"If it's just for penalties, you make more prominent the role of intensivists and discharge planners, and you're much more conscious of the frail elderly and managing them in an acute setting, simply to avoid being penalized for avoidable complications or readmissions or suboptimal functional status (in the case of implants)," says Keckley. "That level of coordinated care represents table stakes."
In addition to those table stakes, you may believe as a CEO that in your market a number of employers and health plans are also interested in two- to three-year contracts with a clinically integrated organization to manage a population on a capitated basis with performance incentives.
If so, you'll probably still rely on some of the same things you'll need to comply with the basic rules of the new game, but truly innovative integration requires more primary care, more mid-level practitioners, and more strategic relationships.
"Both [strategies] operate from the same chassis, but when we talk to the hospitals, they don't understand the difference in the two, saying, in effect, the first strategy is 'just compliance,'" Keckley says.
That could be as far as you want to go, and that could be the right answer for your organization. But if you step back from that line of thinking, both approaches are really addressing the same fundamental issues of how to best organize healthcare services across sites and professional groupings.
The only difference is that in the first scenario, any re-engineering of processes, relationships, and ownership structures comes from the position of avoiding giving up revenue. In the second, you're at risk for some additional income you might receive, or in order to do the deal, you might have to accept a lower base pay to participate.
"Both are tied to financial outcomes. Both are transparent. Both require interaction with payers. And both are multidisciplinary," Keckley says.
He sees a leadership attitude almost as though innovation into an ACO-type structure by definition means capitation with CMS, Aetna, or Humana or Blue Cross, for example. "It could mean that or it could mean capitation directly with Georgia Power or Wal-Mart," Keckley says. "That requires a different and broader set of clinical services."