how to achieve aco cost savings: innova5ve strategies for ......non-aco providers have legicmate...

HowtoAchieveACOCostSavings:Innova5veStrategiesfor

PerformanceImprovement

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HowtoAchieveACOCostSavings:Innova5veStrategiesforPerformanceImprovement

TableofContents

Introduc5on

PartI:DecisionTime:HowCananACOModelWorkforYourOrganiza5on?

• ReluctantProvidersCanBenefitfromFreshApproachtoACOs

PartII:DevelopmentStrategiesthatPutYourACOonPathtoSavings

• FourACODevelopmentDecisionsThatWillImpactReturnonInvestment

• ACOEconomics101:Op5mizethePhysicianNetworkForPa5entChoice

PartIII.InnovateinYourACOtoAchieveTripleAim

• CanProvider-LedACOsandAAPMsDeliverHealthCareTransforma5on?

• UnifyACOQualityandCostIni5a5vestoBoostLong-termResults

• ACOsMustCreateLearningEnvironmentforPhysicianstoBePartnersinChange

PartIV:Consumer-DirectedStrategiestoCreateStrongerLinkswithPa5ents

• SharedDecision-MakingMayBetheNextConsumerHealthMovement

• RedesigningHealthCarefortheNewConsumer



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Introduc5on

AnAccountableCareOrganizaCon(ACO)isanopportunitytocreateanewapproachtohealthcare,but

manyprovidersarenotpreparedfortheface-offwithfinancialrisk.Withoutaclearpathtobreakingeven—orbeSer,areturnontheirinvestment—providerorganizaConsarewaryofhowtoinventandoperate

anACOwhileremainingfiscallysound.TheexperienceofearlyadoptershasdemonstratedthatachievingACOgoalsisnotagiven,eveninalow-riskmodel.Asmodelsincorporatedownsidefinancialriskfor

providers,thesituaConisevenmorethreatening.

Thise-BookisforproviderswhounderstandthattheywillneedtoembraceACOmodelsinthefuture.Itis

alsofororganizaConsthatdevelopedorjoinedACOsandfoundsavingstohavebeenelusive.

WebelievetheACOdoesrepresentanopportunitytocreateabeSerandmoreraConalmodelofhealth

care,butthatachievementdemandsinnovaCvestrategies.

InnovaConiskeytoanynewbusinessventure,butespeciallyforACOs.TheACOmodelwillrequireimprovingperformanceinanenvironmentwheremostofthecurrentFee-for-ServiceincenCvessCll

appeartoexist,butareactuallyupended.ProviderswillconCnuetobillforservicesandreceivepayment,

delivercaretopaCents,andrefertospecialtyservices,technologyandinpaCentcare.ButthoseacCviCeswillnolongerexclusivelygeneraterevenue;theywillalsogenerateriskandcost.

ACOsthathaveapproachedtheirnewventureswithcreaCvity—establishingmoreandbeSertouch-points

forpaCents,sharingdata,usingtelemedicineandothertoolstomaximizeefficiency—willseegains.

Likewise,ACOsthathaveworkedwithphysiciansastheirpartnerstoinnovatechangewillseeopportuniCesforbeSerpaCenthealthandlowercost.

Technology,infrastructureanddataareessenCalforACOdevelopment.Butofevengreaterimportanceis

determininghowtousethosecomponentstoinspireproviderstofindsoluConsforunifyingqualityand

costiniCaCves,andtofulfillpaCentdesiresformoreinformaConanddecision-making.

WehopeyoufindthesearCclesinteresCngandinformaCveinyourjourneytoACOsuccess.


FoundedasICLOPSin2002,RojiHealthIntelligence®guideshealthcaresystems,providersandpa5entsonthepathtobe\erhealththroughSolu5onsthathelpprovidersimprovetheirvalueandsucceedinRisk.

RojiHealthIntelligence®isaCMSQualifiedClinicalDataRegistry.

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PartI:DecisionTime:HowCananACOModelWorkforYourOrganiza5on?

ReluctantProvidersCanBenefitfromFreshApproachtoACOs

byTheresaHushRojiIntelBlog;March28,2018

It’snosecretthatCMSwantstomove

providersawayfromMIPSandtheFee-for-Servicepaymentsystem,

towardanAlternaCvePayment

Model(APM)likeanAccountableCareOrganizaCon(ACO).Thispast

January’sannouncementofanaddiConal124newACOsimpliesthat

wehavereachedaCppingpoint,with

ACOsbecomingmoreprevalentthanstandardFee-for-Servicepayments.

ButthatopCmismoverstatesthestatusofACOs,bothintermsof

numbersandsuccess.DespiteasteadyincreaseofnewACOapprovalsandACOproviderparCcipaCon—including

anaSracCve5percentbonusforproviderswhoparCcipateinanAdvancedAPM(AAPM)withfinancialrisk—thepaceofgrowthismoderate.Only2millionmoreMedicarepaCentswereaSachedbyCMStoACOsfrom2017to

2018.JustoverhalfofACOshavesuccessfullycomeinunderexpenditureandsavingstargets,withamuchsmallersharereceivingbonuses.

InaddiCon,inthesixyearssincethefirstACOswereapproved,onlyaroundathirdofMedicarebeneficiariesinthe

regularMedicareprogramhavebeenaSributedtoanACOforservicesoverall.That’ssignificantlybelowthe50percenttargetsetbyCMSfor2018,andalongstretchtoreachAdvancedAPMstatus,orACOswithfinancialrisk.

Forprovidersundertherisk-basedNextGeneraConACOmodel,severalACOsactuallyterminatedtheirprogramsintheendof2017becausetheyfearedfailureunderrisk.

MajorityofProvidersAreS5llUnpreparedfortheACOModel

Clearly,themajorityofprovidershavenotbeenreadytomakethechangetoanACO.Why?Onlyasmallnumberofthe562ACOshavesucceededinachievinganysavingsatall,andsomenowriskrepaymentstoMedicare.The

majoritylacktheconfidencethattheycanorganizeeffortsthatwillpayoffinsavings,loyalandsaCsfiedpaCents,andcontentedphysicians.



https://rojihealthintel.com/2018/03/07/who-wins-and-loses-if-cms-kills-mips/



https://www.healthaffairs.org/do/10.1377/hblog20171120.211043/full/

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Non-ACOprovidershavelegiCmateorganizaConalandmarketissuesthatraisebarriersforACOparCcipaConor

development.OneisanetworkcoststructurebasedonhospitalorlargegroupownershipoffaciliCes,technology

andhigh-endspecialtyservices.Oncecashcows,theseinvestmentsarenowcostlytoanACOorganizaCon.

SomecurrentACOsareinconcentratedurbanareasandhavemorematurenetworks,marketpenetraConor

dominance,andexperienceinvalue-basedcommercialinsuranceparCcipaCon.ButforproviderswhohaveyettodeveloporparCcipateinACOs,therearelegiCmatereasonstobereluctant,includingcurrenthighercostscoupled

withlackofphysiciannetworkcohesionorengagement.

PhysiciansAretheFrontLineofACOs,ButNotAlwaysintheInnerCircle

Technically,theACOmodelisphysician-focused,becausepaCentsareassignedtophysicianswhoaredeliveringthe

majorityoftheirprimarycareservices.BasedonthataSribuCon,allothercostsareassignedtotheACO—regardlessofwhethertheaSributedphysicianorderedthecare.

MostphysiciansarenowemployedbyhospitalsandhealthsystemsorlargemulC-specialtygroups.Evenin

geographicareaswiththelargestpercentagesofindependentpracCces,aminorityofphysiciansareontheirown.OfthoseprimarycarephysiciansmakingupthecoreofACOaSributedpaCents,evenmoreareemployedbyhospitals.

Nonetheless,physiciansremainbothskepCcalanduninformedabouthealthcarereform,withadecliningnumber

believingthatACOsarelikelytoincreasequalityordecreasecost.Physiciansalsostronglymournthelossoftheir

clinicalautonomyandCmeforpaCents—whostronglyagreethatCmewiththeirphysiciansistoolimited.

ForanACOtosuccessfullyprovidecohesive,coordinatedandcosteffecCvecare,thefrontlinephysiciansmust

believethattheyhavetheassistanceoftheirACOorganizaConstoprovidethiskindofcare.TheywillneedinformaConandsupport,buttheyalsomustbepartoftheenterprise’sdesignandthoughtleadership.

ACOsShouldEmbraceHealthCareConsumerismToWinLoyalty

WhenanACOisformed,parentorganizaConandprovideraitudestowardandtreatmentofpaCentsojendiehard.ACOapplicaConandreviewofaSributedpaCentsaregearedtoviewingthemasassets,ratherthanas

individuals.Techniquesonhowto“manage”paCentsandavoidnetwork“bleeding”arefrequentlydiscussed.ThisprevailingviewofpaCentsasamonolithicgroup,disCnguishedmainlybyrisklevel,is—tosaytheleast—

troublesome.

PaCentconcernsaboutprovidersarewell-documented,andalltheseissueswillbecarriedovertoanACOunlessleadershipreengineersaitudes,processesandpaCentcommunicaCon.Whybother?Becauseinformed

consumersarecriCcaltotheACO’ssuccess.UnlesspaCentsareguidedwithfactsandcostinformaConabouttheiropCons,theywillnottrustACOproviders.



https://www.ama-assn.org/sites/default/files/media-browser/public/health-policy/PRP-2016-physician-benchmark-survey.pdf

https://www.ama-assn.org/sites/default/files/media-browser/public/health-policy/PRP-2016-physician-benchmark-survey.pdf

https://physiciansfoundation.org/press-releases/the-physicians-foundation-2016-physician-survey/

https://physiciansfoundation.org/press-releases/the-physicians-foundation-2016-physician-survey/

https://rojihealthintel.com/2017/02/14/turning-patients-into-health-care-consumers-for-economic-survival/

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ArecentpaCentsurveyrevealedsomenoteworthydataforprovidersformingACOs:

• PaCentsnotonlyagreewithphysiciansthatvisitCmeisinadequate;evenmorepaCentsthanphysicians

believethistobetrue.

• 90percentofpaCentsbelievethattheirprovidersshouldlookbeyondresultsandevaluateobstaclesto

improvementintheirhealth.

