By Pearson Talbert
Whenever a friend who doesn’t work in healthcare asks me how things are at the office, I just smile and say, “Busy.” It seems like a reasonable alternative to a lengthy PowerPoint presentation. We are, after all, in the midst a sweeping transformation in the American healthcare system—one that will have implications as dramatic as the banning of patent medicines, the discovery of antibiotics, or the creation of group medical insurance.
Taken individually the challenges are substantial – added together, they are require a comprehensive strategy and extensive team of healthcare leaders to address. The ACA puts providers (hospitals and practitioners) solely at risk for managing the health of an entire population. Under this model, the healthcare system shifts from treating disease to maintaining patient health and wellness. The ideal outcome reduces healthcare costs while creating a healthier population. The current “episodes of care” approach becomes obsolete, and coordination of care emerges as the new norm.
Ultimately, providers become responsible for maintaining the health of people who are well and managing the conditions of those who are at risk or chronically ill. It’s a huge responsibility, with a tremendous potential for reward. The first and most obvious step in this transition involves an increased emphasis on disease management, wellness programs, health coaching, and preventive services such as screenings and immunizations.
It’s no exaggeration to say this approach transforms Americans from patients to beneficiaries. As beneficiaries, they enjoy improved health and quality of life as they move along the healthcare continuum—from health maintenance, disease management and episodic care to rehabilitations, long-term care, skilled nursing and hospice.
In order to thrive in this new environment, hospitals will have to broaden their reach beyond employer groups and take a more active role in improving community health. It’s a big step, but a logical one, since hospitals are trusted healthcare leaders.
The Patient Protection and Affordable Care Act (PPACA) aims to achieve lower costs, increased quality and an enhanced patient experience through the introduction of a new model for care delivery and reimbursement: the Accountable Care Organization (ACO). ACOs take the concept of the patient-centered medical-home model to a different level, with more of a contracting emphasis and specific rules and regulations. The PPACA included some of the requirements set by CMS for the Shared Savings Program for Medicare ACOs. Additional requirements were set in early 2011, and the Medicare ACO program opened for business the following January.
By early 2013, 106 new ACOs had entered into agreements with CMS, taking responsibility for the quality of care they provide to people with Medicare in return for the opportunity to share in savings realized through high-quality, well-coordinated care. An additional 32 ACOs began participating in the testing of the Pioneer ACO model by the Center for Medicare and Medicaid Innovation (Innovation Center). Some private payers have also opted to join the movement, including Cigna, which has set a goal of establishing 100 accountable-care initiatives by 2014.
To ensure that savings are achieved, ACOs must hit targets for improving care coordination and meet quality standards while providing services that are appropriate, safe and timely. No small feat in the current environment, where most of the care provided is still reimbursed under the fee-for-service model.
Still, the only constant is change, and the willingness of providers to rise to the challenges before them is truly admirable. There’s little doubt that the future of ACOs and America’s health care system are deeply intertwined, or that the success of the ACO model could result in a viable model for many hospitals and a healthier future for the physical and economic health of many Americans.