Healthcare reform was all about the patients: It's there in the name: the Patient Protection and Affordable Care Act. So when federal legislators passed the PPACA and formalized the accountable care organization model, it's safe to say they had the healthcare consumer in mind.
"The accountable care process is fundamentally designed to make sure more people get the healthcare they deserve," says Roy Beveridge, MD, CMO of Humana, one of the country's leading health and well-being companies that has decades of accountable care experience. "The winners [of ACOs] clearly are the patients," he says. "Patients will certainly be cared for better." Humana has more than 900 accountable care relationships with providers in various capacities, including medical homes, joint ventures and integrated delivery systems.
Emily Brower, executive director of accountable care programs at Newton, Mass.-based Atrius Health, a nonprofit alliance of six community-based medical groups and a home health agency participating in the Medicare Pioneer ACO program, agrees. "What we're doing to better understand our patients' clinical needs and preferences and being able to connect with them through care transitions…will result in better, safer care and a better experience for the patient," she says.
But there are so many other players in accountable care that someone has to come out on top. So who are those entities that are "winning" accountable care, and who is "losing?" Experts from around the industry weigh in.
Winners
Physicians. Primary care physicians are being encouraged to increase their volume of services because of the focus on preventive care, says Bruce Eckert, MBA, CPHIMS, FHIMSS, national practice director for Beacon Partners' Strategic Advisory Group. Dr. Beveridge from Humana notes that specialists also see an uptick in visits under accountable care, because patients will be encouraged and reminded to get their eyes checked or get a colonoscopy.
Additionally, providers often receive added support in an ACO model, which Ms. Brower says is beneficial. "For our clinical teams, [the model] is definitely a win," she says, explaining providers gain a broader understanding of their patients' experience with care through care coordination and case management support.
Home health. In the ACO construct, "part of the idea is to provide care in the most appropriate, most effective and efficient setting," says Mr. Eckert. "A lot of services can be provided in the home cost-effectively." Also, for many Medicare beneficiaries with mobility or transportation limitations, the home may be the most appropriate place to receive care.
Health IT. For any ACO to be successful, it must gather, manage and analyze data, especially clinical and claims data. And to do so efficiently and effectively, providers need health IT support. "The long-term winner of ACOs is the health IT industry," Mr. Eckert says. Several technologies have already been introduced in the accountable care and population health management space, with many more to come down the road, he says.
In addition to using technology to manage data, many ACOs are turning to solutions that can assist patients in managing their health on their own and engaging patients in real time. According to Mark Lutes, member of the Epstein Becker Green's healthcare and life sciences practice and chair of the firm's board of directors, technology companies that enable this behavior through smartphone and tablet apps, for instance, will also be big winners in the ACO space.
Losers
In contrast with the entities that have a lot to gain from the accountable care model, the following two groups may face an uphill battle when it comes to being valuable in the ACO space.
Post-acute care. Often, post-acute care settings, such as skilled nursing or long-term care facilities, have high costs associated with their services, putting them at a disadvantage in the cost-minded ACO landscape. Additionally, ACOs are hyper-focused on readmission rates. "If there are post-acute care providers and the setting wasn't clinically appropriate for the patient and they end up being readmitted, that's a large negative in the ACO business model," Mr. Eckert says.
However, there is a place in ACOs for post-acute care providers that focus on partnerships, can share information and are "best in class" when it comes to quality, according to Ms. Brower. "I think there are winners all across the continuum for [organizations] that are doing a really good job helping us take care of patients," she says. For SNFs and other post-acute care providers, this means working in partnership with the ACO to develop and follow a care plan for patients, and making the ACO providers part of the care team. This should be of upmost importance for post-acute care providers, as an ACO is likely to stop referring patients to a facility with quality or communication issues in favor of one that is willing to partner.
Hospitals. Unless hospitals are part of a larger clinically integrated organization, they are at a disadvantage under accountable care, as the ACO model encourages providers to keep patients out of the expensive inpatient setting.
If providers are successful, it could represent a "significant reduction in revenue" for hospitals, says Mr. Eckert. "In the short run, hospital utilization is reduced…with almost no reduction in costs, because so many hospital costs are fixed," he adds.
However, hospitals have capabilities required for accountable care that other providers are less likely to have. For instance, hospitals tend to have more intellectual capital and systems and information infrastructure than other provider organizations. "If they can leverage those capabilities around care and quality management, they will be strong players in the ACO world," Mr. Eckert says.
While post-acute care providers and hospitals may currently have some issues excelling in the ACO model, accountable care is still making its way into the mainstream and these groups can still position themselves for success in the model. So this group of "losers" may be more appropriately dubbed underdogs, as they are down but not out.