• MostpaCentsareveryconcernedabouttheirabilitytopayformedicalcare.

• Mostbelievethatthesystemistoocomplicatedanddon’tunderstandreforms.

BusinesshasunderstoodforalongCmethatconsumerloyaltyderivesfromaddressingconsumers’expressed

needs,notbytellingthemwhattheyshoulddo.ForanACOtoachieveamoresuccessfulcaremodel,paCenttrustisessenCal.ThattrustmustbeearnedbyaconcertedefforttoachievewhatFee-for-Servicehealthcarecouldnot

—providingreliable,accessibleinformaConforhealthcareconsumerdecisions.

Would-BeACOsIncreaseChancesofSuccesswithInnova5veDevelopment

ThechallengeforACOsrestsontheirabilitytoachievecostsavings,fortworeasons:First,mostACOsscore

similarlyonqualityreporCng,regardlessofsizeororganizaConalstructure.Second,savingmoneyisthehardpartandthehighestconcernfororganizaConsatfinancialrisk.

SeveralfactorsseemtopredictACOcostsavings.Onthequalityfront,ACOsthathavebeenintheprogramlonger

tendtodobeSer.Predictably,morephysician-ledACOsachievesharedsavingsthanhospital-ledACOs.Andsurprisingly,smallerACOsseemtodobeSerthanlargerorganizaCons.

NotethatACOsuccessappearstodovetailwithphysicianappreciaConandpromptaSenContopaCentconcerns.Thissuggeststhatsizemaynotbeasmuchadeterminantofsuccess;rather,ACOsshouldworktowardbeSer

physiciancommunicaConandstrongerleadership.Furthermore,hospital-basedACOsshouldrethinkhowtheyare

construcCngtheirACOstobemoresuccessful,asignificantchallengetothemodel.

LayaSolidFounda5onwithaCrea5veACODevelopmentAgenda

ManyorganizaConsnaturallyassumethattheycanachievesuccessbasedonhistoricalprowessofmarketshareandsizeintheFee-for-Serviceworld.ButitappearsthatsuccessfulACOsaretrendingtowardleaner,more

physician-andpaCent-focusedorganizaConsasamodelthatcanwork,if—aBigIf—thereisenoughcashforthe

iniCalandongoinginvestment.

ProvidersenvisioninghowtoconstructasuccessfulACOshouldconsiderthisdevelopmentagenda:

• CreateanACOprimarycarenucleus.AnucleusofprimarycarephysiciansisthecoreofanACO.CostinformaConisavailablefromMedicare,withpermissionbythepracCce,thatcanbeusedtoevaluatethe

groupbasedonpastqualityreporCngandcosthistory,inordertoidenCfypotenCallysuccessfulgroups.



https://physiciansfoundation.org/press-releases/the-physicians-foundation-2017-patient-survey/

https://physiciansfoundation.org/press-releases/the-physicians-foundation-2017-patient-survey/

https://catalyst.nejm.org/do-independent-physician-led-acos-have-a-future/

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• DevelopanACOplanaround5,000-10,000pa5entsofthoseprimaryphysicianpracCcestargetedaslikely

successfulandwilling.AmulC-specialtygroupmayneedtoconsiderseparaCngbusinessunitsof

parCcipaCngprimarycarephysiciansandotherprofessionalstaff,toaligntheireconomicswiththeACO.

• Createdegreesofsepara5onfromexis5ngorganiza5ons,ifneeded.Regardlessofwhetherahospital

organizaConorphysiciangroupisleadingthechargeonACOdevelopment,physiciansaresocentraltotheservicesthattheyshouldbeleadersoftheorganizaCon.ReferralpaSernsbuiltonstokingvolumeto

specialistsandtechnology-drivenserviceswillrequirereevaluaConofspecialtyservices(andfees)bythe

ACO.PoliCcallychallengingtoaccomplishinoneorganizaCon,thiseffortcouldbenefitbycreaCngaseparateenCty,atleastonapilotbasis.ThiswouldhelpremovethoseparCcipantsfromtheorganizaCon

whodonotbelieveintheACOorareaversetofinancialrisk.

• Appointapa5entadvisoryboardthatparCcipatesindevelopmentandongoinginiCaCves.Toaddressthe

healthcareconsumerissuesidenCfiedpreviously,theACO’sleadershipmustbeindialoguewithpaCents,

includingpaCentswhowillnotbeaSributedtotheACO.

• ChoosetechnologyforpopulaConhealth,analyCcs,qualityreporCngandguidanceoftheACO.Begin

assessmentoftheproposedpracCcesandpaCentpopulaContoestablishthekeyiniCalareasoffocus.

• Establishpa5entcommunica5onpreferencesandmechanisms.ACOapprovalistoolatetobeginthe

processofsecuringcommunicaConchannels,whichshouldbedrajedinconcertwiththepaCentadvisory

boardandmodifiedasneededlater.IfthereareexternalvendorswhowillplayaroleinpaCentcommunicaCons,theycanbepre-selectedduringthisphase.

• Establishmaterialsforpa5entsoncostandkeyiniCaCvesthatwillhelpthemunderstandwhattheACOis,howtheymaybenefit,andhowtoprovideinputaspaCentsandparCcipants.

Alloftheabovearepre-applicaConacCviCesthatcanbedonebygroupscurrentlyinvolvedintheMIPSprogram.Infact,usingthefourcomponentsofMIPScanhelporganizaConsdothespadework:reviewingcomparaCvecosts,

establishingpopulaConhealthandperformanceimprovement,andcreaCngqualityregistriesforMedicare-specificpopulaConsalongwithallMIPS-eligiblepaCents.

ThesuccessofACOsmaylieintheabilityoftheprincipalstoside-stepcurrentcultureandobstaclestocreatea

newdesignforcare,poweredbyphysiciansandpaCents.FororganizaConssCllholdingoutondevelopment,thepromisingtrackistostartsmallandgrow,usingcurrentdataandinfrastructureunderMIPSasanACOstart-up.

ImageCredit:IsraelEgío

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http://www.modernhealthcare.com/article/20170404/NEWS/170409996

http://www.modernhealthcare.com/article/20170404/NEWS/170409996

https://rojihealthintel.com/about/advantage/

https://rojihealthintel.com/solutions/improve-performance/

https://unsplash.com/photos/SHJMuYQSRn8

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PartII:DevelopmentStrategiesthatPutYourACOonPathtoSavings

FourACODevelopmentDecisionsThatWillImpactReturnonInvestmentbyTheresaHush RojiIntelBlog;April25,2018

“It’snothowyoustart,buthowyoufinish”mightbethewaysomeACOs

mustnavigateadifficultpathtosuccess.ButfororganizaCons

planninganewACOventure,that

rockypathmaybeavoidable.

TheearlydaysofACOdevelopment

arebehindus,andACOmodelstotakeonfinancialriskarenow

underway.AchievingareturnonACO

investmenthasproventobeelusiveformostproviders.Thereisprogress,

butnovictoryyetinsight.

SoACOsandindustrywatchersaresearchingforthekeysthatallowsomeACOstoexperiencemoresuccessthan

others.Whetherphysician-ledorhospital-led,primarycare-orspecialty-lopsided,largeorsmall,downside-riskor

no—thequesConishowtoreplicateACOfeaturesthatwilldrivesuccess.

EarlyDecisionsWillAffectACOFuture

ManyACOshavegrownorganically,outofexisCngrelaConshipsandestablishednetworksformedforhealthplancontracCngpurposes;or,formedbyhealthsystemswiththeiremployedproviders.TheprovidernetworksofACOs

canthusreflectfamiliarandpoliCcalalignments.ButhistorydoesnotnecessarilycontributeanidealstructureforanACO.

InparCcular,anACObuiltontradiConalFee-for-ServicerelaConshipswillbechallengedwhenthatACOmoves

towardfinancialrisk,unlessitiswillingtoinnovateitscaredeliveryandcustomerservice.PhysiciansmustbeabletoshareintheACOdevelopmentandlearningprocesstoaccomplishthis.Medicaldecision-making,useof

resources,referralstootherproviders,andpaCentrelaConshipswillallshapetheACO’squalityandfinancial

performance.TransparencyofdataanddecisionprocessesshouldbeestablishedforphysiciansaswellaspaCents.



http://www.healthcarefinancenews.com/news/meaning-risk-aco

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1121170/

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PartnersoftheACOshouldrealizethatnomagicalformulahasbeendiscovered.ACOshaveexperiencedsuccess

andfailureacrossdifferentgovernancestructures,sizesandprovidercomposiCons,andevenfromyeartoyear.In

short,ACOsuccessmaybestbedeterminednotbyconcretestructuraldesign,but,rather,bythetransformaConalcultureoftheorganizaConandthecommitmentofitsparCcipaCngproviders.

Inthatlight,weofferfourcriCcaldecisionareasthatwillinfluencetheACO’scapacityfortransformaConandsubstanCvelyaffectitsreturnoninvestment:

• PhysicianparCcipaConandACOphysicianculture;

• Datasharing;

• InnovaConandexperimentaContoimprovecareandoutcomes,aswellascosts;

• ConsumerandpaCentempowerment.TheseresemblequesConstypicallyencounteredbyanygoodstart-upcompany:

• Whatisourmarket?

• Whatareweselling,andhowisitunique?

• Howdoweengageourpartners/employees?

• HowdowesaCsfyourcustomers?

FourACODevelopmentPrinciplesthatWillBenefitReturnonInvestment

1.DeterminehowphysicianswillbeinvolvedintheACObeyondcaregiving.

PhysicianshavejoinedACOsforavarietyofreasons,includingtheabilitytoaffordinfrastructureandparCcipateinValue-BasedHealthCare.ButparCcipaConandpartnershiparedifferent.Theneedfordialoguewithphysiciansand

inclusioninACOdevelopmentcannotbeoverstated.PhysiciansmusthavetheCmeandresourcestochange,as

wellassupportforprocessesthatdemandmorefromthem.Forexample,reviewofdataandperformanceimprovementwillinvolveworkoverandaboveclinicalCme,detracCngfrompaCentcare.Physiciansmustbe

allowedtheextraCmeforsuchiniCaCves,alongwithconflictresoluCon,withcompensaConandotherrewards.

