Accountable Care Organizations and Patient-Centeredness

As you may know, the proposed Accountable Care Organization regulations were released yesterday.  I’ve posted links to the various documents and some early news reports on my blog:  Accountable care organization proposed regulations released for public comment.  I’ll be participating in the ACO Watch roundtable discussion on the ACO regulations this afternoon – feel free to listen in live (Friday, April 1, 2011, 4 PM ET) or to the recording, at your leisure.

One notable item from the Society for Participatory Medicine’s perspective:

For many of the criteria defining what it is to be an ACO, the federales have said simply: Please explain how you meet criterion x.  (They may change this approach in the future, once they have more experience under their belts.)

When it comes to patient-centeredness, however, an ACO must meet all 8 criteria identified in the proposed reg (this quote starts on page 84 of the 429-page main regulation (it’s linked to from the post above; please note that once the proposed regulation migrates from the “on display” version to the Federal Register’s published version next week, the pagination will change):

We propose that an ACO would be considered patient-centered if it has all of the following:

∙ A beneficiary experience of care survey in place and a description in the ACO application how the ACO will use the results to improve care over time. As discussed in more detail later in the document, and as proposed in section II. E. of this proposed rule,scoring on this survey would help the ACO meet the quality performance standard.

∙ Patient involvement in ACO governance. As discussed in more detail later in the document, the ACO would be required to have a Medicare beneficiary on the governing board.

∙ A process for evaluating the health needs of the ACO’s assigned population, including consideration of diversity in their patient populations, and a plan to address the needs of their population. As discussed in more detail later in this document, the ACO would be required to describe this process as part of the application and describe how it would consider diversity in its patient population and plans to address its population
needs.

∙ Systems in place to identify high-risk individuals and processes to develop individualized care plans for targeted patient populations, including integration of community resources to address individual needs. This proposal and application requirements are discussed in more detail later in this document.

∙ A mechanism in place for the coordination of care (for example, via use of enabling technologies or care coordinators). The ACO would be required to describe its mechanism for coordinating care for Medicare beneficiaries. In addition, the ACO should have a process in place (or clear path to develop such a process) to electronically exchange summary of care information when patients transition to another provider or setting of care, both within and outside the ACO, consistent with meaningful use requirements under the EHR Incentive program. The ACO would be required to describe their process or their plan to develop a process to electronically exchange summary of care information during care transitions. Additionally, in section II. E. of this proposed rule, we propose to include care transitions measures as part of the assessment of ACO quality.

∙ A process in place for communicating clinical knowledge/evidence-based medicine to beneficiaries in a way that is understandable to them. This process should allow for beneficiary engagement and shared decision-making that takes into account the beneficiaries’ unique needs, preferences, values, and priorities. The ACO would be required to describe its process, as discussed in section II.E. of this proposed rule, for communicating clinical knowledge/ evidence-based medicine and describe how the ACO providers/suppliers will engage the beneficiary in shared decision-making.

∙ Written standards in place for beneficiary access and communication and a process in place for beneficiaries to access their medical record. As part of its application, the ACO would be required to submit its written standards for beneficiary access and communication. Additionally, the ACO would be required to describe its process for beneficiaries to access their medical record.

∙ Internal processes in place for measuring clinical or service performance by physicians across the practices, and using these results to improve care and service over time. As described previously, the documents submitted to meet leadership and management criteria related to quality assurance and clinical integration program would satisfy this patient-centeredness criterion.

We believe that this list provides a comprehensive set of criteria for realizing and demonstrating patient-centeredness in the operation of an ACO. Accordingly, we are proposing to require that ACOs demonstrate patient-centeredness as required by the statute by addressing all 8 areas outlined previously.

There is a 60-day comment period.  So I ask you: Did the federales get this right?  Is it too much to ask that an ACO go 8 for 8?  What’s missing?  Is shared decisionmaking a step further than patient-centeredness, or is that something that the Society should seek to have baked into this definition?

What do you think?

David Harlow is a health care lawyer and consultant. He serves as the Chair of the Society for Participatory Medicine’s Public Policy Committee. His “home blog” is HealthBlawg.  You should follow him on Twitter.

