Transforming Health Care Through Accountable Care Organizations

June 17, 2015 / By Barbara DeBuono, MD

The design and implementation of accountable care structures like ACOs has been a popular mode of transforming healthcare from volume- to value-based healthcare delivery systems. As was oft-quoted in the early stages of ACO development, they are akin to a unicorn—that is, everyone knows what they look like but no one has ever seen one. Now, as ACOs have evolved and have some experience under their belt, the common quote seems to be “when you’ve seen one ACO, you’ve seen one ACO.”

Issues and Challenges

While every integrated delivery system that engages in accountable care may not necessarily be called an ACO, those that operate within a framework of payment aligned with performance do face similar issues and challenges. Among these are:

• Identifying the threats and challenges facing their organization;
• Establishing a common set of goals among key stakeholders from the hospital, providers, care managers and others regarding cost, quality measurement, performance targets and delivery system changes needed in a value-based delivery system;
• Understanding population health management;
• Strengthening communication within the delivery system and forging new, collaborative relationships among providers, payers and patients;
• Assessing the ability to engage in risk-based contracts and determining appropriate financial, quality and outcome metrics and targets;
• Tackling variation among providers, patient outcomes, facilities and geography;
• Managing multiple, non-standardized quality metrics and standards, as well as making the transition from process to outcome measures; and
• Effectively using multiple sources of data, and in some instances, new types of data altogether, to manage population health. This includes identifying and targeting at-risk patients for better care management and gauging progress in outcomes as well as total cost-of-care.

This is not an exhaustive list of challenges, but these are the common themes we have seen not only with our own clients, but from colleagues throughout the field.

Lessons Learned

I’ve been thinking quite a bit about ACO lessons learned, issues and challenges, from our experience, from our client’s experience, and from what we’re hearing from those in the field. Here are some of the common themes:

• Leadership is essential within the ACO, including an articulated vision for the future and a pragmatic approach to building the right team to drive the agenda forward.
• Communication is imperative from leadership and among partners, payers, providers and patients early in the process and on a regular and ongoing basis. Communication about lessons learned throughout the ACO journey engages stakeholders and creates motivation for building success.
• Collaboration and engagement are important building blocks. As one speaker at a conference noted, “You can’t run an ACO population like an HMO, you need to engage and sell, it’s not command and control.” From the design of the program throughout its implementation, it is critical to collaborate and engage all parties—and to build a strong foundation for trust and transparency.
• Education about population health management, total cost-of-care, and provider engagement is important at the onset. Education, along with communication, collaboration, and engagement, enables common understanding of “the why, the what, and the how.” This isn’t a one-time training or a single educational session; this is ongoing, regular education, particularly given the dynamic nature of ACOs and the healthcare environment itself.
• Actionable data, transparency, and data sharing are key to success. Data is part of the foundational structure for any ACO. Data on cost, quality, and performance is a must for (1) assessing existing strengths and readiness for taking on risk; (2) identifying and managing the care of populations; (3) establishing financial targets; and (4) monitoring progress in health outcomes, quality, and total cost-of-care. The data has to be translated into easy-to-use, easy-to-access, relevant insights that help stakeholders accomplish their goals; the data has to be valid, well analyzed, and shared. The analytics emanating from the data should also enable peer comparisons and benchmarking to determine ACO performance in relation to others. Building an infrastructure to house and enhance multiple data sources, and then create the actionable information to drive decisions, behavior, and change is no small feat, but, as we know from experience, it is vitally important.
• A new mindset about claims data has to be adopted. My colleague Gordon Moore, MD often remarks that claims data itself provides actionable information for population health management. As the integration of claims and clinical data evolves, it’s important not to dismiss the power of this administrative data. As noted by another colleague recently, “the ‘aha!’ moment with claims data comes when providers can see what’s happening outside of their offices.”
• Focus should be on the populations you can impact. Using data and analytics, ACOs can target at-risk individuals (from a health status/illness burden and/or cost perspective) and engage them in better coordinated care and care management. The 80/20 rule is a good one to follow when thinking about the populations you should manage first (typically, 20% of your patient population contributes to 80% of costs and utilization).

These lessons, gleaned from numerous ACOs over several years, tell us that the foundation for healthcare transformation is good data along with a strategy around alignment, collaboration and transparency.

Barbara A. DeBuono, MD, MPH is vice president, Market Development for Populations and Payment Solutions at 3M Health Information Systems.

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