Theresa Hush

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What makes an accountable care organization (ACO) successful? While there have been many studies trying to figure out the secret, most are incomplete because they’re more focused on organizational attributes. 

The true key to achieving high savings, more patient volume, and better health outcomes is to effectively use clinical and cost data with physicians to create interventions that improve performance.

While ACO’s need plug-and-play tools for their specific systems, physician networks, and competitive ingredients, none of that will matter if the essentials are not in place. So let’s explore the six secrets to ACO success.

1. Lead with a vision of value-based clinical care.

Design your ACO leadership venture for clinical excellence with a value-based emphasis and with collaboration of clinicians.

 Unlike historically volume-based goals, ACOs with a value-based vision involve clinical leaders and clinicians to identify and implement best clinical practices through data. Clinically-focused value will help you develop cost interventions that go beyond administrative activities and establish standards of patient care that are transformative and worthy of physicians and patients. 

2. Build an effective data infrastructure with robust clinical and cost data.

ACOs need comprehensive and detailed data to conduct macroanalysis on costs and microanalysis on costs and quality.

 This means that your ACO should be collecting patient-identified clinical data, data on social determinants of health, and prescribing data from provider systems to integrate with claims data. Your ability to control exacerbations (and resulting high costs)in patients with chronic disease depends on your ability to first identify patients with persistently poor control of their conditions, and compare their outcomes, costs, and treatment modalities. These analyses will lead you to establish best practices, and interventions to get patients on the correct pathway to improvement.

A technical infrastructure that provides for safe and secure patient data is essential. 

You can build it, buy it, or do some combination - but security is key. HIPAA-compliance is a baseline requirement for all systems, but it’s not a substitute for an effective data architecture. Unless you’re an organization with a large budget, the smartest choice is likely working with an outside vendor. The good news is that you can purchase affordable 

secure technology infrastructure services

 even on a small budget. Look for companies that facilitate access to patient records across providers as well as solid applications for using your data, including analytics, patient episodes of care (or another cost engine), quality measurement, and population health.

3. Target initiatives to reduce costs and improve outcomes, based on episodes of care data for key conditions and procedures. 

Patient episodes of care include all the services that are related to the diagnoses within a defined period of time. Done right, this approach will enable your ACO to compare costs across all patients within a single condition or procedure, revealing patients whose costs exceeded norms, and the factors involved. With the involvement of physicians, ACOs can turn clinical episodes that reveal problematic outcomes, exacerbations and complications into tailored population health initiatives and clinical pathways that “reset” the ACO path toward value.

4. Foster physician-focused collaboration.

Physician-focused collaborations and improvements are a must for supercharging your physician buy-in. 

Most physicians say that they don’t get good or actionable cost data from their organizations. The best ACOs actively involve physicians in investigations around cost drivers, data sharing, coaching, and improvement activities. For example, do your physicians have routine access to ACO analytics? Are they involved in clinical intervention developments as a result of episode-revealing analytics?



5. Apply effective quality and evidence-based measurement.

Quality measurement and quality reporting should be two very different activities, and your emphasis should be mostly on the former. 

Quality measurement should be a process for your ACO to generate patient improvement in outcomes and cost over time. Because it is dynamic and continuing, measuring quality and cost together through episodes will reveal opportunities that boost savings

Quality measurement should flow immediately into interventions and improvement activities.

Quality reporting, on the other hand, is a regulatory requirement. It involves a set of static quality measures that are reviewed once per year for a sample of patients. The measures fall short of helping you target best practices, beyond closing gaps in care.

Your ACO will achieve success if you measure improvement of patients over time, acknowledge providers who have adopted best practices, and implement clinical and administrative interventions that result in improved outcomes for patients.

6. Create a multidimensional improvement program.


Successful ACOs tackle the largest issues impacting costs, which requires understanding those costs at a granular level.

 You can achieve this by implementing an effective multidimensional improvement program that identifies and prioritizes at-risk patients in various populations based on patient risk factors, conditions, and outcomes. Take behavioral health, for example. Are your clinicians involved in integrated primary/behavioral health initiatives? Do you have formal referral arrangements with external or community resources? Do you provide or arrange for patient programs for education and risk prevention or management?