PhysiciansmustunderstandthesharedcommitmenttoACOgoals.Thatunderstandingcomesfromsharingof

performancedatainaposiCvelearningenvironment,experimentaConofcareredesignonasmallscale,and

developmentandevaluaConofACOiniCaCves.

Itisespeciallyimportantforphysicianstounderstandthebusinessfocusanditsexpectedreturnoninvestment.

TheyshouldbeabletoidenCfywherethesavingswillbegenerated,whatitwilltakefromthemtodoit,andhowtoexplainnewprogramstopaCents.PhysiciansshouldseeaggregateaswellastheirindividualimpactsonACO

successorfailure.



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2.MakedatathebedrockofACOcommunica5onswithphysiciansandwithpa5ents.

PhysiciansshouldrouCnelyreviewdataonclinicaloutcomes,clinicalqualityandcoststhatareCedtoACOperformancegoals.Butthatisjustabasiccourtesy.Here’swhatisreallyimportant:thefullstoryshouldbetold

throughdata,sothatphysiciansarenotseeingpiecemealresultsofseparateiniCaCvesortheirownpaCents.

PhysiciansshouldseethebreadthofdatathatwillreflectpaCentillnessanddifficulCesreflectedinoutcomesandqualityperformancemeasuresorcost,includingvariaConsincare,withtheopportunitytoinvesCgatereasons,cost

ofcarewithepisodecomparisons,uClizaConandreferralpaSerns,andothercostdrivers.

Likewise,ACOpaCentswillbenefitbyadeeperunderstandingoftheACOdeliverysystem.Firstofall,theyneedto

knowhowtheycomparetoothersinsimilarpaCentpopulaConsandagainstbenchmarks.Theyshouldbeableto

seequalitymeasuredataforwhichtheyqualify,andtheirresults.AndpaCentsshouldunderstandhowthecostoftheircarecompareswithothers.

3.Embraceinnova5onandexperimenta5onintheACOtoimprovecareandcostsoverthelongrun.

The“easier”costreducConsforACOsusuallyinvolveeffortstoreducereadmissionsandinappropriateadmissions,

andtorefocuspost-acutecare.CoordinaConofcareandpaCentoutreachmayalsohelptokeepservicesin-house,

whichwillsaveCmeandmoneybyavoidingduplicaConofservices.

Butthemostsignificantinroadstoqualityandcostswilleventuallycomefromreformsthateitherre-engineercare

deliverytohighriskandvulnerablepopulaCons,helpingphysiciansandpaCentsmakevalue-baseddecisionsonlifestyleandtreatment,orthatreduceFee-for-ServiceincenCvesforoveruseofservices,parCcularlyspecialty

services,throughepisodicpaymentarrangements.

4.Empowerconsumersandpa5entswithinforma5onthatwillfacilitatetheirhealthstatusandvalue-basedmedicaldecisions.

AdopConofanACOmodeldoesnotnecessarilychangehowtheenterprisetreatsnewandexisCngpaCents.WeencourageACOstoviewpaCentsascustomerswithlegiCmatepreferencesaswellashealthneeds,respecCngtheir

rightstodata,costtransparencyandchoiceoftreatment.Thisisahistoricaldeparturefromtherealityofmost

healthcareorganizaCons,whichunfortunatelymaynotviewpaCentsastherealcustomers.Instead,theymayviewpaCentsasaccounts,asassets,revenuesourcesandsubjectsinresearchorotheracCviCeswhoneedmanagement

andcontrolledchoices.

OnlyACOsthatrespecttheircustomersarelikelytomaintainpaCentloyaltyandachievebeSerperformance.All

ACOfuncConsmustincorporatepaCentcommunicaConandpaCentchoiceintoiniCaCvesandfosteracustomer

serviceculturethroughouttheorganizaCon.Ofmostimportance,ACOswillneedtoensurethatpaCentsreceivethevalueinformaConcomingfromresearch,accuratecostinformaCon,andenoughCmewithphysicianstomake

informedtreatmentchoices.

AsHMOstaughtus,downsideriskforprovidersandparCcipaCngphysicians—whileincenCvizingeveryonetohave

“skininthegame”ofachievingsavings—mayhavetheunintendedconsequenceofnegaCvelyaffecCngpaCents.




https://rojihealthintel.com/2018/03/14/can-provider-led-acos-and-aapms-deliver-health-care-transformation/

https://www.ncbi.nlm.nih.gov/pubmed/24719703


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Thereisariskofdenyingcare,skimmingpopulaConsforhealthierindividualsandredliningpopulaConsaltogether.

WhileACOsmayformontheconceptofbeSerquality,aitudestowardpaCentsandconsumerswillaffectthat

careinarisk-basedmodeloverCme.

Consumersinprivatehealthplansmaynoteasilybeabletogooutofnetworktonon-ACOproviders,butthosein

Medicarewillvotewiththeirfeet.ACOsthatworkhardwithpaCentstowintrust,engagethemwithinformaConanddecision-making,andrespecttheirrighttodataandinformaConwillberewardedwithpaCentswhoachieve

beSerresultsandremaininthenetwork.

ACOReturnonInvestmentWillRequireCultureShib

ACOsspendmostoftheirlead-uptodevelopmentongovernance,providernetworkformaConandfinancing.

Certainly,theformfortheACOissignificant,andthesedecisionswilldetermineACOstructureandpresence.ACOfuncCons,however,willbemoreimportantforachievingactualcostsavingsandimprovedpaCentoutcomes.

ThosefuncConswillbebuiltonchangesthatareenergizedbymission,involvementandaitudeswithintheACO.

AculturethatembracesinnovaConandcreaCvitywillberequiredforanACOtosucceed.Inthesamewaythatanynewbusinessdevelopsandgainsground,itsstakeholderphysiciansmustfeelengagedinitspurpose.Andits

customersmustbeaSractedontheirownterms,notthoseoftheACO.

ImageCredit:RyanMcGuire





https://cdn.gratisography.com/photos/444H.jpg

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ACOEconomics101:Op5mizethePhysicianNetworkForPa5entChoice byDaveHalpertRojiIntelBlog;April4,2018

TheinauguralMIPS2017submission

periodclosedinafogofuncertainty.ThedemiseofMIPSloomsonthe

horizon,withliSlediscussionof

opportuniCesforimprovement.HeathandHumanServicesSecretary

AzarhasadvocatedforremovingthequalityreporCngcomponentofMIPS,

whiletheMedicarePaymentAdvisory

CommiSee(MedPAC)recommendedscrappingMIPSaltogetherand

pushedforatransiContoAlternatePaymentModels.

NotethatneitheroftheserecommendaConsadvocateareturntoasimpleFeeforServicemodel—itisnot

sustainablefinancially.Value-BasedHealthCareisheretostay,butAdvancedAlternatePaymentModels(AAPMs)withfinancialriskarethefavoredpath,ratherthanatransiConalprogramlikeMIPS.TheQualityPaymentProgram

alreadyincenCvizesprovidersparCcipaCnginAlternaCvePaymentModels,withACOsbeingthemostpopularopCon.Sincethefirstapprovalsin2012,thenumberofACOshasincreasedeachyear;therearenow561Medicare

SharedSavingsProgramsandNextGeneraConACOs,with10.5millionaSributedbeneficiaries.

ThebigquesConforproviders:HowtoincreaseconfidenceinReturnonInvestmentforACOdevelopment?WithmillionsofdollarsinpotenCallossesatstake,creaCnganACOwithtwo-sidedriskrequiresunderstandingthe

detailsofMedicare’seconomicmodel.DrawingontheexperienceofACOswiththebestperformancetrackrecords,providersaremostlikelytosucceedbyfocusingonfivekeyareasthatwillinfluenceoutcomes:

• OpCmizeACOphysiciannetworkforpaCentchoice;

• Improvecostperformancethroughspecialtyreferralsandpost-acutecare;

• ManageparCcipaCngproviders’riskandreward;

• ReengineerprocessesforchroniccondiCons;

• FacilitatepaCentMedicalDecision-Making.

AlthoughthereareotheropportuniCesforachievinghealthcaresavings,concentraCngonthesefiveareaswillreapthemostgains.Let’stakeacloserlookathowtoopCmizetwofluidcomponentsoftheACOtobuildasolid

economicfoundaCon:thephysiciannetworkandthepaCentpopulaCon.


https://morningconsult.com/2018/02/15/hhs-may-nix-reporting-requirements-for-value-based-care-program-azar-says/



http://www.medpac.gov/docs/default-source/reports/jun17_reporttocongress_sec.pdf?sfvrsn=0



https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/SSP-2018-Fast-Facts.pdf


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HowMedicareA\ributesPa5entsCanAffectACOSavings

MedicareaSributespaCentstoanACOthroughaformulabasedonwhichprovidermostrecentlyprovidedservicestothatpaCent—eitheraprimarycarephysicianoraspecialist.IfthepaCentisassignedtotheACObasedona

primarycarerelaConship,oddsarethepaCentwillstaywithintheACOnetworkanditsreferralarrangementstoreceivecare.However,iftheassignmentistoaspecialtyphysicianbecausethepaCentonlyreceivedcareduring

prioryearsforaparCcularcondiConorprocedure,paCentcareislesslikelytobecoordinatedsuccessfully.

AStrongPrimaryCareNetworkBe\erPosi5onsACOsforSuccess

SinceallpaCentshavefreechoicetoseeanyMedicareprovider,thefirstjoboftheACOistoopCmizethe

possibilitythatthepaCentwillstaywithintheACOnetworkandreferralarrangementstoreceivecare.Thisisthekeystonetomanagingcosts.DevelopingastrongprimarycareACOnetworklaysthefoundaCon.

ToavoidbeingCedtopaCentswhoarenottrulymanagedbyanACOprimarycareprovider,ACOsshouldbewary

ofcertainpiuallsintheaSribuConmethodology.Forexample,paCentsmaybeaSributedbasedonanencounterwithaNursePracCConerorPhysicianAssistant,regardlessofseing.So,apaCentwhoseesaNursePracCConerin

aspecialistseingmayCpthatpaCent’saSribuContothespecialist,parCcularlyiftherearemulCplevisitswiththatNP.IncaseswheretheNPisinahighcostseing(e.g.anoncologycenter),anACOwillbechallengedto

managethesepaCents’healthcareexpenditures.

