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Lessons Learned from Vermont on Building Community ACOs

Janice Simmons, for HealthLeaders Media, May 20, 2010

Through Vermont's earlier "Blueprint for Health" initiative for chronic care patients and the state's collaboration with the Dartmouth Population Health Research Center," Vermont has been exploring additional sets of population health based measures for its ACO pilots, Hester notes.

Any ACO pilot also will need to have threshold capabilities in five areas to get started, the report said.

  • First, the ACO must be able to manage the full continuum of care settings and services for its assigned patients—both public and private—beginning with a patient centered medical home approach to primary care.
  • It must be financially integrated with both commercial and public payers (Medicare would begin in 2012). All payers will need to participate, so that at least 60% to 70% of patients in a provider's practice can be eligible for inclusion in a shared savings model.
  • A health information technology platform that connects providers in the ACO—and allows for proactive patient management is essential—along with a strong financial database and reporting platform for managing the global medical budget. This information starts at the practice level with a Web based clinical tracking system, which provides flow sheets for individual visits, a registry for chronic illnesses, and population based reports.

    In addition, Vermont has an all-payer claims database that all commercial payers already are "syncing into a common system" and then generating reports, Hester notes.

  • Physician leadership—as well as the commitment of the local hospital CEO and leadership team—will be vital to driving changes in process, cost structure, and mission.
  • And, it must have process improvement capabilities to change both clinical and administrative procedures to improve the ACO's performance to achieve financial and quality goals.

But what will the ACOs eventually look like? Probably if you're seen one pilot ACO in Vermont—you've seen one. Achieving the necessary critical mass of patients that would support statistically meaningful measures of performance may require either a consolidated performance pool involving multiple payers—or expanding the ACO to include multiple hospitals.

The former is more likely, Hester says. "You'll need a certain critical mass in order to make the shared savings pools work," Hester says. It probably would have to be in the area of at least 15,000 patients. The latter could greatly complicate implementation issues, particularly governance. "We have a lot to learn and a lot of experimentation [to do] in terms of what kind of structures it can support, Hester says.


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Janice Simmons is a senior editor and Washington, DC, correspondent for HealthLeaders Media Online. She can be reached at jsimmons@healthleadersmedia.com.

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