In case you missed the news, Gov. Deval Patrick put the state on notice last week that over the next five years, he wants the entire Massachusetts health care system to shift to a new way of working. The current system, he said, provides financial incentives for more care rather than better care. “By most accounts, better-quality care — meaning integrated, whole-person care — equates to lower cost. From now on, we propose to pay for that rather than the fragmentary system we have today,” he said.
At the center of that shift, the buzzword of all buzzwords in the months to come, is “ACOs,” or Accountable Care Organizations. We offer a rudimentary guide to ACOs here. The bill that the governor filed last week briefly defines ACOs as “connected or integrated groups of health care providers that achieve improved health outcomes and lower the cost of care.”
But what does that mean? What is this shift going to look like? CommonHealth spoke today with Dr. Marc Bard, chief innovation officer in Navigant’s health care practice and author of a forthcoming book: “Accountable Care Organizations: Your Guide to Strategy, Design and Implementation.” He kindly boiled it down for us into five main points:
1. In the current system, you are your own health care general contractor. An ACO would be more like a package tour.
“American health care system” is actually an oxymoron. There is no system of care. If it resembles a system at all, it resembles an ecosystem. That’s an important concept because an ecosystem is an essentially competitive system in which each element is fighting for survival, and there’s no attempt to organize an ecosystem, it just evolves. In the US health care system, each patient — individually operating in an an entirely transactional and fragmented environment — is essentially his or her own general contractor for care.
First and foremost, an accountable care organization is designed to be a system of care, an organized, integrated system of care. It’s a little bit like booking a package tour: You sign up and it’s all coordinated for you. You don’t have to worry about booking your airfare, your hotels, the sites you’ll see. It’s all integrated because they anticipated what your needs are — it’s a package tour with a purpose, and the purpose is optimizing your health in an efficient way.
2. ACOs are organized around the patients’ needs, not the providers’.
The system right now is organized primarily around the needs of the institutions delivering the care and their capacity to deliver it, utilizing the way they’re currently organized. So the individuals accessing the so-called system have to access it on the terms of the system rather than based on their own needs.
For example, what’s amazing to me is that, with a fair degree of accuracy, my car dealer seems to know when my car needs an oil change and actually notifies me. My doctor, whom I adore, doesn’t seem to know when I need an annual exam, and doesn’t contact me. Or take my wife, who has to essentially book her mammogram exam; her bone densitometry if she’s due fo that; her colonoscopy if she’s due for that; and her pap smear — as opposed to the system recognizing that in 2012, this is what she needs and saying, ‘Let’s book them all together, one call.’ Wouldn’t that be different?
3. ACOs reward outcomes rather than activities.
Right now, the system rewards activities. You do something, you get paid for doing something. In the future, it will reward outcomes, which is critically important. So that simply providing you with a service, if it doesn’t demonstrate an outcome of improved health, ultimately will simply not be rewarded.
If I’m taking care of a patient with a chronic illness — let’s take diabetes — unless I can begin to demonstrate that under my care, his or her blood glucose is well managed, his or her sight is preserved, sensation in his or her extremities are preserved, his or her cholesterol is well mtaintained at a safe level — and I can go on and on and on – I’m simply not going to get either paid or rewarded, it depends on how extreme we go.
(Here I interjected: But so much of the outcomes are not in the hands of the provider!)
It occurs to me that I need to sit down with my patients and say, ‘Your health matters as much to me as it does to you, so how are we going to work together to make this work for you? Because we are now partners in your health. We both benefit by your good health and we both, by the way, suffer from ill health. So the real question is: How do we design the care for you and all our diabetics so that complying with what’s recommended is the easiest option? I often liken the ACO to concierge medicine for everybody.
4. ACOs reward efficiency rather than activities.
Interesting concept: If a test has already been done, and it’s required for some other reason, it would be awfully nice to be able to access the test that’s already been done and not have to repeat it. And the amount of that that goes on every day is astounding.
But also, if an ounce of prevention really is worth a pound of cure, then it starts to focus on prevention, early detection, early intervention, and avoids the more costly components of health care delivery: Emergency Room use, use of hospitalization, and so forth. So it’s really trying to anticipate rather than react, and that’s really the most fundamental change: We’re starting to reward primary care doctors for doing what they went into primary care for in the first place — which is keeping people healthy, ancitipating threats to their health and preventing them.
The number of times I saw a patient with a very early medical problem and treated them very aggressively to prevent something! There’s no glory in that. I could see a ltitle infection in a finger and know that if this infection isnt’ treated aggressively, hand infections are very, very serious. So I’d jump on it as an outpatient and the patient woudl think of me as being a little histrionic, and I’m thinking, ‘You don’t understand!’ It’s about changing the mindset around efficiency.
5. ACO’s help open the door to transparent, real-time data for everyone.
Have you ever driven a Prius? If you watch the dashboard, the dashboard actually gives you information in real-time that allows you to optimize the car’s performance. That’s the way it’s got to be in health care, for the patient and the delivery system.
Every patient selects what’s being called a “medical home” — usually a primary care doctor — but rather than care being delivered by a doctor, the care is designed and managed by a doctor and delivered by those most capable of meeting the comprehensive and integrated needs of the patient. That could be a health educator, a nutritionist, a social worker, a care coordinator, a nurse, a Nurse Practitioner, a Physician’s Assistant, a psychologist, a primary care doctor, even in some cases a specialist. And this team of people, using current available technologies, is monitoring the health status of a population of patients.
The way the system works now is: any time Marc Bard is in the presence of a doctor, with the exception of acute trauma or somethig like that, it’s because Marc Bard initiated a visit. Because the unit of measure in today’s environment is a doctor’s office visit. In the future, that health care team, using public health surveillance measures that are available– and by the way, every part of an ACO is currently operating somewhere, we’re not inventing anything new, we’re just putting it together. And so the team is monitoring the patients, and believe it or not, they’ll know if you haven’t signed up for your colonoscopy and they’ll reach out to you and say, ‘We know that this is something that you’re not looking forward to but let’s educate you a little bit about it because it’s really not so bad….”
Next: Dr. Bard makes a few predictions about how the ACO shift will play out.