A\ribu5onFormulaCanResultinMoreACOSpecialistsandHigherCostPa5ents

HowtheACOincorporatesprimarycareandspecialistsinthephysiciannetworkisessenCaltomaximizepaCent

connecConanddecreasecost.ThereisaparCcularrisk,especiallycommoninhealthsystemswithmanyemployedphysicians,ofincludinglargemulC-specialtyandsingle-specialtygroups.Inlargesystems,anetworkdominatedby

specialistsparCcipaCngunderasinglelegalpracCceenCtyisareality.SinceMedicaredefinesparCcipaCng

pracCcesbytheACO’sdesignatedTaxIdenCficaConNumber,anACOwithspecialtyvolumerisksthehigherlikelihoodofpaCentsbeingaSributedtothosespecialistsforreceivingspecialty,butnotprimary,care.

Specialist-dominatedpaCentaSribuConresultswillskewtheACOpaCentpopulaContowardhighercosts.Evenwhenrisk-adjusted,theACOhaslesslikelihoodofreducinghighercosts,especiallyintheshortterm.Becausethe

medicalhomeofthepaCentisnotwellestablished,thereislessopportunitytoavoidemergencyroomvisits,

servicesofotherspecialistsoutsidethesystemfordifferentcondiCons,andcoordinaConofcare,ingeneral.AhandfuloflargersystemsormulC-specialtygroupswithastrongprimarycarecoremayhavetheresourcesand

experiencetoovercomespecialistaSribuConissues.Butformost,itwilltakeyearstorecognizeandcorrecttheissue.



https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/Shared-Savings-Losses-Assignment-Spec-V5.pdf

https://www.hhnmag.com/articles/3650-whose-patient-is-this-anyway

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ThreeWaysACOsCanBe\erAlignA\ribu5onofPa5ents

ACOscanadjustaSribuConwiththreekeystrategies:

1.IncorporateaStrongPrimaryCareCore,StrengthenedbyPhysicianLeadership.

AnACOsponsormusthaveacorenetworkofprimarycarephysiciansthataccountsforthevastmajorityofpaCent

aSribuConstoitsACO.Ifthisnetworkdoesnotexist,orifthepopulaConaSributedtoprimaryphysiciansislessthantheminimumpopulaConoftheACO,itmaybewisetoconsiderdelayunClthisgoalisachieved.

ASribuConisoneofthestrongestpredictorsofACOsuccess.TheidealaSribuConisbasedonprimarycare

aSachment—notbecausethiswilleliminatepaCentswhomayalreadybechallengedwithhigh-costcondiConsbut,rather,becauseitwillbehardertocoordinatebestcareforthepaCentwithouttheprimarycareteam.Conversely,

theACO’sgoalisalsonottotargetonlypaCentswhoareincontroloftheircomplexcondiCons.TheACOmustdevelopitsfoundaCononamedicalhomeandneighborhoodmodeltorespondtopaCents’condiCons,risksand

barrierstocareinacoordinatedwaythatdealswiththewholepaCent.TherearemanyreasonswhypaCentsare

appropriatelyseeingspecialistsandnotprimariesfortheircare—buttheymayalsonotbethebestiniCalpaCentpopulaConfortheACOtobeginitswork.SuccesswillrequirestagingofACOdevelopment,andthenetworkwill

changeoverCme.

InformaConaboutexisCngACOsiscompellingenoughtoproffera“smallerandlighter”opConwithacarve-outof

physiciansfromalargerhealthsystemintoadedicatedACOnetwork.Ashospitals,physicianpracCcesand

extendedserviceshaveconsolidated,largeenterpriseshaveformed—ojenwithdemonstrablyhighercosts.ThoseconsolidaConswereintendedtogainmarketshareandpaCentsunderValue-BasedHealthCare.Butlargersize

doesnotguaranteesavings.Also,bureaucracyandpoliCcsoflargeorganizaConscanimpedeinnovaCon.BusinessesseekingmarketdisrupConojendevelopnewsubsidiariesthataremorenimbleandunencumberedto

createchange.AnACOmaybewellservedtoconsiderasimilarapproach.

2.UseAppropriateSelec5onCriteriaforACOProviders

HowACOsselectprovidersrequiresadifferentapproachthanunderFee-for-Service.BasicACOeconomics

penalize,ratherthanrewardvolume.Thus,thetradiConalphysicianselecConcriteria—numberofphysicianadmissions,volumeofservices,andhigh-endservices—hurtanddonothelpACOefforts.Instead,ACOsshould

considertheirproviders’previouscostprofiles,requesCngcopiesofMedicareQRURs.Thesecostreports,inaddiContoexpenseprofiles,willalsoflagaSribuConissuesforspecialtyphysicianswhoareprovidingtheplurality

ofprimarycareservices.

Otherdataonproviderswillalsobeofvalue.TheseincludepaCentsurveys,qualityrankingsfromhealthplans,referralarrangementsandpreferences,andreviewoffinancialandqualitydata.PhysiciansparCcipaCnginanat-

riskACOare,inessence,goingintobusinesstogetherandtyingtheirfuturerevenuestothesuccessoftheenterprise.Thesephysiciansshouldbewillingtosharedatatostrengthenthatenterprise.



https://naacos.memberclicks.net/beneficiary-attribution

https://www.cms.gov/medicare/medicare-fee-for-service-payment/physicianfeedbackprogram/obtain-2013-qrur.html

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3.UseMechanismsThatEncouragePrimaryCareA\ribu5on

SomemechanismsexisttofacilitateprimarycareaSribuCon.TheideaistocreateastrongerbondbetweenthepaCentandtheprimarycareproviderandavoidun-referredcare.

PrimarycareproviderscanuseAnnualWellnessVisits(AWVs)toensurethatpaCentsareseenandevaluated.

PaCentsaSributedtospecialistscanbeofferedAWVstobegintheprocessofengagingthepaCentwithaprimarycarephysician.WhilethesevisitsrequireextraCme(andarenotprobono)theyprovideaforumforprevenCve

care,screeningandchronicdiseasemanagement—aswellasaproacCvemechanismtocalculaterealpaCentriskforpopulaConhealthiniCaCves.TheprimarycareconnecConandprevenCvecareareamongentryrequirements

thatsomeadministratorsandphysicianswithACOexperienceconsiderimportant.

AnnualWellnessVisitscanalsobenefittheACObyadjusCngaSribuCon.AnAWVeachyearwillensurethatthepaCentsbeingcaredfor(andkepthealthy)conCnuetobeaSributedtothatACO.Sincespendingtargetsarebased

onpaCentsseenduringthepriorperformanceperiod,ACOsshouldalsoensurethatthosewhohadanAWVthepreviousyearreturnduringthecurrentyear.

Primarycareproviderscanalsohelptocurbthemyththatavisittoaspecialist(alongwithanotherroundof

diagnosCcs)meansbeSercare.ASharedDecision-MakingprocessthatpromotespaCentacCvismwillhelppaCentstoweighbenefitsandharmsofservicesandmakebeSermedicaldecisions.Forexample,homebasedpalliaCve

careattheendoflifeforpaCentswithinanACOledtocostsavings,ashospiceuClizaConincreased,whilehospitalizaConsdecreased.Inshort,paCentchoicecaneffecCvelyalignwiththeACO’sstrategicobjecCvesifboth

thephysicianandpaCentareprovidedtheCmeandsupporttosetgoalsandmakedecisions.

LessonsonEconomicsfromPastFinancialRiskModels

AnACOdiffersfromanHMO—thepredominantmodeloffinancialriskinpastdecades—bytwomainfeatures.

First,theACOisaproviderenCtyanddrivestheorganizaConofitsphysiciannetwork.Second,thepaCentisfreeto

chooseprovidersfromtheenCreMedicarephysicianpanel,withoutpenalty.

ThesetwoaspectsmustbeinbalancefortheACOtoachieveefficienciesaswellasimprovedpaCentoutcomes.

PaCentsmustbesaCsfiedtostayinthenetwork.TheirsaCsfacConstemsfromamoretrustedrelaConshipwiththeirmainphysicians,agreatersenseofinvolvementandcontrol,andmoreinformaCon,inkeepingwiththeir

goals.

Let’snotsugarcoatit—havingalotofprimariesinthenetworkandpaCentsaSributedtoprimariesisn’tenoughforanACOtomakeit.Thereismuchmorerequiredforsuccess.GoodcommunicaConmethods,enoughCmetoask

quesConsandmakechoices,andcosttransparencywillallaffectpaCentloyaltyandacCon.ButwithoutsoundselecConofanACOnetworkorphysicianswhoarewillingtoleadandinnovate,anACOcan’tevengetoffthe

ground.

ImageCredit:PatrickTomasso BacktoTableofContents



http://medicaleconomics.modernmedicine.com/medical-economics/news/top-risks-and-rewards-acos


https://www.beckershospitalreview.com/hospital-physician-relationships/6-ways-acos-differ-from-hmos.html

https://unsplash.com/photos/HM731qUoUas

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PartIII:InnovateinYourACOtoAchieveTripleAim

CanProvider-LedACOsandAAPMsDeliverHealthCareTransforma5on? byTheresaHush RojiIntelBlog;March14,2018

“InCmesofrapidchange,experiencecouldbeyourworstenemy,”saidJ.

PaulGeSy.Hemighthavebeengivingusadviceonhowtotransform healthcare.

WehavereachedtheCppingpointforbroaderadopConofACOsand

otherAdvancedAlternaCvePaymentModels(AAPMs)toorganizehealth

careandpaymentunderboth

Medicareandcommercialinsurance.Butourrecentexperiencecannottell

uswhethertheseapproacheswillwork.

This,despitethefactthatanesCmated10percentofinsuredindividuals—32millionpeople—werealready

coveredbyprivateandpublicACOservicesinmid-2017.AndwereachedthatpointevenbeforeMedicareapproved124newACOsfor2018,foratotalof10.5millionMedicarebeneficiaries.Notethattheprivatesector

coversmoreACOpaCentsthanMedicare,althoughthemodeloriginatedasaMedicaresoluCon.

