From The Advisory Board Company

Keys to Success With Accountable Care Organizations

Lisa Bielamowicz, MD


October 13, 2010

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Hi. I'm Dr. Lisa Bielamowicz, and I am a physician and the Managing Director with the Health Care Advisory Board, the research division of The Advisory Board Company. I lead our work in hospital-physician alignment strategy and have been spending a lot of time in past several months working with physicians across the country and helping them understand the impact of healthcare reform and accountable care and what this may mean for their practices.

Of course, all of the changes that are occurring today as systems organize to become accountable care organizations, or ACOs, will affect different types of physicians in different ways. Clearly, there is a new emphasis being placed on the primary care physicians in our communities. If you think about an accountable care organization, what is going to be required of physicians and hospitals and other members of the ACO working together, in order to be able to take total cost accountability for care, to be able to deliver a higher value care product?

High quality, low cost to the patients we serve. Enhanced primary care is going to be the backbone of the ACO. We're going to need our PCP practices to be able to not only do the great job that they are doing today in delivering high quality care but to provide more comprehensive care, enhanced chronic disease management, coordinate care with other providers across the continuum, and really engage patients in being active care partners in a way that is new and more energized than we ever have before.

Unfortunately, primary care physicians are busy. They are already working long hours within their practices today, and if they alone as physicians did all of the things required of them, if they develop a medical home delivery model, they'd be spending 22 hours a day within the 4 walls of the practice. Clearly that is not something that's going to be sustainable.

We can't heap more work on PCPs. The real answer here, we think, in building the medical home, is a transition to team-based care, to physician-led teams with a huge array of support from other providers working underneath them -- mid-level providers, nurse practitioners, physician assistants, nurse health coaches, LPNs. Folks that are within the practice, as well as maybe new additions to your team, with everyone working at the top of their license to make sure that we're providing comprehensive care to the patients that we serve. We understand that this is going to be a big transition for PCPs, and it's going to require a lot of time, energy, mindshare, and perhaps some investment of dollars as well. That's why we think that primary care physicians need to be thinking of 2 imperatives right now.

Two Key Imperatives

First, it's going to be much easier to make these transitions if you are allied with the right partners in your market who can provide the necessary support that you need to build the medical home within your practice. Is there a hospital or health system that can work with you to help you make that transition, to provide infrastructure, both access to resources within your practice as well as care management and other enhanced services at the level of the health system, where you can feel that you are referring your patients to a high-quality coordinated service?

Second, you need to be actively engaging your payers. Transitioning to this model is going to require you to practice care in a different way. Perhaps we need to provide enhanced access to disease management services, to engaging patients through different portals like an electronic or telephonic visit. Right now, the payers don't pay you, in most cases, for delivering care in this way. We need to make sure that we are compensated for the time we are going to spend delivering care using these new methods. Fortunately, we're starting to see payers willing to collaborate on this front.

Now, on the flip side, while primary care is being reinvigorated by many of the changes that are occurring in the country today, we're finding many specialists feeling a little bit unstable and disconcerted about what accountable care could mean for them and their practice. Of course, the goal of accountable care is to try to treat patients at the lowest level of care. Could something that is currently being treated today with a procedure or in the specialist's office be handled more effectively through enhanced primary care and prevention?

I think there is a possibility that coordinated, enhanced care will reduce the demand for some high-end procedures and specialist services. However, we always have to remember that we're also experiencing shifting demographics in this country. Aging of the population leads to a continued disease burden. It's going to take a lot of work to change that momentum. So baseline growth for services will probably at least match the destruction of demand that we will see through enhanced primary care and care coordination.

It is going to be important for specialists to realize, though, that their roles may change. Some of the medical management that you're doing within your practices may be taken on through enhanced primary care. And you might relate to those practices in different ways. You need to have an active seat at the table today as accountable care organizations are forming in your market. Should you choose to join an ACO actively or relate to multiple accountable care organizations, should they be created within your market? I think that is a question that is going to be market specific. However, you should have an active seat at the table to make sure that you are part of standardized care delivery, of ensuring seamless hand offs from care site to care site. And you should make sure that you, as well, are compensated for how you might be delivering care in a new way, consulting with PCPs electronically or telephonically. Our research shows about half to two thirds of all consults could benefit from that lower level of interaction. Give more knowledge to more patients more quickly and at a lower cost. Today you're not paid for delivering care like that. You need to make sure that if you are spending your time interacting with patients and referring physicians in a new way, the payment system is supporting it.

Overall, when assessing short-term imperatives for physicians, first and foremost get educated on what reform and accountable care are going to mean for you. Start figuring out who the right partners in your market are going to be. We're all going to be more effective in providing higher quality, low cost care for the patients we serve if we're working together as a coordinated unit.

With that said, you as a high-performing physician want to make sure that you're working with the highest-performing physicians and organizations within your market. Forming those bonds and relationships today is going to be key.

And then, finally, make sure that you are working to make this a sustainable system. Work with payers; work with the hospitals in your market. How we partner to make sure that our practices remain stable and solvent -- and that our independence is preserved -- is going to be not just the short-term imperative but the long-term objective of transitioning how we're delivering care to the demands of healthcare reform.