Report from the Front: Accountable Care Organizations & Patient-Centered Medical Homes

By Norman Chenven, MD, CEO and Founder, Austin Regional Clinic

Austin Regional Clinic (ARC) is a multispecialty medical group in central Texas with 18 locations and nearly 300 physicians. Over the past 30 years our business model has been driven by the payment models of employers, commercial health plans and government programs. There have been dramatic changes over that timeframe as payers have experimented hoping to encourage and reward hospitals and providers for providing increased value for the health care dollar. Increased value, simply defined, is higher quality at a lower cost. Accountable Care Organizations (ACOs) and Patient Centered Medical Homes (PCMHs) should be viewed and understood in the context of this long history of seeking increased value.

Even though ACOs and PCMHs represent worthy next steps in this search, they should not be viewed as panaceas but rather as incremental stepping stones in an evolutionary process. These two acronyms describe programmatic approaches to providing health care to individual patients but with the common thread that the medical delivery system engaged in these approaches takes responsibility for a defined population and reaches out to the patients in that population proactively to identify gaps in preventive and or chronic care. This can result in the prevention of problems and/or the delivery of more focused medical help and resources to patients in need thus hopefully avoiding expensive catastrophes.

This approach is conceptually quite different than the traditional medical model of only responding to individual patients as they present themselves to their doctors and the delivery system. The traditional approach is reactive by design. ACOs and PCMHs are conceptually proactive in their philosophical bias — they scan the entire patient population for which they are responsible with the intent to identify the neediest and then intervene. In order to accomplish this, substantially more infrastructure is required, such as the electronic medical record and software that analyzes patient information (such as emergency room use, hospitalizations, diagnoses, lab results, prescription use patterns) for the purpose of identifying those who are in need. In ACOs and PCMHs, those patients must be contacted in order for preventive care to be provided. This means that, in addition to the data analysis, additional staff is needed to provide the outreach calls, health coaching and education, and to fully staff  teams of doctors, nurses, behavioral health specialists and social workers.

Preventing problems proactively saves money and misery by avoiding future medical problems. Conceptually this is nothing more than ”preventive maintenance” that is made possible by care management fees that our group negotiates from the health plans for population management activities. The past 18 months have been very interesting as one payer after another has approached our medical group, ARC, and the hospital system, Seton Healthcare Family, that is our partner in caring for a large population of our patients.

The basic requirements for ACO/PCMH activities have been used in managed care programs in the past but they tended to emanate from the health plan headquarters rather than the provider’s office. And that is a major difference. When the health plan made decisions about patient care, they base those decisions on benefit criteria and global statistical medical necessity rather than by case-by-case evaluations with input from the primary care physician. As we continue along this evolutionary path and patient care decisions are made in the provider’s office, we see a lot of creativity in the field with extended physician visits, programs to provide continuity after discharge from the hospital, implantation of home monitoring devices, and more.

More and more of these changes are taking place across the continuum of care. Hospitals, physician groups, payers, and ancillary health entities are finding ways to communicate more about their patients, thereby expanding coordination of care between primary and specialty care physicians, between physicians and hospitals, between hospitals and post-hospital care, and between patients and physicians.

It is important to continue on this path of increased system integration, patient coordination, and physician accountability in health care. Health care providers, payers and patients are slowly coming together around a common vision of what health care delivery should look like and how it should function.

We need to constantly find new and better ways to communicate this vision and this healthcare delivery model to more physicians, health care organizations, and most of all patients. This is why ARC supports this accountable care website project by the Council of Accountable Physician Practices. By putting forth a vision of what accountable care should be, perhaps we are drawing a blueprint for a patient-centered foundation that will contribute to evermore ACO development.

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