Making Care Organizations and Payers Accountable for Patients
Centering care around patients and incentives around outcomes requires physicians, insurers and patients to work together in new ways. But the potential results — hospitals focused on patients, payments that focus on care outcomes rather than on the volume of procedures, lower health care costs and a healthier population — make it a model worth trying.
Physicians, academic leaders, hospital executives and government officials talked about ways to bring together insurance, hospitals and medical professionals through accountable care organizations during a panel session titled “Patient-Centered Care and Accountable Care Organizations in an Era of Health Care Reform,” held during the University of Miami Global Business Forum, Jan. 12–14, 2011. ACOs are networked groups that accept responsibility for the cost and quality of care delivered to a specific population. The health care reform legislation passed in 2010 directs the Centers for Medicare and Medicaid Services to create a voluntary national program for ACOs and contract with them.
The Cleveland Clinic, praised by President Barack Obama as a model for reform, is one example of how an ACO might look. Ranked by U.S. News & World Report as one of the nation’s top four hospital systems, it integrates physicians and hospital services into a single care model. Toby Cosgrove, president and CEO of the Cleveland Clinic Foundation, explained how it differs from most: There is physician leadership; all employees, including physicians, are salaried; 8,000 hours each year are spent on professional review; and everyone operates under renewable one-year contracts, rather than tenure. Instead of organizing operations around professional groups, the Cleveland Clinic uses what Cosgrove calls “a rather novel idea, a hospital organized around patients.”
“We put the professions together, medical and surgical. The idea was to organize it around either organ systems or disease systems, and to have a single leadership and a common location,” Cosgrove said. “Take, for example, the Miller Family Heart & Vascular Institute. It has cardiac surgeons, cardiologists, vascular surgery and vascular medicine [together].”
To keep care patient-centered, Cleveland Clinic uses integrated electronic medical records and established metrics for measuring patient outcomes to ensure quality and pools experience. “Medicine is no longer an individual sport,” Cosgrove said. “Medical knowledge doubles every two and a half years. No one individual is able to learn it all.”
It has also made service changes, such as offering same-day appointments, allowing visitors at all hours and providing sleeping arrangements for them. To ensure that patients can easily identify caregivers, uniforms are color-coded for different kinds of caregivers. Patients also have open access to their medical records.
While ACOs have the potential for better outcomes, happier patients and lower long-term health care costs, implementing them is challenging.
For one, physicians may be reluctant to cooperate, said Stephen Jones, president and CEO of the four-unit Robert Wood Johnson University Hospital system in New Jersey. “Physician groups in New Jersey are mainly fragmented,” he said. “For a state that has an 8.5 million population, there are many ones and twos, and very few multi-specialty groups.” The system spent a year developing an ACO, Robert Wood Johnson Partners.
Even when physicians are interested in joining an ACO, Jones said, there are concerns about maintaining a large enough supply of primary care providers. Getting everyone on the same technical platform for sharing medical records and information also presents infrastructure and IT problems.
Despite these challenges, there is demand for this type of care. “Over the last year, in the development of Robert Wood Johnson Partners, we found many organizations in the community are looking for this leadership,” Jones said. “Our county has 10,000 employees total, and they are looking to RAJ Partners to manage the health for them.” Labor unions, large pharmaceutical companies and educational institutions have expressed interest as well.
“There is a strong business case for health care reform: an increase in quality and managing the cost. Hospitals are a strong economic engine, and it is our responsibility to businesses to manage down costs,” he added.
To do that, though, accountable care needs to reach beyond ACOs to payers including health insurance companies and Medicare, said John Bigalke, vice chairman and U.S. national industry leader for health sciences at Deloitte LLP.
“ACOs are the tip of the iceberg,” he said. “How do we create [payer] systems that cross over all aspects of care, from prevention to rehabilitation?” He suggested the answer would require “a holistic view of the consumer” before that consumer is ever a patient, including focusing on long-term risks such as obesity in adolescents.
The Cleveland Clinic has taken such a view, creating preventative programs aimed at changing behaviors that have high health costs over the long term, including obesity, smoking and sedentary lifestyles. “The thing that will bankrupt the health care system is the epidemic of obesity, which accounts for 10 percent of health costs in the United States and will soon rise to 20 percent,” Cosgrove said. To combat it, the clinic has a free weight management program for employees — who have lost a collective 188,000 pounds since the program began — and a campus ban on smoking, including not hiring smokers unless they take advantage of a cessation program.
In addition to working preventative care into their models, payers in a patient-centered, accountable care model will need to remove plans that provide incentives to doctors to follow a case-by-case model, rather than a long-term, patient-centered model, Bigalke said.
Some of the blame for that case-by-case model rests with the government, admitted Anthony Rodgers, deputy administrator for the Centers for Medicare and Medicaid Services (CMS). He promised CMS is working to change it.
“The system does what it’s paid to do, and right now it’s paid to initiate transactions, and not coordinate care, because there are no consequences for not integrating care,” Rodgers explained. “We take that responsibility, and we are realigning how CMS will operate in the future.”
Rodgers identified three current goals for CMS: leveling out “an unjustified variance in patient safety, health care cost and quality outcomes”; reducing long-term costs; and creating a healthier population through preventative care and education. He was quick to explain that CMS would approach those goals through “descriptive policy, not proscriptive policy,” and added, “If we’re successful, there will be a less of a regulatory environment in health care.”
While there are still many unanswered questions about accountable care, the panelists agreed that the current system certainly has to change, and physicians, hospitals and payers must work together to find better ways of doing things. “The system is broken, whether you’re government, physician, or patient,” Bigalke said. “We’re losing globally despite the wonderful things we do. So try to start the conversation by giving the other party the benefit of the doubt, because they are trying to do the right thing.”
Squire, Sanders & Dempsey LLP sponsored the session, which was presented by the School of Business.
By Brandon Ballenger