ACO Development Fatured in Accountable Care News (07.21.11)

Developing an ACO Between Two Competing Health systems  

May 2011
Article published in Accountable Care News June edition
By: Marcel Devetten, MD, Chief Quality Officer at The Nebraska Medical Center and board member of the Accountable Care Alliance

Long before the official announcement of any proposed rulemaking for the development of Accountable Care Organizations, the chief financial officers and directors of contracting for The Nebraska Medical Center and Methodist Health Partners realized they shared these common goals: looking for opportunities to improve quality and efficiency of care and to reduce costs.  In order to accomplish these goals, the health systems knew they needed to also improve alignment with physicians.

The new Accountable Care Act introduced the perfect vehicle to move forward. An ACO would allow physicians across different health care organizations to work together without violation of any federal or state laws. Thus the Accountable Care Alliance (ACA), a limited liability company, was formed on January 22, 2010, for the purpose of ‘creating and monitoring health care quality standards for participating hospitals and physicians.”

The ACA invited five physicians from each of the two partnering health systems to join the board of directors. The only non-physician members on the board are the CFO’s of the two health systems, assuring that the new ACA would be physician led and driven.

Furthermore, rules were adopted to prevent one of the two health systems from dominating the decision making process. The board charged a medical management committee, chaired by the physician quality leaders of the two organizations, to develop and implement relevant quality metrics that would be widely supported by physicians across the two health systems and that could be used to improve patient care and outcomes.
 

The medical management committee began quality improvement projects for several high volume procedures and/or diagnoses, including hip and knee replacement surgery, common colorectal surgical procedures and percutaneous coronary interventions. In addition, a subcommittee studying the ambulatory care environment for appropriate quality measures was instituted. 

The medical management committee has taken  inventory of existing databases and data collection systems between the two health systems, and has decided that registries and databases initiated and supported by medical specialty and subspecialty groups (such as ACA, STS and NSQIP) could generally count on physician buy in, and were therefore best suited for comparisons between the partnering health systems.

The committee then invited physicians from the two health systems to sit around the table and compare existing care pathways that were utilized by the various physician groups practicing within the two systems. Interestingly, most physicians were eager to participate and fully supportive of the process. As a matter of fact, the extent of variation between different groups, both in established practice and in outcomes, were quite eye opening for many of the participating physicians.  

Another major discovery was the near complete absence of a pre-operative standardized evaluation in both health systems. Hospitalists and anesthesiologists met to develop pre-operative standards, rapidly identifying some significant gaps in the existing process, such as the lack of screening that hip/knee replacement surgery candidates were given for pre-existing sleep apnea. Within the group of orthopedic surgeons, the discussions focused predominantly on transfusion support and DVT prophylaxis. Existing evidence-based guidelines from relevant specialty groups were introduced in the discussion by the physician quality leaders, and were incorporated in consensus clinical pathways whenever possible.

The emerging consensus order sets were then reviewed by the nursing leadership of the two partners, to coordinate them to the nursing care plans.
Another major focus has been on reducing 30-day hospital readmissions.  The ACA has established procedures to review readmission processes and develop best practices. 

Some of those best practices include a new discharge plan for those at risk for readmission and a care transition plan that has been implemented for patients who are discharged to nursing home care or a skilled nursing facility. This follow-up care is helping to prevent a relapse of the patient’s condition requiring readmission back to the hospital.

Key to the success of the ACA progress has been communication with large and small groups of physicians about the goals and plans of the ACA. Several large meetings have been organized to introduce the concept to all interested physicians. In addition, written communication has been shared with physicians through newsletters and electronic media.

Once consensus pathways and order sets were developed, informational meetings were held with all specialty physicians affected by the pathway. Topics of discussion included use of the order set; outcome metrics comparing physicians using the standardized pathways and orders with physicians who did not; and sharing of any cost-savings resulting from a reduced use of resources and/or readmissions.
 

Discussions with payers to cover startup costs and share cost-savings have progressed steadily, with most payers expressing an interest to work with our ACO. The proposed rules for accountable care organizations under the CMS shared savings programs have been carefully studied, and several comments and requests for clarification have been submitted to CMS. We obviously have an interest in becoming an ACO under the CMS plan, and we anxiously await the issue of the final rules prior to any decision about an application. Meanwhile, we are very pleased by the cooperation and positive changes that have resulted from these very early steps towards better care integration.

We understand that there is still a ways to go towards the development of a well integrated health care delivery system, but we think that our physician driven model with its emphasis on quality (and without much discussion about costs) is very promising for improving care across our two health care systems.