CMSispushingMedicareawayfromthecurrentpaymentprogramintoAAPMs,includingACOs.Theagencyis

clearlysupporCveofMedPACrecommendaConstooverhaulMIPS,thealternaCveMedicareValue-Based

Reimbursementprogram,andescalaCngAAPMparCcipaCon.

So,nowthatwe’rehere,canACOsandotherAAPMsactuallydeliveronthegoalsofcostcontrolandquality?As

theAAPMmodelofACOsmovestowardgreaterrisk,effecCveacConstocontrolcostswillbeessenCal—anddisrupCvetotheirproviders,theirarrayofservicesand,potenCally,totheirpaCents.HerearesomecriCcal

quesCons:

• HowcanprovidersstewardasystemthatdependsonvoluntarypaCentloyaltytokeepserviceswithintheACO?

• HowcanACOs—especiallyfacility-andtechnology-heavyACOs—sustaincontrolledcostsbelowabenchmarkwithannualreducCons?



https://www.healthaffairs.org/do/10.1377/hblog20170628.060719/full/

http://www.healthcarefinancenews.com/news/cms-medicare-adds-124-acos-2018



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• Willprovidersbewillingtotrimspecialistsandtechnologytokeepwithinbudget?

• CanprovidersreallydeliveronbeSeroutcomesforpaCents,includingthosewithhighriskanddifficult

socialneeds,andsClllowercosts?

ThisiswhereACOeconomicsandpaCentneedscomeintoconflict.ACOanalyCcswillidenCfywhichpaCentshavehigherriskandwhichpaCentshaveproblemaCcuClizaCon.Theexpenditurethresholds,loweringeachyear,create

riskforprovidersastheybegintolaunchprogramstoaddresssoluConsforthesepaCents,suchasbeSerservice

coordinaConandnecessaryintervenCons.

ACOSuccessIsErra5c,butBeliefRunsHigh(NotAlwaysAmongPhysicians)

SuccessamongACOshasbeenspoSy,atbest,anddifficulttoachieveformostorganizaCons.ThedifficulCesariseacrossalltypesofACOstructures:physician-led,hospital-led,jointlyled,andsoon,althoughatleastoneanalysis

confirmsmuchbeSerresultsfromACOsledbyindependentphysicians.AddiConally,whilefirstyearacCviCescan

yieldeasiersavingswithlowerreadmissions,sustainedeffortisdifficultanduncertain.Indeed,ACOscangofromsuccessoneyeartomissedtargetsthenext,makingithardtokeepproviderswhenfinancialriskisimposed.

Thefactis,noonehasdiscoveredthetried-and-truerecipeforACOsuccess,despitethevarioussuccesscriteriaopCmisCcallylistedbyACOvendors.And,tobesure,specificsystemshaveachievedbigpayback.Beliefinthe

modelrunshighwithintheindustry.ManyproviderorganizaConsmaintainanopportunisCcbeliefintheabilityto

capturemarketshareandgrow.HealthplansandotherfinancialwatchdogsholdthecurrentFee-for-ServicesysteminsuchdisdainthattheyviewamoreorganizedalternaCvewithbeSerintenConsasagoodstep.Healthplanshave

foundawayofpartneringwithproviders,ensuringongoingbusinessservicesandcontractsthatkeeptheboSomlinehealthy.

Forprivatephysicians,ACOsappeartoofferachancetoacquireinfrastructurethatmightotherwisebe

unaffordableand,possibly,apathtomaintainindependence.However,physicianswhoactuallyparCcipateinACOsarenotuniformlyconvincedthatthemodelcanbesuccessful,andmanydonotevenunderstandtheparCcularsof

theirownACOs.InaddiCon,manyphysiciansdonotbelievethattheACOactuallycontributestosavingsanddonotfeelbenefited.

Con5nuedACOSavingsRequireMoreThantheBasics

AnecdotesfromtheACOfrontlinesshowthatmanytendtopursuethesameiniCaCves.Amongthem:

• Effortstoreducere-admissions,suchaspost-dischargecontactorarrangementsforajercare;

• Popula5onhealthini5a5vestofillgapsincare(suchasthosedefinedbyqualitymeasures);

• Analy5cstoiden5fyhighriskindividualsorthosewithhighemergencyroomuseandsteertheminto

variousintervenCons,ifpossible,suchascasemanagement;

• AnnualWellnessVisits,whichmaybecombinedwithothereffortstoelicitpaCent-reportedoutcomes,gatherqualitydata,establishrisklevels,orsegueintoChronicCareManagement,aswellasother

reimbursedconCnuityofcareprograms;


http://www.nejm.org/doi/pdf/10.1056/NEJMsa1600142


http://www.modernhealthcare.com/article/20170204/MAGAZINE/302049983

https://www.healthaffairs.org/doi/10.1377/hlthaff.2016.1427


http://thehealthcareblog.com/blog/2016/04/25/the-aco-delusion/

http://thehealthcareblog.com/blog/2016/04/25/the-aco-delusion/


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• Physiciandatasharingandgoalseeng,includingembeddedcompensaConplanincenCvestomeet

targets;

• Pa5entoutreachwherethepaCentisaSributedtospecialistsbutappearstohavenoprimarycareprovider;

• Variousdisease-basedmanagementprograms,ojenbeginningwithdiabetes;

• Iden5fyingvaria5onsincare.

NothingiswrongwiththeseiniCaCves.TheyaresolidwaystotakeresponsibilityforapanelofpaCentsandmoveawayfromepisodic,acutecare.Theyarealsonoteasytoorchestrate,becausetheydemandaddiConalworkload

frompracCces,changesinworkflow,datagatheringandphysicianengagement.

Eveniftheseprogramsareperfectlyimplementedandsuccessful—mostorganizaConsonlyhavebandwidthfora

few—theywon’tbeenoughtoproduceongoingsavings.Why?InaddiContothefactthattheexpenditures

benchmarkdemandsmoresavingseveryyear,theseiniCaCvesdonotaddressthekeyareaswherehighcostsmayreside.

ToachievesubstanCalsavings,ACOswillneedtotargetloweruClizaConofservicesbeyondjusthospitalizaConandemergencyroomuse.TheymustlooktothedriversofsuchcostsandfacilitateresoluConofpaCentneeds.

FourWaysACOsCanAchieveBreakthroughsinQualityandCost

ThecostdrainofanagingpopulaCon,coupledwithobesityandchronicdisease,mustpushproviderstoadoptmechanismsthatarewellbeyondthescopeofmostcurrenthealthcareproviders.ACOswillneedtocreatebridges

tocommunityorganizaConsaswellasconnectdirectlytothepaCent,goingwellbeyondtradiConalrolesandservices.It’satallorderfororganizaConsthataretransiConingfromsimplyprovidingservicestoembracing

accountabilityforpaCenthealth.However,thereisnosurerwayforACOstoachieverequiredsavingsthanto

addresstherisingprevalenceofrisk,diseaseprogressionandinequityofcare.

1.Reducehealthdisparityamongpa5ents.

TheACOagendausuallytendstofocuson“reducingvariaCon”incareasacostproblem.IfpaCentpopulaConsweretrulyhomogenous,thiswouldmakesense.Butnotallgroupsofpeoplehavereceivedthesametypeofcare

inthepast,duetoinequiCesCedtorace,ethnicityorgender.

ReducingvariaConisaprocess-orientedtasktofillgapsincare;improvingoutcomesrequiresthatservicesbeindividualizedtopaCentneeds.ACOshavehadadifficultCmeaddressingcostsandqualityeffecCvelyforgroups

suchasminoriCesandwomen,asrevealedbytheirperformance.

WhydoeshealthequitymaSertotheACOgoal?Becauseminoritygroupsandwomenrepresent,intheaggregate,

asubstanCalnumberofpaCentswhogenerallyhaveahigherincidenceandseverityofchroniccondiConsthatwill

havealargeeffectontheACO’sresults,butwhoalsohavelegiCmateconcernsortrustissueswithproviderswho




https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3320738

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havestereotypedthemorfailedtocommunicateeffecCvely.AddressingdisparitywillaffecttwokeyfactorsinACO

savings:paCentloyaltyandfocusedintervenCons,bothofwhichwillimpacttotalcosts.

ReducinghealthdisparitycanhaveaprofoundeffectonoutcomesandaffordabilityofcareforpaCents,accordingtoaRoadMapsuggestedbytheNaConalQualityFoundaCon.ThisshouldalsohelpdisCnguishprovider-ledACOs

frompayeriniCaCves,likeHMOsofthepast.Theprovider-ledACOshouldhaveamissiontodelivercompassionateandrespecuulcarewiththeintentofimprovingpaCenthealth;itwilltakemorediligenteffortstotestand

implementhealthcareintervenCons,alongwithimprovedcommunicaCon.

2.ImplementSharedDecision-Making.

Aswe’vediscussedinaseriesofarCclesonmedicaldecision-making,onekeytoachievingbeSerresults—both

clinicallyandfinancially—istoclarifythebenefits,potenCalharmsandcostsoftreatmentsforpaCents.SharedDecision-MakingprovidesapathforpaCentstoraConallychooseservices,facilitatedbytheirphysicians’

informaConandguidance.

SharedDecision-MakingrequiresCmeforconversaConsbetweenphysicianandpaCent,whichinthepasthave

beenmarkedbyinterrupConsandfailuretorecognizethepaCentasaraConaldecision-maker.

ToachieveposiCveresultsonsavings,theACOmustworktore-calibratephysicianaitudes,encouragingabeSerunderstandingandappreciaConofthepaCentasdecision-maker.Onlythroughtruephysician-paCentpartnerships

willpaCentsmaintainloyaltyandfollowthroughonplansmadewiththeirproviders.

3.Partnerwithcommunityorganiza5onsorseeksupporttoprovidenecessarysocialservicestopa5ents.

ManypaCentsfacehardshipinmanagingbothhealthcareandhealthcareexpensesbecauseofunmetsocial

needs.SomeAAPMmodelshaverecognizedthisbyincorporaCngsocialsupport,suchasCPCPlus.ACOs,however,havenosCpulatedrequirementtofacilitatesocialservicestopaCents.

