Accountable Care



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Accountable Care Organizations The health reform law of 2010 aims to improve the health of the population and the quality of health care delivery while reducing costs. In addition to expanding coverage to 32 million previously uninsured Americans. One tool to pursue these goals is the creation of a national voluntary program for accountable care organizations. (ACOs) (allhealth. org). Healthcare today is fragmented; ACOs would bring it all together the different components parts of care for the patient such as primary care specialist, hospitals, home health care, etc. nd make sure that all the parts work together. Accountable Care Organizations (ACOs) are networks of physicians and other providers that could work together to improve the quality of health care services and reduce costs for a defined patient population. It is estimated that Medicare will save $940 million in the first four years alone. Today most public programs and private insurance plans pay for health care on a fee for service basis. This means that doctors, hospitals, and other providers are paid for each service they furnish to a patient.

Critics of this system contend that it creates incentives for providers to furnish or order more services. Different providers who see the same patient often fail to coordinate their activities, leading to duplicate or conflicting treatments. (Healthaffairs. org) The ACO focuses on clinical integration of a network of providers, with incentives for providing care with a focus on quality while reducing overall utilization. In order for the ACO to be successful a number of core competencies must be addressed. These include: * Developing Physician Leadership * Changing Participating Physician Behavior Development of Processes for Integrating the Continuum of Care * Implementing Information technology Systems to report and measure on Quality and Cost * Developing a Compensation model to Give Physicians Incentive to Participate * Marketing the Concept to Payers and Patients to Build Volume and Drive Support According to The Camden Group (Riegel, B and Tung, C ) ACOs have been defined as organizations that : A. Can provide primary care and basic medical/surgical impatient care for a population of patients B. Are willing to take responsibility for the overall costs and quality of care for the population. C.

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Have the size and scope to fulfill this responsibility. ACOs will probably include one or more hospitals and could include nursing homes, outpatient centers, home healthcare, rehabilitation and other providers of medical care to seniors and others enrolled in Medicare. ACOs will make providers jointly accountable for the health of their patients, giving them financial incentives to cooperate and save money by avoiding unnecessary test and procedures. Those that save money while also meeting quality targets would keep a portion of the savings. Providers can choose to be at risk of losing money if they want to aim for a bigger reward.

The ACO concept began with the observation that physicians who are tied to a particular hospital often already function as a sort of informal network for most of their care. These facts suggest that groups consisting of one or more hospitals and doctors who use the hospitals, but aren’t employed by the hospital might be brought together in organized systems. Public and private payers could then hold these systems accountable by assessing whether they provided high-quality care to their usual patient population while reducing the unnecessary use of resources.

Organizations that took steps to improve their performance would be financially rewarded; this would encourage further steps to improve care management, leading to further rewards and a steady evolution towards fully coordinated care systems. This writer found through researching this topic that there are many obstacles that will need to be resolved before ACOs will be fully accepted. First to the public they appear to be more like a HMO so what’s the difference? According to the research (kaiserhealthnews. org) Patients will be able to get out of ACOs.

Who will be the leaders of the ACOs? Physicians would have to overcome several hurdles. ACOs require clinical administrative and fiscal cooperation and physicians have seldom demonstrated the ability to effectively organize themselves into groups and agree on clinical guidelines. ((N ENGL J MED. org) Multispecialty group practice is necessary to manage care across the continuum, but aligning specialties under a multispecialty group can be challenging when there are great income disparities between the ways physicians are paid.

Primary care providers are critical to the organization but with our current delivery system finding enough primary care doctors will be challenging. The structure of an ACO may be a single corporate or an organized network of independent but associated health care professionals. Integration of services could be organized by a hospital system or could be formed by other medical provider groups incorporated under the ACO umbrella. This type of organization would be called horizontal complexity with the many departments and specialized personnel taking to run the ACO organization.

Being that the ACO is bringing the whole healthcare concept together the spatial complexity (Sultz & Young, 2011) comes into play off site locations are different from the main sight of the home office. All the departments and physicians would communicate via electronic medical records. Home health agencies would be able to receive direct physician orders and lab results as would physician to physicians and department to department. An ACO has extensive policies having to provide high quality care and standards and if unable will lose their share of any savings and contracts.

