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By Brent A. Metfessel MD

The Patient Protection and Affordable Care Act (ACA), affirmed after the November 7th 2012 presidential election, includes a number of policies and potential projects with the aim of improving quality of care while reducing costs – or at least greatly slowing increases in health care costs from year to year.

Included in this effort are CMS payment incentives for providers that can show care patterns that meet the goals of high quality, cost-efficient care.

HHS and ACOs 

On March 31, 2011, the Department of Health and Human Services (HHS) released a set of proposed new rules to aid clinicians, hospitals, and other health facilities and providers to improve coordination of care for Medicare patients using a model known as Accountable Care Organizations (ACOs). ACOs that are shown to lower health care cost growth while meeting CMS quality benchmarks, including measures of patient/caregiver experience of care, care coordination, patient safety, preventive health, and health of high-risk populations, will receive incentive payments as part of the Medicare Shared Savings Program.

But, in some proposed models ACOs may also be held accountable for shared losses.

Care Co-ordination

Coordination of care means that hospitals, physician offices, and other providers have a complete record of patients’ episodes of care, including diagnostic tests, procedures, and medication information.  This potentially would decrease extra costs from unnecessary duplication of services as well as reducing medical errors from incomplete understanding of the patients’ illness histories and medical care provided.

It is also believed that better coordination of care may prevent 30-day hospital readmissions (which occur for nearly one in five Medicare discharges), since needed post-discharge care would be more readily obtainable with more aggressive care coordination.

Medicare patients in ACOs, however, would still be allowed to see providers outside of the ACO, and proposals exist to prevent physicians in ACOs from being penalized for patients with a greater illness severity or complexity.

According to a CMS analysis, ACOs may result in Medicare savings of up to $960 million over three years.  Although the Affordable Care Act’s ACO provisions primarily target Medicare beneficiaries, private insurers are also beginning to create care models based on the accountable care paradigm.  Insurers could offer similar incentives to the ACO model described above, and which might include features such as performance based contracting or tiered benefit models that favor physicians who score highly on care quality and cost-efficiency measures.

Only the Beginning

ACOs and other implementations of the accountable care paradigm, however, are in their beginning stages, with a number of pilots around the country currently being conducted to more fully evaluate the concept, and there still is some controversy over the best way to achieve these goals. It is a continuing balancing act.

The critical point here is that in all likelihood, with the advent of the ACA and other initiatives, stemming the upward tide of medical cost increases becomes an even higher priority, and no matter what the final models will look like, the success of any of the models requires a high level of care coordination – requiring information systems that are fully compatible and allow seamless and errorless transmission of information between sites of service and the various providers that can be involved in patient care.

More:

1. Ground Breaking Book Explains Why Accountable Care Organizations May Be the Answer the Health Care Industry Has Been Seeking!
2. Evaluating ACOs at Mid-Launch
3. How Using a ‘Scorecard’ Can Smooth Your Hospital’s Transition to a Population Health-Based Reimbursement Model
4. Doubting the Accountable Care Organization B-Model

Assessment

Thus, wherever a patient goes for care, all the information needed to provide high-quality and cost-efficient care is immediately available.

References

Feds Take Critical Look at Meaningful Use Payments”, InformationWeek Healthcare, October 24, 2012.  http://www.informationweek.com/healthcare/policy/feds-take-critical-look-at-meaningful-us/240009661 [Accessed on November 2, 2012].

Conclusion