Chasing the ACO Unicorn
Accountable care organizations (ACOs) are difficult to define, varying in models and scope, but generally “you know one when you see one.” Often likened to unicorns due to their elusiveness, ACOs are poised to transform healthcare spending but not without a lot of work on the back end. While programs differ, many U.S. organizations are gearing up to grab the unicorn by the horn.

From capitation model to fee-for-service or shared savings models, ACOs come in many shapes and sizes, reflecting the needs of the creators themselves. “A community has to figure out its healthcare needs to build blocks towards integrated care,” says Joe Damore, vice president, Premier healthcare alliance. That includes defining targeted populations as well as assessing needs, risks and costs.

Controlling risk factors

Premier, as a hospital and health system-owned organization headquartered in Charlotte, N.C., has various collaboratives to enhance hospital performance and population health status, including two ACO collaborative tracks: implementation and readiness. The tracks assess best practices to promote wellness and reduce waste across the continuum of care. Some members in both are ACOs and others are building the capabilities to become an integrated care facility. The implementation track focuses on early ACO implementation and pursues national payor contracts while the readiness collaborative seeks to enhance selected accountable care capabilities and maximize learning and shared lessons.

Bon Secours Health System, based in Marriottsville, Md., is a member of Premier’s implementation collaborative. Within the overall Bon Secours system, Bon Secours Medical Group Virginia in Richmond is building out an employee wellness pilot program to reduce organizational costs and improve employee health based on ACO principles. With 12,200 employees across 88 plus locations, the system spends $75 million to care for its workforce, says Robert J. Fortini, PNP, vice president, chief clinical officer, Bon Secours Virginia. He and his colleagues forecasted an 11.5 percent increase in continued employee healthcare costs. Thus, the wellness program, running from January until August, hopes to flatline the projected increase to remain at the $75 million cost threshold and improve employee health and productivity via better employee attendance and less sick time used.

“We know that 20 percent of the employee population drives 80 percent of current-year costs,” adds Fortini. “A 1 percent reduction of employee utilization would save us $750,000.”

Participating employees underwent a health risk assessment and screening for risk factors such as hypertension, diabetes and depression. In return, employee health insurance premiums stayed at 2011 levels; equating to an $800 rebate incentive.

Out of the 700 identified employees with multiple risk factors (highest risk), 300 voluntarily enrolled in a program that utilizes health coaching via 12 contacts during the course of the pilot.

While still piloting, Fortini says the enrollment is better than expected.
Why Connected Healthcare Matters to UPMC - 32.32 Kb Source: Rasu Shrestha, MD, MBA, University of Pittsburgh Medical Center

Forging clinical integration

The integration of EHR and health information exchange (HIE) tools are necessary to enable the sharing of electronic health data and integrated care, Damore says. ACOs must assess health IT considerations in the planning stage. However, because there is no granularity at this stage of the ACO game, an organization’s health IT infrastructure must be flexible because the model will change over time and situations will evolve as federal initiatives and organizations themselves change, says Jason Goldwater, MA, MPA, vice president of programs and research at eHealth Initiative. “You don’t want the infrastructure of the ACO not to align with the health IT infrastructure because it would be self-defeating.”

The Washington, D.C.-based nonprofit recommended establishing a health IT infrastructure to support and seamlessly deliver accountable care in its January report. “It needs to support the secure, interoperable transfer, the collection and the storage of data through the model,” Goldwater adds.

To build toward integrated care, organizations should “forge clinical integration in care delivery processes across the continuum,” says Damore. Echoing this sentiment, Rasu Shrestha, MD, MBA, vice president of medical IT, medical director of interoperability and imaging informatics at University of Pittsburgh Medical Center (UPMC), notes that interoperability is leading the ACO charge. To successfully coordinate care and reduce costs across a system, an ACO must avoid duplicative evaluations and testing, he says. Thus, providers will need access to tests and studies delivered outside their EHR systems; ACOs will need to work with payors to get claims data on care provided outside their organization.

UPMC has its work cut out: the 4,200-bed system contains 8.7 million patient records across UPMC and the UPMC Health Plan. Because UPMC and its Health Plan are separate entities under HIPAA, their data should not be co-mingled, but stored separately,  Shrestha says.

UPMC has worked on integrating clinical data as well as information from the UPMC Health Plan, so UPMC physicians have the ability to access information on patients’ services received inside and outside of the UPMC network via the UPMC Health Plan. Conversely, health plan staff have access to UPMC health plan member information that is not available through claims, but is required to improve National Committee for Quality Assurance, Healthcare Effective Data and Information Set and Centers for Medicare & Medicaid Services (CMS) star ratings. These include childhood immunization and blood pressure data.

Achieving ROI of a different kind

At this point, it can be too early for some organizations to calculate ROIs for their ACO initiatives. Instead, better patient care can provide anecdotal evidence of efforts. From a financial standpoint, it can be hard to measure savings 15 to 20 years out, says Steven Robertson, MBA, executive VP, CIO at Hawaii Pacific Health (HPH) in Honolulu. As the state’s largest healthcare system, HPH joined Premier’s implementation collaborative in 2011 to benchmark themselves against national standards and local participants also partnered with Premier.

“Much of the ROI benefit is from improving long-term health and this doesn’t translate well into a 12-month operating budget,” says Robertson. “However, transparency of care at every level and true collaboration among providers is integral.” An EMR can position a provider, according to Robertson, but transparency, partnerships, communication and trust are required to make the software and data useful tools in achieving meaningful change.

The connected data helped HPH achieve an understanding of outcomes that fosters communications among clinicians, which creates better health for patients. At the end of March, only 14.2 percent of diabetes patients were classified as having poor control of their disease, reports Robertson. One year after entering the diabetes program, the patients ranked in the top 10 percent nationally for meeting all diabetic control measures—cholesterol levels, blood pressure, kidney function and blood sugar levels have improved, including 80 percent of diabetes patients having their blood pressure under control.

As organizations consider how to successfully saddle up the unicorn that is accountable care, they must plan and assess their health IT, as well as targeted population goals.