The Joint Commission and the Secretary of Health and Human Services are part of the open system approach with regards to paying a bigger reward with greater savings meeting quality benchmarks. ACOs will be governed by a body that primarily comprises the health care providers in that ACO but also incorporates the voices of the community and the Medicare patients it serves. Decision making would be known as group-base (participative). According to Accountable Care Organization (2010, part 2) Leaders will require strong, capable clinical, fiscal, and administrative, operations skills.

The majority of ACOs will be incorporated into large hospital systems or physician groups. This interorganization relationship for accountable care is being brought on by cut backs by Medicare and Health Insurance. ACOs fall under the third form of IOR as the cluster of organizations mesh together in a social system to attain collective and self-interest goals to resolve specific problems in a target population (Tolbert & Hall, 2011 p. 144) According to (Health Affairs Health Policy Brief August, 2010) ACO providers would work together to improve quality of health care services and reduce costs for a defined patient population.

The whole ACO concept is not a new thought it falls under a population ecology paradigm and a totally new paradigm. Back in the 1970s, joint ventures between physicians and hospitals tried to operate as health insurers on their own. More often they contracted with health insurers to provide total care to an enrolled population. Many of these arrangements turn out to be so –called capitation payment schemes in return for a fixed monthly payment for each enrollee. In effect a capitated group took over the functions of an insurer deciding which providers patients could see and what services would be furnished.

This was done so that care was managed without going above a fixed financial ceiling. Some of these arrangements still exist today. Other concerns were that capitation would replace incentives to provide too many services with incentives to deny care. Under the ACO system public and private payers would be able to hold them accountable by assessing whether they provide high quality care while reducing the unnecessary use of resources, organizations would be financially rewarded, this would encourage further steps to improve care management, leading to further rewards and a steady evolution toward fully coordinated care systems.

This writer has discussed the physicians role and responsibility but what about the patients’ responsibility. For an ACO to be successful they must have patients that are committed to them. One thought is to have patients share in the cost savings the other is increase consumer awareness. Whatever form ACOs eventually take, one thing is certain the era of fragmented care delivery should draw to a close. Patients have suffered at the hands of wasteful, ineffective and poorly coordinated care systems with cost that are proving unsustainable.

ACOs will be an important new tool for giving Medicare beneficiaries the affordable, high quality care they want, need and deserve. The early results are mixed for the 5 year test of Medicare physician Group. Ten groups were involved some received bonus some did not the group that did not found that the costs for their patient populations grew faster than those for comparable Medicare beneficiaries in the same geographic area. Possible explanations include the group’s limited ability to manage the care of non-enrolled patients and fact that participating providers were still paid on a fee-for-service basis.

The government will begin to accept applications for the ACO Shared Savings Program January 2012, and the first ACOs are expected to be launched in April. References Tolbert, P. S. & Hall, R. H. (2009). Organizations: Structures, Processes, and Outcomes, Pearson Prentice Hall, Inc. New Jersey Gold, J(2011). Accountable Care Organizations Explained. Retrieved from www. Kaiserhealthnews. org Chin, D. Hickman, B. (2011) ACO Organization and Governance. Retrieved from www. healthcarestrategygroup. com Lake, T. Stewart, K. & Ginsburg, P. B. (2011).

Making Accountable Care Organizations Real. Retrieved from www. nihcr. org Ward ,D. (2011). Explaining alternative types of ACO Structures. Retrieved from http://rewwardhealth. com/archives/653 Glaser, J. (2011) Accountable Care Organizations and Health information exchange. Retrieved from http://www. hhnmag. com Morrison, I. (2011). The Future of ACOs. Retrieved from http://www. hhnmag. com Kocher, R. & Sahni, N. (2010). Physicians versus Hospitals as Leaders of accountable Care Organizations. New England Journal of Medicine. 363:27 pg. 2579-2582

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