Accountable care organizations, the patient-centered medical home, and health care reform: What does it all mean?
ABSTRACTMedical care in the United States is plagued by extremely high costs, poor quality, and fragmented delivery. In response, new concepts of integrated health care delivery have developed, including patient-centered medical homes and accountable care organizations (ACOs). This article reviews these concepts and includes a detailed discussion of the Centers for Medicare and Medicaid Services’ ACO and Shared Savings Proposed Rule.
KEY POINTS
- Compared with other developed countries, health care in the United States is among the costliest and has poor quality measures.
- The patient-centered medical home is an increasingly popular model that emphasizes continuous coordinated patient care. It has been shown to lower costs while improving health care outcomes.
- Patient-centered medical homes are at the heart of ACOs, which establish a team approach to health care delivery systems that includes doctors and hospitals.
- Applications are now being accepted for participation in the Centers for Medicare and Medicaid Services’ ACO Proposed Rule. The 3-year minimum contract specifies numerous details regarding structure, governance, and management, and may or may not involve risk—as well as savings—according to the plan chosen.
PREDICTING ACO READINESS
I believe there are five core competencies that are required to be an ACO:
- Operational excellence in care delivery
- Ability to deliver care across the continuum
- Cultural alignment among participating organizations
- Technical and informatics support to manage individual and population data
- Physician alignment around the concept of the ACO.
Certain strategies will increase the chances of success of an ACO:
Reduce emergency department usage and hospitalization. Cost-savings in patient-centered medical homes have been greatest by reducing hospitalizations, rehospitalizations, and emergency department visits.
Develop a high-quality, efficient primary care network. Have enough of a share in the primary care physician network to deliver effective primary care. Make sure there is good access to care and effective communication between patients and the primary care network. Deliver comprehensive services and have good care coordination. Aggressively manage communication, care coordination, and “hand-offs” across the care continuum and with specialists.
Create an effective patient-centered medical home. The current reimbursement climate fails to incentivize all of the necessary elements, which ultimately need to include chronic-care coordinators for medically complex patients, pharmacy support for patient medication management, adequate support staff to optimize efficiency, and a culture of wellness and necessary resources to support wellness.
PHYSICIANS NEED TO DRIVE SOLUTIONS
Soaring health care costs in the United States, poor quality outcomes, and increasing fragmentation of care are the major drivers of health care reform. The Patient Centered Medical Home is a key component to the solution and has already been shown to improve outcomes and lower costs. Further refinement of this concept and implementation should be priorities for primary care physicians and health care organizations.
The ACO concept attempts to further improve quality and lower costs. The proposed ACO rule released by the Centers for Medicare and Medicaid Services on March 31, 2011, has generated significant controversy in the health care community. In its current form, few health care systems are likely to participate. A revised rule is awaited in the coming months. In the meantime, the Centers for Medicare and Medicaid Services has released a request for application for a Pioneer ACO model, which offers up to 30 organizations the opportunity to participate in an ACO pilot that allows for prospective patient assignment and greater shared savings.
Whether ACOs as proposed achieve widespread implementation remains to be seen. However, the current system of health care delivery in this country is broken. Physicians and health care systems need to drive solutions to the challenges we face about quality, cost, access, care coordination, and outcomes.
