Accountable care organizations (ACOs) focus on improving the patients’ health and experience while reducing costs.
Ramon Cancino, MD, MSc, is Director of Primary Care for UT Health Physicians and Medical Director at UT Health Hill Country. He specializes in family medicine.
Virgen Rodriguez-Perez, MD, a UT Health Physicians family medicine physician, remembers a different time. “In my other practice, we were seeing as many patients as possible because that was the way we made money,” she says.
Primary care physicians across Texas are used to practicing under this model. Traditional fee-for-service care incentivizes high patient visit volumes rather than high-quality care. This type of medical practice is often not patient-centered and can lead to unnecessary and often redundant utilization of healthcare resources, disjointed care and poor patient outcomes.
Dr. Rodriguez-Perez now follows a different model, and her patients are benefiting, she says.
“Now, before many of my patients arrive, my medical assistant and I know what cancer screenings are due, whether or not they have recently been to an emergency room or hospital, and when their last diabetic foot exam was,” Dr. Rodriguez-Perez says. “I can focus on prevention and, if my patient gets sick, our team can get that patient into the office the same day to avoid having to send that patient to the emergency room.”
The value-based care model she describes is one that focuses on achieving what is known as the Triple Aim — improving a population’s health and patient experience while controlling avoidable costs. Quality is often measured using Healthcare Effectiveness Data and Information Set (HEDIS) metrics and the patient experience. Costs are measured by factors such as avoidance of emergency room visits for ambulatory care, sensitive conditions and hospital readmissions. Incentives are based on their performance on these measures for specific patient populations. In the U.S., many more practices are now practicing both fee-for-service care and value-based care models. The latter is the cornerstone principle around which ACOs are structured.
The Value of ACOs
Because the goals of value-based care are different from those of fee-for-service care, the structure through which care is delivered must be different as well. Traditional fee-for-service care practices are designed to see a high volume of patients, while high-performing ACOs often collaborate with hospitals, have physician leaders focused on improving performance, utilize sophisticated information systems, provide effective feedback to physicians and have embedded care coordinators.
The U.S. healthcare market was not always focused on value, but the U.S. has a history of attempting to restructure health care to decrease costs. Previous attempts to restructure care delivery have included the health maintenance organizations of the 1980s and 1990s and the Medicare Physician Group Practice Demonstration pilot program in the mid-2000s. Costs continued to rise. In 2011, the U.S. Department of Health and Human Services, via Medicare program section 3022 of the Patient Protection and Affordable Care Act of 2010, created ACOs in an effort to contain rising U.S. healthcare costs by helping physicians, hospitals and other healthcare providers better coordinate care for patients.
The term ACO has had many definitions. The term “accountable care organization” was originally used by Dr. Elliott Fisher and Glenn Hackbarth in 2006 during a public meeting with the Medicare Payment Advisory Commission. The Centers for Medicare & Medicaid Services define an ACO as “groups of doctors, hospitals and other health care providers who come together voluntarily to give coordinated high-quality care to their Medicare patients.” In general, the ACO framework focuses on ensuring that all patients, especially the chronically ill, receive the right care at the right time.
Since 2011, value-based purchasing contracts and ACOs have multiplied. As of 2017, there are more than 900 ACOs in the public and commercial sectors. In the public sector, the Medicare Shared Savings Program had nearly 490 participating organizations as of 2019. This program rewards providers who deliver high-quality and low-cost care to Medicare patients. Similar contracts are being done in the commercial sector, such as Blue Cross Blue Shield’s Alternative Quality Contract in Massachusetts. In both examples, providers enter into an agreement with an insurer to take on financial risk associated with the care and outcomes of specific patient populations. Although the structures can differ, the goals are the same: increase quality of care and aim to reduce unnecessary healthcare costs.
Important to ACOs are a focus on developing a shared mental model of care collaboration, data transparency and continuous improvement. Teamwork and collaboration are demonstrated through care management and integrated care across different care locations. Organizations collect and share data on process and outcomes metrics via integrated health information technology, often a shared EHR. Teams use this data for continuous improvement using structured and standardized methods for improvement and continual self-auditing for improvement in goals.