AsmoreprovidersrecognizepaCents’needforsocialsupport,communitymodelsareemergingtodevelopinvestor-ownedsocialimpactbonds,medical-legalpartnershipsandothersocialsupportvehicles.ACOsthatare

targeCnglong-termoutcomeimprovementshouldconsidersocialsupportintervenConsamongtheirtoolstomeet

thisgoal,aswellastogarnerpaCentloyalty.

4.Developmeasuresandpaymentstructuresforspecialists,especiallyepisodicpaymentcontracts.

OnedownsideofmostACOmodelsistheambivalentrelaConshipbetweentheACOanditsparCcipaCngspecialists.UnderFee-for-Service,specialtycostsareanexpensive,ojenuncontrollableitemfortheACO.Thereis

consternaConabouttheparCcipaCon—ornot—ofspecialists,withsomeACOschoosinga“contractual”modelfor

referralphysicians.

AbeSerapproachistoorganizepaymentepisodesforparCcipaCngspecialists,coupledwithmeasuredShared

Decision-Making.Underthismodel,specialtyphysicianscanguidepaCentsthroughaprocessofmakingtreatment



https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2017.1301

http://onlinelibrary.wiley.com/doi/10.1111/j.1525-1497.2005.40266.x/full

https://innovation.cms.gov/initiatives/comprehensive-primary-care-plus

http://www.goldmansachs.com/our-thinking/pages/social-impact-bonds.html

http://www.oecd.org/cfe/leed/UnderstandingSIBsLux-WorkingPaper.pdf

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decisions,andanyresulCngdecisiontoundergoproceduresortreatmentcouldbepartofanepisodiccare

agreement.Thatwouldcappaymentstothespecialty,whileensuringthatFee-for-ServiceincenCvestoperform

treatmentsandproceduresareabsentorreduced.

CanProvidersLeadtheTransforma5onoftheIndustry?

Sofar,ACOsavingsarelukewarm.WhilesomearguethatperformancetodaterecognizesthatneitherprovidernorpaCentiscompelledtojoinanACO,thisisnotthesolefactor.TheexisCngACOprogramhassimplynotdemanded

parCcipaCon.TherequirementswillchangesubstanCallygoingforward,sCmulaCngACOstobemoreinnovaCve

anddemanding.

ButcantheyleadthetransformaCon?Thatremainstobeseen.IfACOsareabletoreengineerapaththat

promotespaCentloyalty,beSermedicaldecisionsandpaCent-centricprograms,theycanlegiCmatelyclaimsuchleadership.ThatwillrequiremoreaSenContoanddiscriminaConamongpaCentgroups,less“buckeCng”of

paCentsintopopulaConsbasedonbroadcriteriathatisprimarilyclinical,andreplacingpaCent“management”or

engagementwithsoluConstoidenCfyandmeettheirneeds.

ACOscanchooseanalternatepath,selecCnghealthypopulaConsandaSempCngtoredlinetheirservicesforonly

affluentorwellpeople.Or,theycantrytomaintainpeacebyavoidingchangeandfocusingoneasysavings.Neitherofthesetworoutesislikelytosucceedinthelongrun.RedliningsickindividualswillbackfireaspaCentsareunable

tofindprovidersandmustresorttofloodingemergencyrooms.Lowhangingfruitisquicklyharvested,leaving

ACOsnoalternaCvebuttomakechangestostaybelowexpenditurethresholdsor,underfinancialrisk,paymoneybacktothegovernment.

Experiencemay,indeed,bethedragonrapidchangeinhealthcare.ButcommitmentandinnovaContoimprovepaCenthealthcanbethegasthatpropelsusthere.

ImageCredit:Luoping



https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/MSSP-ACO-data.pdf

https://unsplash.com/photos/5ecaeHJ2ahg


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UnifyACOQualityandCostIni5a5vestoBoostLong-termResultsbyDaveHalpertRojiIntelBlog;April18,2018

Let’sfaceit.There’sapreSylowbar

tomeeCngMedicare’sACOQualityrequirements.MostACOshave

achievedacceptablequalityperformanceforMedicareShared

SavingsPlans(MSSPs).Theyhave

not,however,achievedthesavingsneededtobesuccessful.

ACOsupporterspointtothe“TripleAim”ofachievinghigherquality,cost

savingsandgoodpaCentexperience

throughanACO.TofulfillthattriparCtegoal,wemustlookpastthe

hypeandexecutequality-costiniCaCvesthatgowellbeyondCMS

requirements.

RecognizetheGapBetweenQualityRepor5ngRequirementsandQualityCare

DemonstraCngqualityandreducingcostsarenotmutuallyexclusive.Whilethereisn’tanautomaCclinkbetweenyourACO’ssuccessinreporCnganditsabilitytocontrolcosts,yourbiggestsavingsshouldberealizedbyfocusing

yourqualityeffortsonimprovingpaCenthealthstatuswhiledesigningbeSercaredelivery.NotethatQualityand

qualityreporCngaredisCnct.

Thelinkbetweenqualityandcost,however,hasnotbeenwelldemonstratedinACOperformance.Quality

reporCngscoreshaveincreasedineachofthelastthreeyears;in2017,theaveragequalityscorewas94.65percent.AlthoughqualityreporCngissuccessful(bothintermsofcompleConandperformance),morethantwo-

thirdsofACOssawzerosharedsavings.Only30percentofACOsreapedthebenefitsofthe$700milliondistributed

byCMS.

TounderstandhowACOqualityreporCngcanmeansoliSleintermsofsavings,let’sexaminetheACOquality

requirements.ACOsareonlyrequiredtoreport15measures;theremainingmeasuresarecalculatedfrompaCentsurveysandthroughCMSadministraCveclaims.Thosemeasuresareabstractandoutofsight.




http://www.healthcarefinancenews.com/news/third-shared-savings-acos-earned-more-700-million-savings


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ACOqualitymeasuresalsodoliSletodemonstratepaCenthealthoutcomes.The15measuresacCvelyreported

consistof8prevenCvecareandscreeningmeasures,2carecoordinaConmeasuresand5measuresrelatedto

chroniccondiCons.Themajorityare“process”measuresthattrackwhetherbasicserviceswereprovidedtopaCents.InaddiCon,theACOonlyreportsmeasureresultsforasampleof248consecuCvelyrankedpaCents;asa

rule,ACOsdon’ttrackqualityacrossenCrepopulaConsnorestablishstandardsbasedonpaCentrisk.ConsideringthatanACOhasaminimumof5,000paCents,itishardtoseehowqualityreporCngprovidesanaccurate

indicaConoftheACO’sstandardofcare.

Formany,thequalityreporCngprocessissimplyamaSerofhiringand/orreassigningclinicalstafftoreviewchartstodeterminewhetheranacConwasperformed,ortorecordthemostrecentvalueforagiventest.Asaresult,the

“getitreported”mentalityremovesqualityfromtheequaCon;thetaskofreporCngbecomesanexerciseinadministraConandwork-hours.Thisisperfectlyillustratedbythe2018and2019ACOQualitybenchmarks.Certain

measuresaresimplygradedona10-pointscale,withoutconsideraConoftheACO’spastresults,theexisCng

populaConorotherACOs’results.

Predictably,thevastmajorityofACOssucceedinreporCng,butarenotdemonstraCngtheirfinancialvaluetothe

levelanCcipatedbytheCongressionalBudgetOffice(CBO).

MakingRealImprovementsinACOQualityandCostSavingsRequiresaPlan

ToachievecostsavingsinpaCentcarewhilepromoCngbeSerhealthoutcomes,providerswillneedtounifytheir

viewofcostsandquality.TherearesomequalitymetricsthatdoCetocost,butsincethey’recalculatedbyCMS,they’reinvisible.ACOsneedtobeproacCveandmovetheseintoaunifiedquality-costmeasuresetforinternal

performancemeasurement.

Theusualsuspectsofexcessivecosts—readmissionsandpreventableadmissions,emergencydepartment

uClizaCon,networkouulow—ojenareACOs’firsttargetsformeasuringcostperformance.That’sagoodstepin

therightdirecCon,butasasolecoststrategy,toolimited.It’struethatpost-acutecarecoordinaConorsimilarprocesseswillproducesavingsfromlong-standingissueslikereadmissions.Butamorecomprehensiveapproachto

redesigningcareforgroupsofpaCentsmostlikelytogeneratetheseissues,suchaspaCentswithChronicHeartFailure,canyieldlowercostsassociatedwithreadmissionsaswellaspreventableadmissionsandemergencyuse.

BycombiningmeasuresassociatedwithpaCentoutcomes,populaConhealthprocessesandcoordinaConofcare,

alongwithcosts,ACOscanmoreeffecCvelytacklethequality-costperformancechallengeacrossalldimensions.

HowACOsCanEstablishIntegratedQualityandCostMeasurement

IntegraCngqualityandcostperformancewillinvolveaholisCcreviewofcaredeliveryandcosts.TherearestarCngpointswithintheexisCngqualitymeasuresthatyoumayusetolinkqualityandcost,butdon’tboxyourselfin!For

example,therearenoqualitymeasuresrelatedtosomeofthespecialty-specificAdvancedAlternatePayment

Models,suchasBundledPaymentsforQualityImprovement(BCPI)ortheOncologyCareModel(OCM).Ifyouareabletoreducecostsonhipandkneereplacements,however,creaCngjointreplacementepisodesmaysCllbea

viable,measurablequalityoutcomeandwillcontributetoalargersharedsavingspool.



https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/2018-and-2019-quality-benchmarks-guidance.pdf

https://www.beckershospitalreview.com/accountable-care-organizations/medicare-aco-savings-miss-cbo-mark-by-2b-5-findings.html

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YouwillmaximizeyourperformancebytargeCnghighcostcondiConsandestablishingbothqualityandcost

measuresthatreflectpaCentoutcomesandcost.Let’sseehowthiscouldbeaccomplishedforpaCentswith

diabetesandheartfailure,specificallyfocusingonhospitaladmissions:

1.Reduceadmissionsrelatedtodiabetesandheartfailure.

ACOsthatcanshijspendingtoofficeandwellnessvisitsaremorelikelytogeneratesharedsavings.CMSisalreadyusingitsadministraCveclaimstotrackAmbulatorySensiCveCondiCon(ASC)admissionsfordiabetesandheart

failure;youcantakeproacCvestepstoinfluencethese,ratherthanjustwaitforyourresults.ConsiderdevelopingyourownqualitymetricsandmeasuretheirimpactonASCadmissions.Avoidthemeasuresyou’realready

reporCng.

