Why success in healthcare hinges on infrastructure

An accountable care organization (ACO) is greater than the sum of its parts. The independent physicians, hospital systems and labs that come together to form an ACO generate benefits above and beyond what might otherwise be available from them individually. This is due in large measure to one of the vital factors of an ACO: its infrastructure.

In this article, our lab leaders examine key infrastructure systems essential to ACO success. They offer up an honest look at what works today and the challenges for tomorrow. They also highlight opportunities for laboratorians to step into the ACO game, leveraging lab expertise to strengthen systems and improve infrastructure.

Round out your knowledge of ACOs by reading The critical importance of quality to an ACO.

Developing an ACO infrastructure requires significant up-front costs, which promise to pay dividends down the road. Improved patient care, better population health management, higher quality scores from the Centers for Medicare & Medicaid Services (CMS), increased revenue and superior data control are but a few of the potential boons that may result from smart infrastructure investment.

Independent physician practices that join an ACO share its infrastructure. In effect, the ACO infrastructure “sits” on top of the practice, providing physicians with access to valuable services and resources, such as:

• Centralized quality reporting through the CMS Group Practice Reporting Option, in compliance with Physician Quality Reporting Standards
• Medical director access to select committees that help formulate evidence-based care recommendations
• High-volume claims data, tightly managed by payers, that can direct patients toward the best care across the ACO
• Better payer contracts due to the negotiating strength of the ACO, with new payer contracts seamlessly integrated into infrastructure

Beyond benefits to participating physicians, an ACO provides an infrastructure of care designed to control costs and improve patient outcomes. The lynchpin of that infrastructure is the annual wellness visit, a 45-minute consultation between the patient and his or her primary care physician (PCP) paid for by Medicare.

Medicare foots the cost because annual wellness visits can improve long-term care management. During the visit, patients can discuss any concerns or considerations, along with quality of life goals and disease management issues.

Numerous benefits can result from the annual wellness visit, including:

• Attribution of the patient to an ACO (in other words, connecting the patient to the ACO for care management and quality tracking)
• Creating a health baseline that informs care decisions in the coming year
• Early disease detection/risk evaluation through tools like falls assessment, smoking cessation, and diabetes screening

Optimize test utilization by consulting with ACO clinicians to help ensure only the most appropriate, cost-effective tests are ordered during wellness visits.

According to our lab leaders, as few as 30-40% of ACO patients have actually had their annual wellness visit. If ACOs aspire to improve patient care, those numbers need to climb to 80% or higher.

Improving care also depends on maximizing the operational efficiency of wellness visits. Care extenders such as medical assistants or trained health care volunteers allow physicians to focus only on what is most essential during the visits. This limits their consultation time to as little as 10 minutes, significantly increasing practice efficiency.

Too often, high-risk patients end up in emergency departments (EDs) due to symptoms that could have been managed more cost-effectively. To mitigate the risk of unnecessary and costly ED visits, ACOs may hire nurses to function as care coordinators for these patients.

Care coordinating nurses field phone calls from patients and caregivers that would otherwise have been handled by untrained office staff. With their medical expertise, the nurses can assess the true nature of a patient’s distress and steer their care in the right direction—which is often away from the ED.

Consider this scenario, adapted from the experience of Peter Gross, M.D., Chairman of the Board of Managers at HackensackUMC ACO.

5:49 pm

Phone rings at an ACO care coordination desk. It’s the daughter of an elderly patient, worried about an episode her mother is having.

• Caller: Something’s wrong with my mom. She’s not speaking clearly.
• Nurse: Can she squeeze both of your hands?
• Caller: Yes, she just squeezed my hands.
• Nurse. Can she lift both of her legs?
• Caller: Yes, she’s able to.
• Nurse: Okay. Come into the office. I’ll tell the doctor to stay late. You don’t have to go to the ED.

6:32 pm

Mother and daughter arrive at the physician’s office. Physician quickly assesses the situation:

• Mother has diabetes
• She took her insulin and then didn’t eat for three hours
• She is experiencing symptoms of hypoglycemia

Physician administers her next dose of insulin, counsels her on mealtime dosing and provides mother and daughter with educational materials.

6:53 pm

Mother and daughter leave for home, relieved and reassured.

Care coordination just saved $10,000 by avoiding a costly hospital admission.

Another important facet of ACO infrastructure is the patient-centered medical home (PCMH). This is not literally a home or physical location. It is instead a model for the delivery of coordinated, high quality, patient-centric primary care.

The five defining features of a PCMH¹ are:

1. Comprehensive health services, from prevention to chronic care, delivered by a multi-disciplinary team that includes physicians, nurses, nutritionists, social workers and more
2. A relationship-based focus on the whole patient through an understanding of their unique needs and who they are as individuals
3. System-wide coordination of care through open communication and data sharing, from hospitals to home health care and everything in between
4. Patient-preferred services that ensure greater access to health care through expanded hours, reduced waiting times, telemedicine and more
5. Commitment to quality through the application of evidence-based medicine and strict performance measures

Adopt a similarly patient-centric approach to lab services that includes direct consultation with physicians, surgeons and even patients themselves.

In an ACO, data should flow seamlessly through the network so care decisions are based on a complete picture of a patient’s medical situation. But the reality today is that disparate systems fail to communicate with one another. Individual physician practices utilize different electronic medical records (EMRs). Laboratory information systems (LIS) cannot interface with hospital billing departments. Commonly today, ACO data are a smattering of disconnected dots.

Invest in an LIS with a robust interface that is able to communicate with multiple EMRs and hospital billing systems—your lab will stand out to an ACO!

What to do about it? One solution is a health information exchange (HIE). These are companies that work with ACOs to facilitate the open flow of data between different systems. So if a patient sees her PCP one day, and then falls ill during vacation and sees another doctor, the HIE can help ensure the patient’s complete medical history is shared and she gets the best care possible.

Though it may come as a surprise to many laboratorians, insurance companies offer another potential solution. They collect buckets of data and can work with HIEs and ACOs to make vital information shareable and actionable.

Finally, but no less important, shared savings must flow as readily as data in an ACO. Everyone’s success depends on carefully controlling costs while maintaining—or exceeding—quality standards. As ACOs mature, a greater percentage should realize shared savings.

In many ACOs, the money finds its way first to the hospital that made the infrastructure investment. From there, remaining savings are distributed to individual physician practices based primarily on their patient populations and quality scores. Given the importance of both population health and quality, labs have a vital role to play in enhancing the vitality of ACO infrastructure through the flow of funds, data and care.