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More Accountable Care Organization Conference Notes: No Faux ACOs Here!

By Jaan E. Sidorov, MD, MHSA, FACP

After a second and equally rewarding day at the Opal Summit, the Disease Management Care Blog has decamped from Austin Hyatt Hotel venue armed with additional Accountable Care Organization insights.

In yesterday’s post, the DMCB mentioned that it discovered there already are a host of ACO-like legal organizations providing patient-centered care to thousands of commercial insurance beneficiaries using evidence-based guidelines and data reporting with feedback under full or almost full capitation. More of them strutted their stuff today. The DMCB was impressed with their physician-friendly culture and repetitive use of the phrase “do the right thing.” While CMS Administrator Berwick has warned the industry that he won’t tolerate applications from faux ACOs, it looks like there are some genuine provider organizations that are primed and ready to go. The only things they’re missing are 1) an upside gainshare contract with Medicare and 2) invites to the conferences, symposia, meetings and forums being held inside the D.C. beltway.

One thing even more striking than the spandex on the Hyatt’s treadmills was that ALL of these organizations had made a huge investment in non-physician coaching programs that, depending on patient need, used both face-to-face and telephonic counseling to change patient behavior.

Additional food for thought:

Organizations that are ready to go for the ACO demos took at least 3-4 years to get where they are today. Unless the building blocks are already present, the DMCB thinks it will be very daunting for a regular hospital or a vanilla physician group to get up to speed by January 2012.

Want to be a truly “accountable” organization? Then you should, in this order, build: 1) an HIT infrastructure that includes an electronic record with an information exchange, 2) a primary care medical home network, 3) nurse-based patent counseling/coaching capability that is either embedded in the medical homes or shared among several medical homes, 4) an ability to assess the needs of your population and your organization’s performance in meeting those needs and then 5) be prepared to negotiate insurance risk-based contracts with the insurers.

Yes, evidence-base patient care protocols are important, but there are exceptions to every rule. Those exceptions are more common that you might think, especially in the elderly. Be prepared to support your providers when they break those rules.

Since it is unlikely that the Federal Trade Commission and the Department of Justice will allow ACOs to zip up an entire local provider market, will ACOs allow those non-participating providers access to their information systems? The DMCB thinks they should because patients “attributed” to ACOs will inevitably wander outside the network and benefit from the information sharing. The economics of upside gainsharing says they shouldn’t allow access, but that wouldn’t be the right thing to do, now would it?

Want to reduce readmissions? Then: 1) have a care management nurse conduct a in hospital visit with the patient, 2) conduct one or more home visits 3) carpet-bomb the patient with phone calls, 4) refer the patient to every community-based organization you can think of 5) over-communicate with the primary care provider 6) expect every discharged patient to be seen by that provider within seven days of discharge and 7) make sure the home health agencies understand you are not out to steal their business.

Heard of “hospitalists?” How about “post-hospitalists,” who are outpatient physicians responsible for seeing a patient within seven days of discharge? Two of the ACO-ready organizations mentioned above are doing this. Really.

While ACOs are taking on gainshares and capitation, they might also want to announce that they have a “center of excellence” that is open for the rapidly accelerating medical tourism business. Since they’re organizing providers to drive better clinical outcomes at lower cost, they could also argue that their hand, plastic or heart surgeons are among “the best” and steal some overseas business from places like the Cleveland Clinic.

Jaan E. Sidorov, MD, MHSA, FACP, is President of PMSLIC, a Pennsylvania physician-directed carrier with proven stability coupled with a strong personal commitment to physicians and physician practices.

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