ThemostrecentlyreleasedresultsshowthatACOsaveraged53unplanneddiabetes-relatedadmissionsand75heart-failure-relatedadmissionsper100eligibleperson-years(howlongapaCenthasbeenanaSributedACO

beneficiary).Person-yearsadjustannualizaContomakesurethatACOsaren’trewardedforcontrollingcostsoverayearforapaCentwhenthatpaCentwasonlyaSributedforashort-Cme(e.g.apaCentbecameMedicare-eligible

halfwaythroughtheyear).ASCadmissionratesrangewidelyforthesecondiCons.Unplanneddiabetesadmissions

rangefromasfewas35toasmanyas160,whileunplannedheartfailureadmissionsrangefrom40to187.

ACOshaveanopportunitytodrasCcallyreducepreventablediabetesandheartfailureadmissionsandtheir

associatedcosts.YourstrategyshouldfocusonpotenCalgapsorstagnantoutcomesinyourpaCents’care,andaddressthereasonsforit.

2.Reviewyourprovidernetworktoensurethatyourpa5entshaveaccesstotheappropriatespecialtymix.

ToavoidagapinspecialtycareforpaCentswithhigh-riskcondiCons,youwillneedtofixthegapsinyournetwork,eitherbyengagingphysiciansasfullparCcipantsoras“otherenCCes.”IfyourACOdoeshaveaccesstospecialty

providers,youwillneedtoidenCfygapsinthataccess,suchaslackoftransportaConorschedulingavailability.PaCentswhocannotaccessnecessaryspecialistswillgoout-of-networkforsuchservices,includingforemergency

andhospitalcare.

3.Aberestablishingthatyournetworkhasthebreadthtohandlepa5entswithcomplexchroniccondi5ons,developmetricsfortrackingtheircarethatcanblendqualityandcost.

Forexample:

• DevelopandtrackaSharedDecision-Making(SDM)Ini5a5ve.Ifprimarycareproviderscanengageina

SharedDecision-MakingprocesseswithpaCents,includingdiscussionsaboutbarrierstotreatment,risks,

andrelevantresearchstudies,youmaybuildpaCentengagementalongwithlowercostsofcare.TheACOcantrackresultsofpaCentoutcomes,costs,andappointmentsdesignatedtodiscusstreatmentopCons,

aswellaspaCent-selectedtreatmentdecisions.SDMmustbecarefullydesignedtoensureappropriateCmeforphysician-paCentconversaCons,butwithsomepaCentgroups,thisapproachcanhaveaquality

andcostpay-offfortheACO.


http://www.ajmc.com/journals/ajac/2018/2018-vol6-n1/medicare-accountable-care-spending-patterns-shifting-expenditures-associated-with-savings


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• EncourageandtrackAnnualWellnessVisits(AWVs).InaddiContobeingacriCcalfactorforongoing

paCentaSribuCon,thesevisitsareanopportuneCmetodiscussyourpaCents’goalsandthestrategiesto

meetthem.

• Analyzedataforthepa5entswhohadpreviousASCadmissionsand/orreadmissions.Forreadmissions,

determineifisthereacommonthread(e.g.onepost-acutefacilityvs.another)thatwillleadyoutoacoordinaCon-of-caresoluConorpost-acutenegoCaCons.

• Measurepost-dischargefollowup.ForpaCentswhohavebeenadmiSed,lookatwhowasseenwithin

sevendaysofdischarge.InaddiContothevisititself,theACOshouldtrackpaCentfeedbackfromthisvisittoidenCfythoseat-riskforreadmissions,suchaspaCentswhodonotunderstanddischargeinstrucCons,

orpaCentswhodonothavehomecareand/orsupport.

4.Engagepa5entsandprovidersinimmuniza5oncampaigns.

CMStracksASCsrelatedtoacutecondiCons,suchaspneumonia,aswellasASCsforchroniccondiCons.The

averagecostforapneumonia-relatedhospitalizaConis$9,700.Thesearenot“expected”costs,andanACOwhose

paCentsincurthemwillseeareducedsavingsattheendoftheyear—andamorevulnerablepaCentpopulaCon.Therefore,immunizaCons(aqualityreporCngmeasure)andASCsforthecorrespondingcondiCons(CMScost

calculaCons)shouldbetrackedtogether.

AsmorepaCentsreceivetheimmunizaCon,performanceratesonthecorrespondingqualitymeasures(ACO-14

andACO-15)willimprove.IfyoudecreasepreventablehospitalizaConsatthesameCme(ACO-43,theAmbulatory

SensiCveCondiCon[ASC]AcuteComposite),youwillhavesecuredyourpotenCalsharedsavingspool.

It’salltooeasytoseequalityreporCngasyoursoleACOqualityresponsibility.ButgeingcaughtupinreporCng

nuts-and-boltsmissesyourACOsrealopportunitytoachievetheTripleAim.Consider,instead,howyoucanuseyourdatatodesignqualityandcostperformanceimprovementusingintegratedmetrics.AmbulatorySensiCve

CondiConAdmissions(alongwithallcausere-admissions,SNFre-admissions,andpaCentexperience)canprovidea

roadmapforyourACO,enablingyoutoidenCfyareasofconcernandtoaddressthemwithlong-termsoluCons,ratherthanshort-termpatches.

ImageCredit:ChrisCharles



https://www.hcup-us.ahrq.gov/reports/statbriefs/sb146.pdf

https://unsplash.com/photos/I6gZ2sqpHaw


�25

ACOsMustCreateLearningEnvironmentforPhysicianstoBePartnersinChange

byThomasDent,MD RojiIntelBlog;April11,2018

TheideabehindACOssoundssimple

enough:Buildanetworkofprimarycarephysicians,specialists,hospitals

andotherhealthcareorganizaConsthatshareriskandresponsibilityto

providecoordinatedcareforeach

paCent.MedicareorprivateinsurersofferfinancialincenCvestoensure

thatACOsprovidequalitytreatmentwhilelimiCngunnecessaryspending.

Primarycarephysiciansserveaskey

liaisonsforeachpaCent’scare.

ButACOrealityismuchmorecomplexanddaunCng.Sharedsavingshaveproventobeelusive.Qualitybenchmarksdonotalwaysaccuratelymeasurewhat’smedicallyrelevant.PaCentaSribuContospecialists,ratherthanprimary

carephysicians,skewscosts.Nonetheless,asMIPScollapsesandpressuremountsforadopConofAdvanced

AlternatePaymentModels,ACOsareascendantasthepreferredopConunderCMS’sQualityPaymentProgram.

InthisintenselycompeCCve,rapidlyevolvingenvironment,wherehealthcareorganizaConsmustlearntomanage

riskorperish,experienceisthebestteacher—withphysiciansasfullpartnersintheprocessofmanagingchange.ThefollowingfourkeystrategieswillhelptocreateanACOculturethatencourageslearningfromsuccessesaswell

asmistakestoimproveperformance,meetqualitytargetsandachievesavings:

1.FosterLearningandInnova5onthroughDialoguewithPhysiciansandOtherProviders

CollaboraCvelearninginanenvironmentthatstresseseducaConoverdictumisessenCalfortheACO’slong-term

success.Severaldifferentapproachescanbebuiltintoprojectsthatreviewoutcomesandcosts.Forexample,inreviewingpaCentoutcomes,clinicianswhotreatthesamepaCentcouldshareperspecCvesoncausesofoutcome

variance.Clinicianslearnfrompeersabouttreatmentoutcomesand,inturn,provideinformaConabouttheirown

paCentexperiences.

Thiskindofpeerfeedbackdoesmorethansimplyfosterlearningfromothers’experience.Ifconductedwithina

culturethatsupportsmutualtrustandcooperaCveproblem-solving,suchexchangescanpromotenotonlyimprovementefforts,butalsodeepcollaboraCverelaConshipsthathelptheorganizaConmoveforwardfromthe

boSomup.Theyestablishamechanismfordialogueamongphysicians,pracCcesandotherclinicians,nurturing

organizaConalnimbleness.


https://rojihealthintel.com/2018/03/14/can-provider-led-acos-and-aapms-deliver-health-care-transformation/

http://journals.sagepub.com/doi/abs/10.1177/1077558716640415

http://journals.sagepub.com/doi/abs/10.1177/1077558716640415

https://pubsonline.informs.org/doi/abs/10.1287/orsc.2.1.88

https://pubsonline.informs.org/doi/abs/10.1287/mnsc.1060.0692


�26

DatasharingisessenCaltothisfeedbackloopandshouldbeusedtobuildteamswithintheorganizaContoreview

paCentoutcomesandcostscollaboraCvelyandwithinperformanceimprovementorpopulaConhealthprojects.

Noneofthiswillhappenquickly.EveryoneintheACOwillbelearningnewprocessesandrouCnes.PaCenceandpersistenceareessenCal,withphysiciansleadingthedevelopmentoftheCmelineandtheprocessofchange.

2.PilotandTestInterven5onsforCostandQualityImprovements

ACOcostandqualityintervenConsshouldbeacollaboraCveeffortofallinvolvedproviders.Thekeyhereistopilot

andtestchanges,seekingphysicianaswellaspaCentfeedback,beforelaunchingintervenConsthroughouttheACO.

Thepilot-tesCngtacCcalsomaybeusedtoengagephysiciansinpaCentlearning.Podcastsand,parCcularly,videos

featuringclinicianscanbeaneffecCvewaytocommunicatewithpaCentsaboutcommonconcerns.Thesetoolscanamplifytheclinician’svoicewithoutrequiringsignificanteffortbyphysicians.Apodcastandvideolibrarycouldbe

usedtogivepaCents24/7accesstoinformaConcuratedbyatrustedprovideransweringkeyquesCons.PaCents

whohaveexperiencedsuccessinself-managementmayalsoberecruitedtoprovidemessagesonlife-styleandmedicaConuse.