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22 Responses to “Accountable Care Organizations and Patient-Centeredness”

  1. The paragraph that describes shared decisionmaking and communicating clinical knowledge/evidence based medicine looks encouraging to me. The devil will be in the details of how an ACO interprets and applies the following statement:

    “This process should allow for beneficiary engagement and shared decision-making that takes into account the beneficiaries’ unique needs, preferences, values, and priorities.”

    From my perspective, we have a long way to go before most providers can meet a goal of offering such a customized level of information services to a population with a broad range of needs, preferences, etc. Furthermore, organizations that provide the information (health care publishers) have a way to go in developing “patient decision aids” that meet the needs of the full spectrum of patients. I plan to expand these thoughts in another post soon.

    • David Harlow says:

      @Janice — Thanks for your comment, and I look forward to seeing your upcoming post. The IT needs for the SDM component of ACOs — and for other components as well — are daunting, and as you may know, the NEJM published a comment last week suggesting that any ACO would run in the red for several years as a result of the required infrastructure investment. This, of course, begs the question: Is healthcare about to be inundated with next-generation MSOs ready to underwrite the capital needs of nascent ACOs?

  2. Thanks for posting this, David. I hope we’ll get more discussion going – I know policy isn’t everyone’s cup of tea but people, THE RULES ARE BEING WRITTEN for how US healthcare providers will be told to treat us!

    SPEAK UP!

    I can’t dig in more because I’m overseas prepping for TEDx Maastricht on Monday… more later I hope.

    • David Harlow says:

      @Dave – Thanks for piping up (I know that’s hard for you :) ).

      We have a 60-day window to evaluate these portions of the ACO regulations and formulate comments. I will reiterate the call for input, so that the Society can be sure to present the patient perspective in all of this. Please be aware that CMS has proposed that every ACO’s board must have a Medicare beneficiary representative. Taken togehter with the proposals outlined in this post and comments, they are definitely moving in the right direction. Please let us know if you think that these rules, collectively, move us far enough forward.

  3. David Harlow says:

    In addition to the section on patient-centeredness, the regulation includes 65 quality measures in 5 categories that will be used to determine how much of shared savings actually get shared by the feds with the ACO. (This is intended as the backstop to simple cost-cutting; providers don’t share in savings unless they can also demonstrate quality improvement.) One category is patient experience of care. The measures in this category are drawn from CAHPS:

    *Getting Timely Care, Appointments, and Information
    *How Well Your Doctors Communicate
    *Helpful, Courteous, Respectful Office Staff
    *Patients’ Rating of Doctor
    *Health Promotion and Education
    *Shared Decision Making
    *Health Status/Functional Status

    Comments are invited by CMS on these measures as well.

    I’ve posted more information on the proposed regs, including a blog talk radio roundtable broadcast the day after the regs were released featuring five middle-aged white guys (yours truly included) at HealthBlawg: http://j.mp/erSVfi

  4. David Harlow says:

    Mike Scott replied to the original version of this post on the SPM listserv, and I am reposting his comment here with his permission:

    I think it is reasonable that ACOs be required to “address” all eight areas, which is what is being recommended. What may be much more difficult will be to define what is meant by “meet” specific criteria.

    I would suggest that the important issue here will actually be the application of a process of continuous improvement in seeking to move towards meeting certain definable criteria over a period of time and being graded on the degree of success in doing so.

    Some of the proposed criteria are pretty easy to meet (e.g., having a Medicare beneficiary on the governing board), but raise questions about the appropriate qualificiations of such a Medicare beneficiary.

  5. Thanks David for the post
    I think that your summary and the GOV is spot on intermsof the vision for US Healthcare. The transition will be PAINFUL for everyone!

    Other key themes…
    -Must use HIT to have any chance of success
    -Quality/outcomes is the real goal of a healthcare system
    -Collaboration is required – but we will be watching to prevent abuse…
    -Gain/Risk sharing is preferred and the carrot/stick
    -Shift the control to providers in service of patients! Long overdue…
    -What HC System will ‘sell’ is health outcomes/population health! at the right price!

    I like to think of it as the US Healthcare Renaissance!
    Strap in it is going to be a BUMPY ride! After all we are redesigning a $2.5 TRILLION industry while it is up and running!