Most importantly, the success of an ACO hinges on practice engagement at all levels, especially in primary care. The reimbursements an ACO receives are highly contingent on quality and cost outcomes, which can be leveraged by a patient population that is adherent, loyal and engaged in their own care. As a result, the longitudinal relationships patients develop with primary care clinicians are often the reason patients adhere to medical advice (such as receiving a colonoscopy, seeing a clinical psychologist, joining a weight-loss program or consulting with a surgical specialist) as well as the reason they follow up. Success in the Medicare Shared Savings Program is contingent upon not only demonstrating value, but also on demonstrating patient attribution through consistency of visits and utilization of resources within a single Medicare Tax Identification Number. Furthermore, it is often the frontline staff — schedulers, front desk workers, benefits coordinators, nurses and medical assistants — who are interacting with patients and providing the initial patient experience. Therefore, on-site physician and staff engagement in making key clinical operations decisions as they relate to ACO metrics is critical.
At the Forefront
UT Health San Antonio aims to be the leading ACO in central and south Texas. The organization is forming an ACO, the UT Health San Antonio Regional Physician Network, in July 2019. In doing so, it has worked to engage all its physicians and staff in a two-year process driven by physician leadership focused on the Triple Aim.
“As a physician-led organization, we wanted to be sure all our leaders and stakeholders were involved in this process,” says Carlos Rosende, MD, Executive Director of UT Health Physicians.
“We continually engage all our medical directors and clinical leaders in our decision-making,” says Bob Leverence, MD, Chief Medical Officer for UT Health Physicians.
The focus on clinician and stakeholder engagement resulted in an enhanced, integrated patient care experience that builds on the practice plan’s experience as a patient-centered medical home. Patients have their own personal primary care physician and can interact with their medical home virtually through an online portal, which allows patients the ability to see test results, medications and their visit histories.
Another layer of personal care exists for ACO patients.
“Our primary care and specialist teams and leaders helped develop workflows, which we use in daily interactions with patients either in person or virtually,” says Kenyatta Lee, MD, Chief Quality Officer for UT Health Physicians.
Local and central teams work together to review every patient with a daily emphasis on identifying gaps in quality metrics. In addition, each afternoon, representatives from all primary care practices discuss care gaps. To ensure members of the team address gaps either in person or virtually, personalized care plans are developed for each patient. Every morning, a practice access teleconference ensures patients with acute needs are seen in a timely fashion. All this activity is supported by a health information technology infrastructure that collects and reports data on care gaps in real-time.
“We worked closely with our clinical leaders to develop our EHR workflows and dashboards that allow us to deliver value-based care to our patients seamlessly,” says Timothy Barker, MD, Chief Medical Information Officer at UT Health Physicians.
The integrated local and central workflows allow clinicians time to deliver patient care.
“We feel we have a lot of support around us, which allows us to focus on caring for the patient in front of us,” says David Cadena, MD, a UT Health Physicians family medicine clinician.
The model of care the ACO will deliver has attracted interest from non-UT Health San Antonio physicians as well. The UT Health Physicians group is developing relationships with community physicians; many are attracted to the Regional Physicians Network model of care and will join it as ACO participants. ACO participants will have the opportunity to utilize the same patient care resources, have direct access to UT Health Physicians specialists, and have access to ACO educational events. The participants will also have the opportunity to receive a portion of any of the shared savings that the Regional Physicians Network would gain.
What Lies Ahead
Ultimately, the goal is to make sure patients receive the best evidence-based care at the right time. The value-based care model (and the ACOs that will deliver this care to patients) is a step toward this goal. Value-based care aligns actions that make sense to physicians and patients — such as improving blood pressure and decreasing hospital readmissions — with incentives. While the U.S. has a long history of restructuring itself and its health care to meet the Triple Aim, recent evidence that suggests billions of dollars were saved by the Medicare Shared Savings Plan ACOs may mean that we are closer than ever to reaching the goal.
Ramon Cancino, MD, MSc, is Director of Primary Care for UT Health Physicians, the medical practice of the Long School of Medicine at UT Health San Antonio, and Medical Director at UT Health Hill Country. As an Assistant Professor and primary care physician, he is also part of the UT Health Regional Physicians Network. He can be reached at email@example.com.