Julie Sanderson-Austin, RN, vice president for quality management and research at the American Medical Group Association, outlines 12 steps to create a successful accountable care organization from a medical group's perspective.
1. Establish governance. Create governance and administrative structures that can encourage alignment around value-based healthcare. The governmental body might also include a payor representative. "As we move away from fee-for-service payments, you need the payor at the table to help formulate a new model," Ms. Sanderson-Austin says.
2. Agree on a new business model. "Group practices need to establish a different kind of relationship with hospitals, moving from a goal of filling hospital beds to improved outcomes and lower costs," Ms. Sanderson-Austin says. As inpatient volume slows, she suggests hospitals might supplement their income by concentrating on outpatient and ancillary functions such as diagnostic testing.
3. Reach out to ancillary providers. Integrate care with other healthcare providers, such as community agencies and social service organizations, so that the ACO can serve broad patient populations and improve outcomes.
4. Develop a team-based mentality. Forging a team-based mentality means less compartmentalization of roles. "Providers can't have the mindset that 'I have a specific job to do and it is not my responsibility what happens next to the patient," Ms. Sanderson-Austin says.
5. Provide adequate funding. Maintain enough funds to cover the core operations of an ACO. For example, ACOs need to undertake population management so that they can anticipate patients' needs and fund patient outreach. "You need to reach out to patients who don't present," Ms. Sanderson-Austin says. "That's a real change for most provider organizations."
6. Develop disease registries. ACOs should develop disease registries that include anyone with chronic disease and follow them to determine whether they are complying.
7. Know potential legal pitfalls. Be aware of legal pitfalls from fraud and abuse and anti-kickback laws. Federal enforcement agencies may alter legal requirements may possibly be changed to encourage ACOs, but how this would happen is not yet clear.
8. Set up medical homes. Implement a patient-centered medical home model, in which patients are assigned to a particular primary care physician. "The success of these relationships will determine the success of the ACO," Ms. Sanderson-Austin says.
9. Adapt IT systems. IT systems are essential because they will support measurement, monitoring and reporting of costs and quality. ACOs need to get real-time discharge data from the hospital and payment data from the insurer that can provide insights such as whether patients are filling prescriptions. Even if each system works perfectly, "it can be a challenge getting IT systems to talk to each other," Ms. Sanderson-Austin says.
10. Sign agreements with payors. Develop relationships, partnerships and signed agreements with payors to support innovative pricing, distribution of premium dollars and shared savings.
11. Stay within budget. Providers must ensure program design can reduce costs as well as improve quality. "This involves pinpointing the costs of taking care of a certain population and what payment level providers can live with," Ms. Julie Sanderson-Austin says.
12. Demonstrate improvement. As the ACO gains more experience and learns from its mistakes, it needs to demonstrate continuous improvement on clinical outcomes, patient experience and cost.
Learn more about the American Medical Group Association.
Read more about ACOs:
-Patient Doubts, Rejection May Hinder ACO Success
-AHA Shows How 4 Key Federal Enforcement Laws Impair ACOs
-5 Key Financial Challenges Hospitals Face Under ACOs, Other New Payment Arrangements
1. Establish governance. Create governance and administrative structures that can encourage alignment around value-based healthcare. The governmental body might also include a payor representative. "As we move away from fee-for-service payments, you need the payor at the table to help formulate a new model," Ms. Sanderson-Austin says.
2. Agree on a new business model. "Group practices need to establish a different kind of relationship with hospitals, moving from a goal of filling hospital beds to improved outcomes and lower costs," Ms. Sanderson-Austin says. As inpatient volume slows, she suggests hospitals might supplement their income by concentrating on outpatient and ancillary functions such as diagnostic testing.
3. Reach out to ancillary providers. Integrate care with other healthcare providers, such as community agencies and social service organizations, so that the ACO can serve broad patient populations and improve outcomes.
4. Develop a team-based mentality. Forging a team-based mentality means less compartmentalization of roles. "Providers can't have the mindset that 'I have a specific job to do and it is not my responsibility what happens next to the patient," Ms. Sanderson-Austin says.
5. Provide adequate funding. Maintain enough funds to cover the core operations of an ACO. For example, ACOs need to undertake population management so that they can anticipate patients' needs and fund patient outreach. "You need to reach out to patients who don't present," Ms. Sanderson-Austin says. "That's a real change for most provider organizations."
6. Develop disease registries. ACOs should develop disease registries that include anyone with chronic disease and follow them to determine whether they are complying.
7. Know potential legal pitfalls. Be aware of legal pitfalls from fraud and abuse and anti-kickback laws. Federal enforcement agencies may alter legal requirements may possibly be changed to encourage ACOs, but how this would happen is not yet clear.
8. Set up medical homes. Implement a patient-centered medical home model, in which patients are assigned to a particular primary care physician. "The success of these relationships will determine the success of the ACO," Ms. Sanderson-Austin says.
9. Adapt IT systems. IT systems are essential because they will support measurement, monitoring and reporting of costs and quality. ACOs need to get real-time discharge data from the hospital and payment data from the insurer that can provide insights such as whether patients are filling prescriptions. Even if each system works perfectly, "it can be a challenge getting IT systems to talk to each other," Ms. Sanderson-Austin says.
10. Sign agreements with payors. Develop relationships, partnerships and signed agreements with payors to support innovative pricing, distribution of premium dollars and shared savings.
11. Stay within budget. Providers must ensure program design can reduce costs as well as improve quality. "This involves pinpointing the costs of taking care of a certain population and what payment level providers can live with," Ms. Julie Sanderson-Austin says.
12. Demonstrate improvement. As the ACO gains more experience and learns from its mistakes, it needs to demonstrate continuous improvement on clinical outcomes, patient experience and cost.
Learn more about the American Medical Group Association.
Read more about ACOs:
-Patient Doubts, Rejection May Hinder ACO Success
-AHA Shows How 4 Key Federal Enforcement Laws Impair ACOs
-5 Key Financial Challenges Hospitals Face Under ACOs, Other New Payment Arrangements