Accountable Care will require industry perspectives and health care delivery practices to shift:
- 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.
Additionally, accountability will bring new performance and utilization risks to providers, as the focus shifts from optimizing business unit performance to optimizing
network performance. At the same time, instead of maximizing the profitability of care, organizations will increase the volume of desired bundled episodes while controlling costs.
The Transformation Process...
As providers assess their risk tolerance, they must also strengthen their ability to coordinate 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,
- Providing coordinated care interventions for individuals and populations. This includes patient-centered 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 coordinate care for the most
complex patients through the health care system, taking their preferences and overall situation into consideration. In addition, coordinating 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 care 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