5 ways Accountable Care Organizations align perfectly with population health management

In the not-too-distant future, Medicare is likely to move between 80% and 90% of medical payments to be “at risk.” This means more potential savings, along with more potential risk. It underscores the need for accountable care organizations (ACOs), which were designed to maximize care quality while minimizing cost.

So what is an ACO? An ACO brings together healthcare providers into one organization, enabling them to deliver more coordinated care packages to patients. A term first used in 2006, ACO was included in the federal Patient Protection and Affordable Care Act in 2009. ACOs can be created through the Medicare Shared Savings Program.

ACOs were designed to drive population health management and improve outcomes. They incentivize a clinically integrated network to open possibilities for proactive care. They promote care coordination to refine resourcing across the continuum. And they encourage strategic investment in less expensive care settings to maintain wellness more efficiently, for example by reducing hospital admissions or the length of hospital stays as well as by avoiding repeated tests and other interventions, and by spotting potential problems earlier.

The lab is not a passive stakeholder in this transformation—it is a vital driver. ACO success and value-based care cannot exist without lab data as well as laboratorian partnership.

Read on for expert insights on how ACOs align perfectly with population health management—and how the lab is needed to support each layer.

You can use population health to break out of the commodity trap. Our services and values give us the unique ability to help our patients and avoid costs down the road. They set us up to be true population health managers..

Joel Shu, MD, MBA
Chief Medical Officer & Chief Quality Officer
Emory Healthcare Network

Having more robust data sets creates amazing treatment possibilities. Consider the following flow chart—ACOs empower healthcare institutions to do all of these things.

With better identification and stratification, you can better understand how different patient types can get ahead of diseases. This is critical to providing “well care,” while avoiding devastating and costly disease progression.

With more integration and more data, a new possibility arises—more complexity. Who is responsible for “owning” the patient relationship? Directing treatment? Overseeing activity? Without a centralized “quarterback,” it can become increasingly difficult to remain accountable over care. And this would create an incredible disservice to population health management.

Fortunately, within an ACO model, your quarterback of care is clear—the primary care physician (PCP). These vital team members are in a natural position to take control of patient health and help to proactively ensure it.

Overall, PCPs are able to see the big picture of patient health. This uniquely empowers them to drive quality and efficient care, which is fundamental to managing populations..

• Data: All data funnel back to PCPs, giving them visibility into longitudinal health.
• Wellness visits: Wellness visits empower the PCP to get ahead of health concerns before they exacerbate.
• Cost-effecient care: Cost-efficient care not only drives value, but also it "is the factor that aligns PCPs to power ACOs," according to Dr. Gross.

Consider this insight from Les Duncan: “So you're not taking care of the patient just when they're in front of you with an illness in your office but throughout their continuum of life. You want to take care of these people not just when they have the flu, but you want to make sure they're taking their meds, that they're compliant, that they are well-fed, that they have someone in their home that cares about them.”

Duncan is not only articulating the mission of ACOs but an evidence-based approach to population health management. And it all comes down to data.

Data highlight the bridges between isolated episodes of care. By accessing data across a patient’s history, you pave the way to initiating a more seamless care approach. This means going beyond treating illnesses to proactively preventing them and their progression.

By facilitating more insights about longitudinal patient health, ACOs enable care teams to expand their reach and drive wellness from the start.

Physicians may have the same clinical information but go about treatment in very different ways. This lack of standardized protocols denies best practices and poses a challenge to population health.

ACO data are the cure. They don’t just point to patient outcomes, but how physicians are facilitating them.

• Which physicians are maximizing health?

• Which physicians are minimizing costs?

• Which physicians are slashing treatment time?

• Which physicians are reducing readmissions?

Illuminating these insights is pivotal to driving evidence-based care, and ACOs are optimized to enable it. Once you identify best practices, you're in a leading position to refine care across specialties. What supports population health better than that?

Managing the health of entire populations requires a high degree of operational excellence, and ACOs catalyze this. To meet quality standards, they incentivize institutions to step back and look at the big picture of process and performance. This can usher in new programs that drive cost-efficient, quality care.

Let’s look at two programs Dr. Astion is recommending to drive population health.

Dr. Astion recognizes the negative impact of testing overutilization. He states, “at my institution, half the time a patient cannot pay.” This is compounded by excessive tests being ordered. What’s the immediate result? His institution has to cover the payment. But what’s the greater impact? “Our ability to deliver an emergency hemorrhage panel to a bleeding patient is affected by these millions of dollars of unnecessary genetic testing that we have to pay out of pocket.”

This inspired Dr. Astion to develop his PLUGS program (Pediatric Lab Utilization Guidance Service). He helped his institution develop genetic test utilization management systems to ensure physicians are only ordering necessary tests. Based on the success of the program, 50 hospital systems went on to join PLUGS.

According to Dr. Astion, “about 5% of lab tests are never retrieved.” To complicate matters further, “when you’re transitioning care from inpatient to outpatient, that’s a big Achilles heel of retrieval.” Dr. Astion urges the lab to partner with their IT department to co-create systems that help ensure results retrieval. We’ll take a deeper dive into this topic in an upcoming LabLeaders article.

As we discussed the many ways ACOs align perfectly with population health management, one thing should be abundantly clear: Data are indispensable. And with data, you can make your lab indispensable.

It's incumbent upon you to reinforce your value every day. Find clever ways to drive quality and slash costs. Identify opportunities to standardize best practices and optimize physician performance. Brainstorm programs to put care improvement into action.

The tools are at your fingertips, and ACOs incentivize using them to make your populations healthier.

So it's population health management. It's a very interesting field. It's growing, of course. And these programs with Medicare are only going to continue to come out as they're successful.

Les Duncan
Director of Accountable Care Solutions
Highmark Health