ACOs are in competition with other value-based payment models - Medicare Advantage Plans, physician organizations backed by equity, large hospital-based systems. That competition affects the long term sustainability of all ACOs to attract physicians and patients. It’s not enough for you to just keep doing what you’ve been doing and hold down costs without sacrificing your physician network and patient health outcomes. Your ACO might chug along for a little while, but it will eventually crash. So implement these six strategies and supercharge your ACO today to create value for your organization and your patients.

. Hush is also a healthcare strategist and change expert with experience across the healthcare spectrum, including public, non-profit and private sectors.

Articles

The true key to achieving high savings, more patient volume, and better health outcomes is to effectively use clinical and cost data with physicians to create interventions that improve performance.
























6 Successful Strategies to Supercharge your ACO

As providers struggle to make progress in value-based healthcare and its transition to financial risk, they are not paying enough attention to this rising trend: healthcare consumerism. The tech industry is pulsing with excitement to bring mobile apps and services to consumers. They believe consumers may be the force of change, disrupting exclusive historical roles of providers in directing healthcare services.

 documents how the shift of healthcare costs from employers and health plans to consumers is driving technology development to bring consumers what they want. And what do they want? They are demanding cost transparency, their own digital health records customization to their interests, demand-based shopping for healthcare providers and services, and decision tools. Consumers want cost control, and they are done waiting for providers to give it to them.

Let’s look at some of the latest ventures now offering alternatives to the bundled solutions provided by most healthcare organizations:

Cost comparison websites to compare prices among providers

E-shopping for treatments once reserved to providers

Apple’s health record, populated by EHRs but managed and shared by consumers

Research and efficacy websites for decision support

Providers face big challenges in responding to consumers

Providers have been merging, acquiring, and building ever-bigger healthcare enterprises. First to gain market share against competitive providers, and then to achieve leverage in payer negotiations, healthcare is big business. Ask providers why, and they point to economies of scale for purchasing electronic medical records and technology and forming accountable care organizations. 

We now know that large healthcare complexes have driven costs rise even higher. Provider health systems have become bureaucratic. It is harder for them to change. Price transparency, shared decision making, and shared data have taken a back burner to operations and population health.

Providers have miscalculated the power of their direct customers-consumers-and the employers paying for the shared cost of their coverage. Big business such as

 JP Morgan Chase, Berkshire Hathaway, and Amazon 

are already taking action. Efforts to repeal the ACA thrust the cost of healthcare into consumers’ personal politics. Aided by the coming of “healthcare age” of millennials, with willingness to challenge traditional systems, and the retirement of boomers with meager savings and debt, both younger and older groups are poised for making change.

Healthcare affordability is now a consumer issue

Affordability of healthcare was once considered an employer and health plan issue. Now, however, affordability of healthcare is affecting benefits, availability of coverage, and consumers’ ability to pay. Driving about half the annual increase in costs is medical technology, according to repeated examinations of annual increases in U.S. healthcare costs. That is worth an examination because at higher costs than other countries, it is not improving our health. 

What exactly is “medical technology”? The term refers to new or improved surgical, medical or diagnostic techniques; advances in equipment; new drugs; and even technology purchased by providers to improve care, such as EMRs. Already on the radar screen for consumers are these technologies:

High-tech diagnostic equipment that has inconsistent coverage

 Investments by providers in EMRs, population health technology, and other technologies, with provider ownership of the patient data

Experimental techniques in surgeries and treatments

Genomic technologies and their application in treatments

The surge in adoption has been facilitated by the fee-for-service reimbursement that allows costs to be passed on to health plans and consumers. Consumer messaging by healthcare organizations highlights best doctors and the latest new technologies. Pharmaceutical companies have redirected marketing away from providers and toward consumers, emphasizing the latest therapies, less side effects, and more flexibility.

Patients are being burned by this approach. Benefit cuts and increasing prices are creating the record medical debt and bankruptcies. Some consumers respond by avoiding healthcare, and a growing number are abandoning coverage altogether. Their alternative? They don’t pay providers.