3.DistributeAggregateCostandQualityAnaly5cstoPhysicians,AlongwithIndividualizedData

ForcostandqualitydatareviewtobebothmeaningfulandeffecCve,pracCcesandindividualphysiciansmust

receivedatathroughatransparentprocessonaregularbasis.Thismarksamajorleapfromthestatusquo,where

mostACOphysiciansonlyreceivetheirowndata,areunawareofwhatelseisgoingonthroughouttheACO,andtypicallyreceivenoaggregateanalyCcsthatmakethemfeelpartofagroupwithasharedsetofgoals.

NotetheHawthorneeffect,wherebybehaviorschangejustfrombeingobserved.Ifphysicianshavenoaccesstodataorignoreit,thereisliSlelikelihoodforchange.If,ontheotherhand,sharingdataisframedasanopportunity

tolearnandgrow,ratherthanasaperformancetask,thereisagreaterchancethatclinicianswillbeinterestedin

engagingindryrunsandpilottests.ReviewingcostdataacrossmulCpleyearsisacriCcalpieceofthisprocess,toidenCfyandhighlightimprovementincosts—whatwilldrivefinancialsuccessfortheACO.

RememberthatsomecriCcalresultsmayneedtobereportedanonymouslytoencourageparCcipaCon.ReporCngonfavorableorbestpracCces,inturn,requireslessneedtomaskfeedback.

4.DevelopRewardsforPhysiciansforBeneficialInputonCostIni5a5vesandInquiries

EncouragingandrewardinginnovaCvethinkingmustbeacentralthemefororganizaConsseekingtomovetoariskmodel.ACOmembersthatinspireothersshouldbeprized.ItisexcepConallyimportantforprimarycarephysicians

tomaintainconCnuityofpaCentpopulaConsinorderfortheACOtosurvive.Butthismustbeaccomplishedthroughengenderingloyalty,notscareorpressuretacCcs.



https://pdfs.semanticscholar.org/91a9/d4198e442075f9394ada4d897aaa3d3cd48e.pdf

https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2016.1107


�27

ThephysicianreimbursementmodelwillulCmatelyneedtochangeinACOs.Therequirementforsignificant

financialriskfortheACOmustfilterdowntothecliniciansinsomefashion.TheACOmustimplementchanges

carefullytoavoidunintendedconsequencesofincenCves,seekinginputfromstakeholdersandtesCngeffectsofincenCvesonaccesstocare,qualityoutcomesandcost.

ClinicianscouldbereimbursedfortheaddiConalCmedevotedtoanalysis,dialogueandcostdatareviewrequiredbytheACO.Theyalsomayberewarded,notpenalized,forgivingnecessaryCmetopaCents,engagingina

thoroughdiscussionofbenefitsandharmsofclinicalalternaCves.AspaCentsbecomemoreinformed,theymay

choosenottopursuecertaindiagnosCcortherapeuCcopCons—andthis,indeed,willassisttheACOinmeeCngspendingtargets.TheCmetakenbyclinicianstoworkwiththepaCent’ssupportsystemmightalsobe

compensated.

PhysiciansCanBecomePartnersThroughLong-TermCollabora5on

TheunfortunateconsequenceofmanyperformancemeasurementprogramsandqualityreporCngrequirementsis

thattheyhaveledtodemoralizedphysiciansandestrangementbetweenphysiciansandorganizaConalleadership.RewardsandpenalCesbasedonshort-termresultssuchasperformancemeasuresservetoundercutthe

organizaCon’sgoalsaswellasphysicianmorale.

ThefutureoftheACOwilldependonbuildingbothpaCentloyaltyandinnovaCveapproachestocostandquality,

throughpartnershipwithphysicians.AjerthetypicalprocessessuchascoordinaConofcare,reducConof

readmissions,andalignmentofreferralsourcesareperformed,theACOwillneedtodigdeepertoachievethesavingstargets.ACOsmustinventmethodstobeSerrecognizeat-riskpaCentstoavoidincidenceorprogressionof

diseaseanditsassociatedcosts,anddevelopcreaCvemethodsofimprovingoutcomesandcostsassociatedwithhighestriskgroups.ThetrustandposiCveaitudeandinvolvementofphysicianswillbeessenCal.

ImageCredit:FabrizioVerrecchia




https://unsplash.com/photos/CcqAFQBQV1A


�28

PartIV.Consumer-DirectedStrategiestoCreateStrongerLinkswithPa5ents

SharedDecision-MakingMayBetheNextConsumerHealthMovementbyTheresaHush RojiIntelBlog;February28,2018

Consumersarerapidlymobilizing

aroundallaspectsofhealthcare—affordability,accesstothesystemand

choicesabouttheircare.Aschangesinhealthinsuranceshijmoreand

morecostontoconsumers,paCents

wanttobeinvolvedindecisionsthatwillaffecttheirfinancesaswellas

theirhealth.

Yettheyfaceadilemma:Theonly

waytoreallyaffecttheircostsistobe

involvedindecisionsabouthowmuchandwhatkindofhealthcare

theyuse.Thatmeansbeinginvolvedinmedicaldecisions.Butwhenprices

arehiddenandconsumersdon’tknowthefactsaboutalternaCve—anduncertain—outcomes,theyneedtheir

providerstopartnerwiththemgetthebesthealthcaretheycanafford.That’swhatSharedDecision-Makingisabout:thepaCentandphysicianworkingtogethertomeetthepaCent’shealthcaregoals.

Thecultureofclinician-paCentrelaConshipsisheavilybiasedtowardpaCentsrelyingonphysicians’recommendaConsforappropriatetreatments,withoutaskingaboutalternaCvesorevidencetobackupthose

recommendaCons.Butasconsumersbearagreatercostburdenfortheirhealthcare,theyarepressingtoplaya

moreacCveroleinmedicaldecision-making.

SharedDecision-MakingPutsPa5entsinChargeofTheirHealthCare

Tothatend,SharedDecision-MakingisanapproachthatplacespaCentsatthehelmoftheirownhealthcare.Itrequiresaccesstoevidence-basedtreatmentoutcomescombinedwithashijintheclinician-paCentdynamic.

PhysicianandpaCentworktogetherasateamtoreviewopCons;butitisthepaCentwhomakestheulCmate

decisionsabouttreatment.

Thismodelhasbenefitsnotonlyforconsumerswhowantmorecontrolovertheirhealthcare,butalsofor

providerswhoarecommiSedtoimprovedperformanceandbeSerpaCentoutcomes.We’vebeenwriCngalot




�29

aboutSharedDecision-Makingrecently.HereisacollecConofthosepoststhatexplorethenutsandboltsof

implemenCngtheprocessforlong-termbenefitstobothproviderandpaCent:

IsSharedDecision-MakingthePathtoImprovedProviderPerformance?

NinestepstoimprovedhealthsystemperformanceviaSharedDecision-Making

TheCruxofSharedDecision-Making:WhoisActuallyDeciding?

SixessenCalelementstoensureappropriatereviewofdata,informaConandthepaCent’sowncircumstances

TimeOut!HowStrategicPausesCanEnhanceMedicalDecision-MakingtoImproveOutcomes

Acloserlookathowstrategicpauses,anestablishedmedicalpracCce,canhelpimprovetreatmentforhypertension,asanexampleofSharedDecision-Making,plussixstepstoensuresuccessofstrategicpause

performanceimprovementacCvity

Don’tJustChecktheBox:CapturethePa5ent’sStorytoDefineMeaningfulGoalsofCare

Aclose,personallookbyanexperiencedprimarycarephysicianathowtakingtheCmetounderstandthepaCent’s

truecircumstancescanimprovecareaspartofaSharedDecision-Makingprocess.

ImageCredit:Tookapic



https://rojihealthintel.com/2017/12/14/is-shared-decision-making-the-path-to-improved-provider-performance/

https://rojihealthintel.com/2017/12/20/the-crux-of-shared-decision-making-who-is-actually-deciding/

https://rojihealthintel.com/2018/01/17/time-out-how-strategic-pauses-can-enhance-medical-decision-making-to-improve-outcomes/

https://rojihealthintel.com/2018/02/14/dont-just-check-box-capture-patients-story-define-meaningful-goals-care/

https://static.pexels.com/photos/71847/illness-waiting-room-doctor-71847.jpeg


�30

RedesigningHealthCarefortheNewConsumer byTheresaHush RojiIntelBlog;9-27-17

Aconsumer-drivencultureshijisemerginginhealthcarethatwill

changethedynamicsofhealthcarepurchasingdecisionsandimpactproviders’boSomline.

Itisbeingfueledbypoliciesthatareincreasingtheshareofhealthcareexpensespaidbyconsumers.Benefitplanswithhigher

deducCblesandcopayments,choicesnarrowedtoproviderswho

demonstratelowercost,restricConofmedicalservices,andhigherpercentagesofpremiumsharingarejustsomeofthe

tacCcsusedtocontrolandredistributecostsfromhealthcarepayerstoconsumers.

Muchofthediscussionfocusesontheneedforconsumerstobe

“beSerpurchasers”ofhealthcare.Theyneedtomakewiserchoicesaboutlifestyleandhealthcare,andbemoreengagedin

theirtreatment.Allofthismakessense.

Thisshijalsoraisesamajorchallenge:Canweprovideconsumerswiththetoolstheyneedtomakethesesmarter

decisions?DotheyhavethatinformaConnow,and,ifnot,howcanwefairlyputtheminthedriver’sseat?Are

physiciansandotherhealthcareprovidersreallyreadytorespondtoconsumers’needstodirecthealthcarespending—andifso,how?

Healthcaresystemshavealottoworryaboutiftheydon’thelpconsumersandshareresponsibilityforgoodhealthcaredecision-making.Failurecouldresultinincreasedbaddebtor,worse,financialloss.

RojiHealthIntelligenceexpertsgiveyoutheintelonhowtoprepareforthechallengesaheadinour65-pagee-

book,RedesigningHealthcarefortheNewConsumer.

• FindouthowconsumersareimpactedbyValue-BasedHealthCare.

• Understandconsumers’keyconcernsabouthowtomakewiserhealthcaredecisions.

• Discoverwhatconsumerswantfromproviderstohelpthemactresponsibly.

• Learnstrategiesfordeliveringservicesthatwillencourageconsumerstoengagewithyou.

Clickheretofindoutmoreanddownloadyourfreecopy.




https://rojihealthintel.com/resources/new-consumer/

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