    • David Harlow says:

      @Paulo — I agree with the points you’ve made and would add that one notable reveal in the regs is that an ACO is to be a freestanding corporate entity founded by health care providers, and not by payors. It will be interesting to see whether and how ACO development on the commercial side (a necessity, as noted in my post on HealthBlawg linked to above) may diverge from development of n the Medicare side. As you know, quite often commercial developments mirror the Medicare structures, so the payors may end up taking more of a backseat role. However, if tere is flexibility for commercial ACOs to operate on slightly different terms from the Medicare ACOs under the agglomeration of rules issued last week, then there may some very innovative developments, including novel payment mechanisms and quality measures. Furthermore, it will be interesting to see whether physician-led ACOs can be put together — either by existing large multispecialty groups, or by agglomerations of smaller practices (as has been done under the BCBSMA AQC), though the latter model (and perhaps the former as well) will require a capital infusion from elsewhere in order to develop the infrastructure required to qualify as an ACO.

  6. Jodi Sperber says:

    Thanks for this post, David.

    I think the ACO regs are well stated, and I’d even agree with the 8 for 8 requirement. It’s easier for me to envision ACOs working within primary care settings, where there is continuity of care. I have less clarity on how well it will play in the hospital setting, where volume is key. I can see friction popping up between the two settings, as primary care works to keep people out of the hospital, and, well, that hurts business for hospitals.

    I echo Paulo’s sentiments re: IT being paramount (which is coming from all fronts at this point; meaningful use and ACOs are intimately linked here) and high quality/outcomes being the goal (even though I realize there is subjectivity in there).

    What I am curious about here is how ACOs in the commercial market will impact payors over time. I can envision smaller practices joining forces to have a better shot at influencing pricing. I know this is on the Feds’ mind, too. Ideally I’d like to see this create a push towards more transparency in pricing, so that there is more consistency overall.

    • David Harlow says:

      @Jodi — Hospitals need to be efficient, too, and if they achieve savings for the Medicare program, they’ll be able to share in those savings. It’ll be interesting to see how much flexibility ACOs ultimately have on the commercial side. Jeff Goldsmith makes a pretty compelling argument for using three different payment models in a commercial ACO (and, for that matter, in a Medicare ACO; given the flexibility shown by CMS in the proposed regs, perhaps the agency might even embrace this approach down the road). I’m quoting myself here:

      In brief, Goldsmith recommends risk-adjusted capitation payments for primary care, fee-for-service payments for emergency care and diagnostic physician visits, and bundled severity-adjusted payments for episodes of specialty care. Primary care would be provided through a patient-centered medical home model, which would likely have a collateral effect of reducing the total volume of emergency care and diagnostic physician visits. Specialty care would be provided through “specialty care marts,” ideally more than one per specialty per market to maintain a little healthy competition.

      My full post on Goldsmith’s Plan B for ACOs is here: http://j.mp/eH87mB

  7. David Harlow says:

    Since ACO’s will have to achieve high scores on patient experience (among other categories of quality measures), ACO wannabes should learn from the masters. Today’s example: an interivew with James Merlino, Cleveland Clinic’s Chief Experience Officer: http://j.mp/gAS5p1 How well would the Cleveland Clinic do on the patient experience measures identified in the proposed rule?:

    *Getting Timely Care, Appointments, and Information
    *How Well Your Doctors Communicate
    *Helpful, Courteous, Respectful Office Staff
    *Patients’ Rating of Doctor
    *Health Promotion and Education
    *Shared Decision Making
    *Health Status/Functional Status

    Please note that aside from any ACO-related shared savings, hospitals are now facing a 2% withhold on Medicare payments, and they get to earn the withhold back based on meeting certain criteria … including how well they do on the CAHPS surveys administered to patients (which is where these measures come from)

  8. […] is a natural disaster, a scientific breakthrough, or a new twist in a policy debate (see: “ACOs“). I read up on the facts and try to make sense of the latest turn of events, but usually […]

  9. […] less so.  (For one example of specific guidelines, take a look at the eight-part definition of patient-centeredness; an  organization must satisfy all eight in order to be an ACO.  Other requirements have no […]

  10. WarmSocks says:

    This really doesn’t look like a template for patient-centered care to me. It looks like rules for more bureaucracy.

    I could go through point-by-point (in fact did, then deleted it), but this is not what patients want. We do not want to be surveyed and lumped into groups and churned through the mill. We want to treated as individuals to have our individual needs met.