How can providers re-orient to consumers?

. Providers see patients as beneficiaries of their services rather than retail customers. Instead, they should understand patients as customers who make valid choices based on their own criteria.  Then, they must help inform those choices.

A patient seeking treatment for atrial fibrillation, for example, has various choices of medical technology, including new drugs and procedures. Each has high consequences. The cost and effects of each drug differ dramatically. Ablation has outcome issues under scrutiny, and serious risks. The goal for providers is to make those differences clear through summary of research data.

Support physicians in efforts to help patients

. Physicians need to guide the process of decisions and provide the data associated with results and any biases in the research.  Organizations must support provider processes, allocate sufficient time, and centrally compile consumer-directed cost and research data.

Most physicians feel responsible for their patients’ health. They will need to transition from only treating patients to providing guidance and education as well as treatment. That will involve training in leadership and understanding of consumer trends.

   3.  

Create communication channels for consumers

. Consumers have challenged provider bureaucracies for obtaining medical records, cost information, and clinical information.  There is rarely someone directly responsible for responding to complaints.  Tools in use for customer satisfaction are not enough to raise issues for identifying consumer value. 

Providers should create new avenues for consumer communication, making it easy to find answers. Areas of potential conflict-access to medical records, billing, the front office staff, and the physician-patient experience should be examined.

Collaborate with technology solutions for consumers

. Technology solutions coming from the industry will require provider cooperation and involvement. Providers should help consumers connect with key applications and respond to questions. Special efforts to connect to scheduling, on-demand prescriptions, and consumer-oriented technology will need decision and engagement and require provider cooperation.

Failure of providers to act on these fronts will create consequences for them that could be irreversible. Consumers who can’t get relief will sideline health systems when they can and seek less costly or intrusive services. Physicians caught between demanding patients and recalcitrant organizations may leave. Sick patients who are stuck in the system will create financial disaster for themselves and for their providers.

Turning a big ship is hard and incremental. Whether providers have enough time to regain the loss of confidence in their operations is not clear. But they may be the torchbearers of this new wave of consumer power if they take the initiative now.

Theresa Hush is the CEO and cofounder of 

. As an expert at creating consensus for desired change through education and collaboration, Hush helps healthcare organizations take actions that will direct their future through meaningful technology and programs

Benefit cuts and increasing prices are creating medical debt and bankruptcies. Some consumers respond by avoiding healthcare or abandoning coverage. Their alternative? They don’t pay providers.

Four Ways Providers Can Help Patients Gain Value in Healthcare

	The healthcare cost “blame game” villainizes either providers for excessive services or patients for demanding too much.  Right now the blame game has pivoted toward the consumer, leveraging higher cost sharing to constrain their overspending and poor choices. That consumer focus has been at the center of employer benefit plans with higher costs for consumers as well as proposals for Affordable Care Act repeal.

	That’s the question health plans, employers and providers should ask if they want to effectively help consumers change their spending.

	There is a growing movement of consumers who are demanding better information and data to make better healthcare decisions. But the truth is that consumers don’t have enough information or knowledge to support them. The lack of information starts with essential clinical data about their own health status and extends to knowledge about cost of services pricing and access to information on treatment options.

1. Start by making full clinical information available to patients.

	At best, patients get the abridged version of their healthcare record. In part, this is due to where the information lies-either in paper records or in providers’ Electronic Health Records (EHR) systems.

	Even if the provider has an EHR, patients don’t always have access to their full data.  At best, they may be able to see or download test results, but will not see physician notes, diagnoses, visit data or synopses of treatments prescribed.  That means that patients are universally required to remember exactly what was said during a visit, including medical terminology used and treatment explanations. Health care is always provided in an “immediate” timeframe, which can stymie patients' efforts to deepen their understanding.

	Additionally, patients have no access to data that the physician used to make determinations-which could include unmentioned physical exam details as well as actual images. Because of this, consumers universally have no recourse later to investigate on their own or with other clinicians.

