is a big part of the soft underbelly of many attempted forays into accountable care. If primary care physicians and small physician groups agree to participate in an ACO, but the primary care physicians work only four days a week, and do not connect their patients to urgent care and other forms of access, and furthermore, lack the information systems and analytics to track and analyze patient access patterns, they are clearly heading for trouble.

And while it is always difficult to approach the complexities of setting up comprehensive accountable care-based care delivery, and while it is also true that some of these problems appear at first to be “chicken or egg” issues—how can one set up communications systems around processes that have not yet been established, for example?—the time is prior to even formally signing a contract, for the leaders of nascent ACOs, to line all these things up. And healthcare IT leaders will absolutely need to be involved in all these planning and implementational processes, as well as the analytics processes to track how the care delivery changes and processes are working.

Yes, all of this is challenging and difficult; but launching an ACO without all these systems in place, including very importantly, all the IT, communications, and analytics systems and processes, in place—can only be a recipe for contracting disaster down the road.






US healh care system is pretty good. Of course there are some flaws but nothing is perfect. And if it were to be compared to other countries' health care systems they wouldn't stand a chance.