    My family doctor takes a complete history – now he’s identified my risk factors. He knows what to watch for and what/when to treat/not treat – individual plan. Coordinating my care is easy for my doctor because he either provides it or refers me to someone else (I have the choice of self-refering (and resent the government trying to deprive me of this option), but would prefer to get my doctor’s expert advice on when/if I need to see someone else). His policy for patients to access their medical records is to provide a copy when requested. Simple, straight-forward, patient-centered.

    The government’s plan treats patients as a herd to be managed instead of as individuals with unique needs. That’s a bizarre definition of “patient-centered.”

    When my current doctor retires, I’ll be specifically looking for a doctor who isn’t part of an ACO. That will tell me that he’s more interested in treating patients than in jumping through the government’s hoops to get less pay for more work.

  11. […] (You may read more on this last topic at an earlier post on ACOs and patient-centeredness.) […]

  12. […] So bottom-line, other than the excessive cost burden imposed (CMS estimates the typical cost burden to be somewhere in the $1.8 million range), the real issue boils down to putting patients or consumers in the conversation or at the table, via ‘shared governance’ and CMS’s indicia of ‘patient-centered-ness’. For an excellent recap by David Harlow at e-patients.net, click here. […]

  13. Nancy Merbitz PhD says:

    As a clinical psychologist working primarily with patients having medical conditions, I have cause on a daily basis to wish for more coordination with physicians and nurses providing care to them. I am in private practice in a rural/small town area of central Illinois. How will I be able to form or participate in an Accountable Care Organization? Or, how will ACOs be encouraged to incorporate the considerable skills of psychologists with experience in healthcare? In my particular case, the only local hospital is Catholic and has very restrictive, doctrinal-related policies that would require me to sign and pledge to follow in my work (not going to happen). What are my options? Thanks!

    • Ben Miller says:

      Nancy – a few quick thoughts – Wow, what a question. Talk about a major issue to discuss! There are several issues that you bring up here. 1) Integration of mental health into the larger healthcare system; 2) Integration and coordination within an ACO; 3) The complexities of independent providers in ACOs; 4) The challenges for mental health period; and, 5) What are the rules for becoming a “member” of an ACO.

      Each of these issues requires more discussion and understanding from the field. Your options, as I see them, are as follows:

      1) Be seen and be heard: mental health has a tremendous amount to offer healthcare writ large. ACOs are no exception! In most discussions like these, mental health is not really “at the table.”

      2)Offer help to the patient-centered medical home world: If ACOs are the “macro” then PCMH are the “micro” – start by becoming acquainted with PCMH, integrate, offer assistance, explore partnerships, try, measure, report, try again, etc. etc. etc.

      3)Talk it out with others interested in this topic. Work together. Collect stories. Make a case.

      I wish I had more time to think this one through, but Nancy, you are hitting an important topic right on the head. Thank you!

  14. bacigalupe says:

    These are sound recommendations. What worry me is “process for” and “systems in place” are defined and measured. The implementation details and the follow-up will be crucial. That’s a problem with most accreditations nonetheless. How it connects with actual patient outcomes? That coordination is in here allows for putting the conversation on the table but I can see how the word will be used in so many ways…

  15. Nancy Merbitz PhD says:

    Hi, Ben –
    Thanks for the encouragement. Does anyone know how to learn who is starting PCMHs? As I mentioned, my small town (11,000 people) has one hospital, Catholic, and has hired up almost all of the local physicians. Working with them is not an option because of the “pledge” I would be required to sign regarding transmission of doctrinal points of view on personal matters. I am the only psychologist in the county, and I wonder what will happen to me when all Medicare providers (and eventually all providers?) have to be in ACOs. And what will happen to psychological treatment availability. There are two physicians not affiliated with OSF St James Hospital, but they are not open to collaboration with a psychologist (and I have researvations about the care they offer anyway). I have no idea who is doing PCMHs anywhere near here. Is there a listing anywhere? Thanks!

  16. […] is a natural disaster, a scientific breakthrough, or a new twist in a policy debate (see: “ACOs“). I read up on the facts and try to make sense of the latest turn of events, but usually […]

  17. […] (You may read more on this last topic at an earlier post on ACOs and patient-centeredness.) […]

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