	Providers have made huge investments in digital health, but the data has been retained for their purposes in decision-making and analysis. More needs to be done to get this same information to their patients, and this is where health plans and other payers can help. As part of their Value-Based Health Care products and negotiations with providers, payers can create benefits or incentives for provider groups that are sharing data and supporting shared decision-making or goal setting with patients.

Provide Consumers With Projected Cost Information 

	Consumers can’t make good decisions without knowing the cost and their share.  But while the lack of price transparency has been a much talked-about concern, little has been done to fix it.  Providers have little incentive to turn patients away from services because their revenues are at stake. 

	Payers have ready access to cost information that can be available to consumers for major procedures, annual costs by condition, and even the relative cost of their own providers’ diagnostics, treatments, and facility costs. 

	The challenge for payers is how to best channel information to consumers as they need it during the decision-making process. Whether online or by phone, however, health plans and employers can fill the gap that providers have been unable to accomplish in making decisions and communicating with providers: what the recommendations of the provider will cost.

2. Facilitate discussion to treatment alternatives and lifestyle changes

	When consumers go searching for information about the benefits and harms of various alternatives, they often can’t find it.  Why? Because access to medical studies is not always accessible without professional credentials and subscription fees.  

	Although all National Institutes of Health (NIH) funded research is available to consumers, others can only be obtained through publishing journals. And finding the full article on the published journals, along with relevant data, is prohibitively expensive. The process, even for the most determined consumer, is daunting and likely impossible for patients trying to access multiple articles.

	Realistically, researching alternatives involves an understanding of physiological functions and clinical information that many consumers don’t have or is beyond normal expectations. So how can health plans help? They can create a foundation for consumers to have discussions with their physicians.

	For example, health plans can provide a list of conditions and procedures where alternative therapies are in use, or effectiveness is under question. This would help consumers raise questions about alternatives with their physicians. Health plans could also educate consumers on questions they should ask about benefits, potential harms, and evidence. Physicians can and should be the curators of medical information for their patients. However, it will take a push from their patients to make that happen.

	Patients must gain the confidence to understand the basic concepts of health care. Contrary to accepted belief, medical science is a discovery process and new knowledge is constantly emerging. Therefore, it is essential for consumers to be able to question whether prior assumptions are still correct. Asking simple questions will lead to knowledge of benefit vs. harm-or to the alternative of recognizing that not enough is known.

	Payers can also facilitate action on the part of physicians to appreciate the growing awareness and financial responsibility of their patients and to better use a shared decision-making approach.

	Once patients ask their physicians to provide literature for major diagnostic and therapeutic interventions, their physicians will be cued to their patients’ concerns and desire for further information. Provider groups should be encouraged through financial incentives and programs to facilitate the shared decision-making approach.  For example, Medicare has recently expanded its coverage of physician care management in ways that will provide incentives for shared goal-setting and discussions of long term treatment options.

Next: Patient engagement vs. patient compliance

Patient Engagement is Not the Same as Patient Compliance

	The financial incentives in the healthcare system generally work to provide more services. But with patients paying a larger share of the costs, all stakeholders must be involved in realistic solutions to avoid disease, concentrate on the most effective treatments, and perhaps use more conservative approaches to interventions.

	Patients were “dinged” in the past for not blindly following their physicians’ orders.  But we must acknowledge that consumers have financial pressures, don’t always understand the reasons for treatments and have unexpected side effects or harms. Establishing ways for them to participate fully in the discussion of their health status and outcomes is an essential component of getting to lower costs and better outcomes. 

Theresa Hush is the CEO and c0-founder of 

As an expert at creating consensus for desired change through education and collaboration, Hush helps organizations take actions that will direct their future through meaningful technology and programs.

Payers can facilitate action on the part of physicians to appreciate the growing awareness and financial responsibility of their patients and to better use a shared decision-making approach. Here’s three ways how.

Theresa Hush

Articles

6 Successful Strategies to Supercharge your ACO

Four Ways Providers Can Help Patients Gain Value in Healthcare

Three ways payers can help consumers make wise healthcare decisions