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ACOs: Overcoming the Cultural Challenges

April 15, 2013
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Becoming an accountable care organization (ACO), and transforming your method of delivering healthcare from fee-for-service to pay-for-performance is a long journey. It is the journey of getting your providers to deliver evidence-based medicine. As I found out recently in an interview with two different ACO leaders, it’s one that comes with numerous roadblocks and challenges along the way.

What Tricia Nguyen, M.D., CMO of Banner Health Network (BHN)— an organization offshoot from the Phoenix-based acute-care healthcare system, Banner Health, expressively created to take on ACO development—taught me was that every challenge comes back to the larger cultural implications of this shift. Even the technology challenges she spoke of, getting physicians to implement electronic health record (EHRs) and adopting disease registries, were cultural.

These “IT” challenges are not as easy as you would think. Nguyen told me of the story of one of her top-performing physicians in terms of Medicare Advantage quality measures, who created a number of workarounds and processes, so he could be a meaningful use provider – minus having an EHR. “He refuses to go on an EHR,” she says.

There are other technology challenges, which have larger cultural implications. When you’re dealing with infrastructure at this level, to integrate the diverse claims and clinical data necessary for this transformation, getting providers (clinical) and payers (claims) on the same page is a matter of trust. I recommend checking out this month’s issue of Healthcare Informatics, Assistant Editor Rajiv Leventhal, writes about how historically this relationship has been a lot more contentious.

There is also the money factor. As this study from Health Affairs indicates, achieving the goals of most ACOs (or in the case of that study, CCOs – coordinated care organizations, which are “ACOs on steroids,” according to the author of the report) would likely erode revenue from the traditional model of reimbursement, fee-for-performance, of which most payer and providers organizations rely upon. The authors of the Health Affairs study says, “organizations could incorporate population-management strategies into their work without regard to their effect on fee-for-service revenues,” but that approach would require “exceptional institutional commitment to reform and strong balance sheets.”

As Nguyen says, this shift involves a completely different way of practicing medicine. Even with the numerous niceties an organization like BHN can offer its physicians, such as creating a physician-heavy board of directors, inviting them to participate in open dialogue meetings, and providing incentives and reimbursement opportunities, you’re still going against a historical tide of how things have been done.

It’s not just physicians either, Nguyen talked to me about how getting patients to change their behavior and be more accountable is the other half of the ACO equation. “We’re going to need to have adult conversations around engaging, empowering, and holding our patients and members accountable for their choices and decision making,” Nguyen told me. Again, as BHN has begun to do, you can offer incentives, and teach them about accountable care, but it’s a huge hill to climb.

Editor’s Note: I initially wrote this as a Marathon inspired piece. But in light of the recent tragedyat the Boston Marathon, I decided to change it out of respect for the victims and their families. Our thoughts and prayers are with everyone affected by this senseless tragedy.

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