Hospitalist Value in an ACO World

More than half of ACOs include a hospital.⁸ However, whether hospital-led ACOs possess an advantage remains to be elucidated. Early reports indicated that physician-led ACOs saved more money.^9,10 However, others argue that hospitals¹¹ are better capitalized, have greater capacity for data sharing, and possess economies of scale that allow them to invest in more advanced technology, such as predictive modeling and/or simulation software. Such analytics can identify high-cost patients (ie, multiple comorbidities), super utilizers and populations lacking care, allowing ACOs to implement preventive measures to reduce unnecessary utilization. Recently released CMS MSSP 2016 performance data¹² showed that nearly half (45%) of physician-only ACOs earned shared savings, whereas 23% of ACOs that include hospitals earned shared savings. However, among all the ACOs that achieved savings, ACO entities that include hospitals generated the highest amount of shared savings (eg, Advocate, Hackensack Alliance, Cleveland Clinic, and AMITA Health). Notably, hospital-led ACOs tend to have much larger beneficiary populations than physician-led ACOs, which may create a scenario of higher risk but higher potential reward.

The emphasis on value over volume inherent in the development of ACOs occurs through employing care strategies implemented through changes in policies, and eventual structural and cultural changes. These changes require participating organizations to possess certain key competencies, including the following: 1) leadership that facilitates change; 2) organizational culture of teamwork; 3) collaborative relationships among providers; 4) information technology infrastructure for population management and care coordination; 5) infrastructure for monitoring, managing, and reporting quality; 6) ability to manage financial risk; 7) ability to receive and distribute payments or savings; and 8) resources for patient education and support.^2,3,13-16 Table 1 summarizes the broad range of roles that hospitalists can serve in delivering care to ACO populations.^17-19

Hospitalists’ active pursuit of nonclinical training and selection for administrative positions demonstrate their proclivity to provide these competencies. In addition to full-time clinician hospitalists, who can directly influence the delivery of high-value care to patients, hospitalists serve many other roles in hospitals and each can contribute differently based on their specialized expertise. Examples include the success of the Society of Hospital Medicine’s Leadership Academy; the acknowledged expertise of hospitalists in quality improvement (QI), informatics, teamwork, patient experience, care coordination and utilization; and advancement of hospitalists to senior leadership positions (eg, CQO, CMO, CEO). Given that nearly a third of healthcare expenditures are for hospital care,²⁰ hospitalists are in a unique position to foster ACO competencies while impacting the quality of care episodes associated with an index hospital stay.

Importantly, hospitalists cannot act as gatekeepers to restrict care. Managed care organizations and health maintenance organizations use of this approach in the 1990s to limit access to services in order to reduce costs led to unacceptable outcomes and numerous malpractice lawsuits. ACOs should aspire to deliver the most cost-effective high-quality care, and their performance should be monitored to ensure that they provide recommended services and timely access. The Medicare ACO contract holds the provider accountable for meeting 34 different quality measures (Supplemental Table 1), and hospitalists can influence outcomes for the majority. Especially through hospital and health system QI initiatives, hospitalists can directly impact and share accountability for measures ranging from care coordination to implementation of evidence-based care (eg, ACE inhibitors and beta blockers for heart failure) to patient and family caregiver experience.

Aligned with Medicare ACO quality measures, 5 high-impact target areas were identified for ACOs²¹: (1) Prevention and wellness; (2) Chronic conditions/care management; (3) Reduced hospitalizations; (4) Care transitions across the fragmented system; and (5) Multispecialty care coordination of complex patients. One essential element of a successful ACO is the ability to implement evidence-based medical guidelines and/or practices across the continuum of care for selected targeted initiatives. Optimizing care coordination/continuum requires team-based care, and hospitalists already routinely collaborate with nurses, social workers, case managers, pharmacists, and other stakeholders such as dieticians and physical therapists on inpatient care. Hospitalists are also experienced in facilitating communication and improving integration and coordination efficiencies among primary care providers and specialists, and between hospital care and post-acute care, as they coordinate post-hospital care and follow-up. This provides an opportunity to lead health system care coordination efforts, especially for complex and/or high-risk patients.^22,23 CMS MSSP 2016 performance data¹² showed that ACOs achieving shared savings had a decline in inpatient expenditures and utilization across several facility types (hospital, SNF, rehabilitation, long term). Postacute care management is critical to earning shared savings; SNF and Home Health expenditures fell by 18.3% and 9.7%, respectively, on average. We believe that hospitalists can have more influence over these cost areas by influencing treatment of hospitalized patients in a timely manner, discharge coordination, and selection of appropriate disposition locations. Hospitalists also play an integral role in ensuring the hospital performs well on quality metrics, including 30-day readmissions, hospital acquired conditions, and patient satisfaction. Examples below document the effectiveness of hospitalists in this new ACO era.