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ACOs Without the Rules: Private Sector Offers Route to Reform

 |  By Margaret@example.com  
   November 16, 2011

This has been an interesting week for the much maligned federal Patient Protection and Affordable Care Act (ACA). Early Monday morning the U.S. Supreme Court announced that it will convene more than five hours of hearings on the individual mandate portion of the act. Monday afternoon it was business as usual at the Department of Health and Human Services and the Centers for Medicare & Medicaid Services, as a trio of heavy hitters announced a competition to award millions of dollars in grants, courtesy of the ACA, to innovators who help improve healthcare and lower costs.

Then Tuesday morning the Optum Institute opened its doors with the mission to help kick-start what it calls sustainable health communities. Think of the ACA's accountable care organizations but without all the rules. The communities even have their own version of Don Berwick's infamous triple aim: increase the quality of care, improve patient experience, and lower overall healthcare costs. (Disclosure: OptumInsight, a sister company within UnitedHealth Group, advertises with HealthLeaders Media.)

Carol Simon, PhD, who has been tapped to lead the Optum Institute, says that similar to CMS, it aims to provide thought leadership to providers, payers, employers, governments, and even consumers as healthcare undergoes the changes introduced in the ACA. She hopes that the institute will become something of a clearinghouse for innovation so that ideas can be shared and implemented among stakeholders. The question the Optum Institute hopes to help stakeholders answer is: How do you change?

The opening of the Optum Institute seems to provide further evidence that despite the political and judicial naysayers, the healthcare industry, while not exactly greeting reform with open arms, sees the value in redesigning our healthcare delivery system to include ACA fundamentals such as integrated and coordinated care. Private industry just wants to set its own course to achieve the triple aim.

Case in point: The development of commercial ACOs. In an earlier column, I wrote about how health plans are creating alliances and partnerships and setting their own rules for meeting quality standards, cutting costs, and earning bonus payments. The commercial ACOs aren't limited to hospital and physician teams either. They include all types of configurations?health plans and physicians, health plans and hospitals, physicians and physicians, and hospital systems and hospital systems.

In a similar vein, the Optum Institute's sustainable health communities, will be more free-form and probably more wonky than the CMS-issued ACO. Simon says the sustainable health community (SHC) model is a goal, rather than a single model, that will be met in several different ways. The community can include policy types, providers, and almost anyone with an idea about how to improve healthcare.

How SHCs improve healthcare quality, bend the cost curve, and increase satisfaction among employers, providers, patients, and payers will be up to each community?with the caveat that they produce the necessary results. "The communities will bring their own resources, culture, and patient preferences to the table," Simon told HealthLeaders Media. She explains that the key to success will be "if we have patients and providers engaged in a way that will improve population health."

SHCs will also address the common complaint that the ACO rule sets no requirements for patient accountability. "We'll want to see patients engaged in terms of their ability to make choices and manage their own health," Simons says.

Part think-tank and part community organizer, the Optum Institute plans to provide a wide range of support for the creation of SHCs, including research and analysis, community-based forums, executive education programs, public policy debates, and industry partnerships.

The results of the institute's first research study demonstrate the enormity of the task. The Optum Institute teamed with Harris Interactive on a national opinion survey to explore attitudes among physicians, hospital executives, and patients about quality of care, accountable care, and what it will take to move to high-performing local healthcare communities.

Among the findings:

  • Patients believe they receive needed preventive care only 33% of the time, while physicians say it's around 50% of the time. Providing preventive care services is key to reducing the incidence of more serious illnesses as well as reducing the cost of medical care.
  • Almost two-thirds of physicians and hospital executives say that there are "significant differences in the quality of care provided by doctors" in their local area. Patients reported that they were unaware of quality differences. Reducing variations in the quality of care requires greater transparency and reporting so patients have the information they need to make informed healthcare decisions.
  • Patients responded that healthcare costs in their community could be cut by 25% to 29% without having a negative impact on quality of care. Physicians and hospital executives thought cuts of about 15% were more feasible.
  • Only 16% of patients, 16% of hospital executives, and 9% of physicians think the healthcare delivered in their community is well coordinated.
  • Looking to the future, 26% of physicians, 38% of patients, and 50% of hospitals believe that their local health community is on course to becoming more sustainable.

Simon says the survey results point to gaps in important healthcare components such as patient engagement. "We have to ask ourselves what groups have successfully put into place programs that bridge these gaps and are they scalable to other areas. Part of the work of the institute will be to identify and assess those programs."

The Optum Institute is looking at CMS and HHS programs to see where it can add value, she says. "There are a lot of experiments out there. I think we can add value as a neutral party that looks at these different programs, sees what works, and then provides opportunities for the programs to be adopted elsewhere."

The Optum Institute is one of several privately funded programs tackling the pressing problems of healthcare reform. We all know government can't do everything. It's good to see the private sector step up to help the goal of better health, better care, and lower cost become a reality.

Margaret Dick Tocknell is a reporter/editor with HealthLeaders Media.
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