7. How close are you to having a "care management" culture to address the continuum of care? Do your case managers work closely with hospitalists and other physicians in assuring that the most efficient care is delivered both in and outside the hospital (e.g., follow-up appointments, alerts for repeat admissions, etc.)? Do your primary care physicians have mechanisms to identify problem signs in patients with chronic disease (e.g., ED activity, specialty referrals required, etc.)? Case management, where the focus is on managing patients who present with complex problems, needs to evolve to care management, where potential problems are identified before they result in expensive care. Ultimately, this will require the capability to do predictive modeling to identify both individual patient risks as well as more general trends that impact health status of a population.
8. Does your approach to capital decision-making include consideration for the potential of the project or equipment to improve efficiency or enhance quality—or both? Traditional ROI models that assume a consistent revenue stream based on today's payment structure could lead to decisions that may be appropriate in the short-term, but fateful for the long-term. Assumptions should weigh the risks of a rapid change in payment structures. And leadership must weigh the pros and cons of investing in the future (i.e., IT and care management infrastructure) versus investing in the present (e.g., more imaging equipment).
9. What incentives are built into your compensation structures? Productivity models (e.g. wRVUs for physicians) work well in a fee-for-service environment, but if payment requires efficiency and quality outcomes, is your incentive structure going to facilitate achievement of the desired behavior and results? Also, a review of incentives for administrative leadership may be warranted—do the incentives reward "silo" performance at the expense of system-wide performance?
10. How informed is your board, medical staff, and middle management? Moving toward systems of accountable care requires all oars moving in the same direction, at the same time, and with a consistent effort. That won't happen unless everyone knows that the rules are changing. The change in mindset and definitions of success will not happen overnight, and in fact will likely take years. Assuring that all participants have a view into the future will facilitate effective change.
The concept of ACOs requires an organizational culture of mutual accountability based on individual responsibility—with a focus on optimizing the health (not just the medical care) of all patients. Are you ready?