Building Blocks to ACO Consciousness

How IT Will Help
Patient Engagement

Bryan Mingle, Contributing Rise Blogger
 Reshaping a national mind-set after decades of practicing medicine with the emphasis on volume over outcome is the challenge and task of the Accountable Care Organization movement.
 As leaders of the health-care industry are readily agreeing right now, it is a transformation of epic proportions.
Technology will assist and, in many cases, facilitate this transformation. Chances for ACO success  increase when available  IT tools link patients to the management of their care, when provider support staff can spot and close wellness gaps along with managing their patients' chronic diseases.
 Help is on the way. Rise Health's Patient Relationship Manager platform, for one,  is poised to do its  part to enable the transition.
 John Glaser, the CEO of health services at Siemens Healthcare in Malvern, Pa. who writes frequently about upcoming changes in health-care delivery, has thought a lot about  the ACO mind-set and also recently listed six IT building blocks to support accountable care.
Here are the switches in mind-set realities that will be occurring in health-care delivery as accountable care models evolve, according to Glaser:

• from care providers working independently to collaborative teams of providers;
• from treating individuals when they get sick to keeping groups of people healthy;
• from emphasizing volumes to emphasizing outcomes;
• from maximizing the use of resources and assets to applying appropriate levels of care at the right place;
• from offering care at centralized facilities to providing care at sites convenient to patients;
• from treating all patients the same to customizing health care for each patient;
• from avoiding the sickest, chronically ill patients to providing special chronic care services;
• from being responsible for those who seek services to being responsible for the needs of the community;
• from putting forth best efforts to becoming high-reliability organizations.

As providers assess their risk tolerance, they must also strengthen their ability to manage several core processes in an accountable care environment. These core processes include:
Identifying, assessing, stratifying and selecting target populations. It will become imperative for providers to store, access, maintain, derive and update population data and categories (stratification) from multiple sources. Additionally, within target populations, providers will select cohorts for specific programs based on predefined metrics (cost, utilization, outcomes).
Providing care management interventions for individuals and populations. This includes patient-centered management and coordination of care events and activities in multiple care settings by one or more providers (e.g., identifying care gaps and situations requiring additional interventions, as well as managing care transitions). The aim is to manage the most complex patients through the health care system, taking their preferences and overall situation into consideration. In addition, managing the overall health of a select population (diabetics, elderly, well, etc.) will require proactive care, communication, education and outreach.
Providing high-quality care across the continuum. While this is an obvious goal for all providers, ACOs must facilitate cross-continuum medical management for active episodes and acute disease processes or for any patient outside of the defined goals of a target population. It also includes fine-tuning coordination among care team members, transition of care planning, targeting venues of care, establishing patient and family engagement initiatives, and monitoring and improving clinical performance.
Managing contracts and financial performance. With new payment models (bundled, shared savings) emerging, proactively understanding patient coverage and financial responsibility will be critical. Financial teams must have a solid handle on estimating reimbursement and associated payment distributions, carrying out predictive modeling for reimbursement contracts, measuring performance against contracts and predicting profitability, as well as integrating with other key processes to share information.
Monitoring, predicting and improving performance. With payment so tightly linked to quality and outcomes, tracking and measuring system performance in key areas become paramount in an accountable care environment. Under value-based purchasing programs, there will be real ramifications for poor care and rewards for improved care. Providers can work with their quality and clinical staff to adapt processes accordingly. In a value-based purchasing model, even low-performing areas can qualify for high payments if they demonstrate year-over-year improvement.
Across the risk spectrum, these accountable care processes will require a range of IT components and capabilities, some of which will introduce new competencies for many providers.

Choosing Wisely

Patients Will Have a Huge
Say in Health-Care Reform;
Doctors Are On-Board

Up to one-third of the $2 trillion of annual U.S. health-care costs is spent on unnecessary hospitalizations and tests, ineffective new drugs and medical devices, unproven treatments, and unnecessary end of life care.
Nine medical groups were each asked to compile a list of  5 misused or overused tests.
Click here to find out which ones and for guidelines to help you make informed decisions.

A closer look at the tests that deserve a close look

Back to Patient-Centered Basics

Doctor to Patient: 'What Do You Think?''



Kevin Pho, a primary care physician in Nashua, N.H., who blogs at MedPage Today's KevinMD.com, is a member of USA TODAY's Board of  Contributors. His writing regularly appears on health blogs, including this one. Here he takes a step back amid all the recent talk of ACOs and health-care reform, and keeps health care  simple.


I recently saw a middle-age man in my primary care clinic who asked whether he should continue his cholesterol medication. He was reacting to new Food and Drug Administration warnings on statins, a class of drugs taken by more than 20 million Americans to lower their cholesterol. Though generally safe, statins can slightly increase the risk of diabetes, as well as mild, reversible memory loss, according to the new warnings.

My patient and I discussed several scenarios, trying to balance these risks against the drug's benefit of preventing heart attacks. Should he discontinue his statin? Lower the dose? Or change to a less potent drug within the same class? With no obvious answer, I finally asked my patient, "What do you think?" It's a question more doctors need to ask.

Involving patient input in medical decisions is a concept known as shared decision-making. According to the Institute of Medicine, it is a foundation of patient-centered care, where care is "responsive to individual patient preferences, needs and values."

Options sometimes limited

Of course, some cases have only one acceptable option: vaccinating children, or surgery for an acute case of appendicitis, for instance. But in the majority of cases, the correct treatment is much less clear. Issues such as cancer screening, end-of-life decisions and whether to pursue elective surgery all have multiple feasible paths. That's where shared medical decision-making plays a valuable role.

My patient, for instance, didn't have a history of heart disease, which weakens the case for statin drugs. Cardiologist Eric Topol of the Scripps Clinic in San Diego says the reduction of heart attacks in patients like mine was 1 in 50, while 1 in 200 patients would get diabetes because of the drug.

So should a patient try to prevent heart attacks at all costs, and accept the drug's side effects? Or is the risk of diabetes too great? The answer will vary, based on the preferences and values of individual patients.

Benefits are many

The benefits of engaging patients are significant. A 2011 Cochrane review, which analyzes the results of medical research, looked at 86 studies that examined patients who used decision aids — such as pamphlets, videos or Web-based tools — to help them make medical decisions. When these tools were used, patients reported an improved knowledge of their options, held more accurate expectations of harms and benefits, and reached choices consistent with their personal values.

But doctors often take a paternalistic approach to care, simply making the decision they think is best. Consider prostate cancer screening, where updated guidelines from the U.S. Preventive Services Task Force have made the decision of whether to pursue testing less certain. The estimated benefit of finding early prostate cancer has been reduced in recent studies, and further diluted by the harms that stem from prostate cancer treatment, which include impotence and urinary incontinence. Despite the complexity of that decision, a 2009 study in the Archives of Internal Medicine reported that barely half of patients recalled being asked for their screening preferences.

Back to my patient. After carefully considering his options, he decided to stop taking the statins. But had he decided otherwise, I would have respected his informed choice and continued the medication. The voice of patients needs to be considered for most medical decisions. That way, no matter what choice is made, it will always be the right one.