Midlands Voices: ACO starts new era of care

The expansion of health care coverage to millions of American families is one exciting component of the recent health reform legislation, also known as “ObamaCare” or, more precisely, the Patient Protection and Affordable Care Act, as amended by the Health Care and Education Reconciliation Act of 2010. The other exciting component is the birth of the Accountable Care Organization (ACO).

This insightful legislation recognizes the essential importance of health care providers, including hospitals, physicians and community health centers, in leading and driving the changes necessary to improve quality and control costs. As with all births, the ACO will require several years or decades to develop, innovate and mature into its optimal and final form.

In general, the ACO is a legal structure allowing independent providers within a given community or region to band together into a single organization to provide preventive, educational, interventional and rehabilitative services to a defined patient population.

Using a “patient-centered medical home” approach, a comprehensive network of providers becomes interconnected via a shared electronic health information network; a common set of clinical guidelines and performance measures; a shared financial risk-reward compensation system; and a redesigned care-delivery process that coordinates the provision of appropriate medical services from cradle to grave for its covered population.

As determined by each ACO’s level of readiness, the traditional fee-for-service system that is based solely on the volume of services rendered is transitioned to a risk-reward sharing system that is based primarily on the quality of patient outcomes.

For the first time, the incentives for both patients and providers are aligned, so that positive clinical outcomes for patients mean positive financial outcomes for providers.

Therefore, the ACO cannot view its patients as passive recipients of medical services, but instead they become vital partners in the prevention and management of disease and injury. Toward this end, ACOs must design their practices to facilitate the transfer of medical knowledge and skills, in order to continuously improve the ability of patients and families to become well-informed, self-motivated health care consumers.

This requires ACOs to innovate their delivery systems to ensure convenient, meaningful and appropriate access to services. These include same-day, evening and weekend appointments; “e-visits” with doctors, nurses, pharmacists and other health care professionals; group meetings for individuals with similar conditions; disease self-management programs; patient mentoring programs; telephonic nurse monitoring initiatives; and sharing of diagnostic and interventional information, including quality outcomes, clinical errors and cohort comparisons.

Health care reform does not force providers to form ACOs, but the end game for health care providers is now becoming more clear, leaving two viable options:
(1) Begin the process of becoming an ACO by developing the capacity to provide comprehensive care for a covered patient population. (2) Do nothing and eventually become a contracted provider for an ACO that is owned and operated by an insurance company or the federal government.

In other words, providers have the choice of being a passenger -- or a driver -- on this new journey into the brave new world of health care delivery.

In either event, the longstanding fee-for-service era will soon have run its course. In addition to the benefit of aligned financial incentives between patient and provider, the reason for its demise is quite simple: We can no longer afford it.

This costly approach to financing the delivery of medical services only works in a country where health care is viewed as a commodity that is bought and sold based on each consumer’s financial capacity -- and not in an enlightened, 21st-century nation that views health care coverage as a basic right of citizenship.

The ACO is designed precisely to work in this bold new environment. The ACO is much more than a building or an MRI or a list of specialists. It’s a financial and wellness partnership, wherein patients and providers are members of the same team and share in each other’s failure or success.

The bottom line for healthcare providers in this exciting new era, to paraphrase Steppenwolf (the band, not the book): "Get your motors running, head out on the highway. Looking for adventure, in whatever comes our way . . . because we're born to be ACOs!" Yes, the time for opposition is over. Hospitals, physicians and community health centers you are now born to be an ACO, so get your organizational motors running and head out on that highway – because it's the only road you've got.

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