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In an ACO, Who's Accountable?

Philip Betbeze, for HealthLeaders Media, April 14, 2011
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?We?ve done a good job of managing a drop in our length of stay, while doing better documentation and raising our case mix index,? he says.

Size matters

Scale, as in the number of patients managed, will be important in the new integration, says Sg2?s Sachs.

?If the minimum size to manage isn?t there, you can?t deliver on results,? he says. ?Likewise, if you don?t have a large enough pool, you can?t make the infrastructure and culture changes that need to be made.?

That said, the scale doesn?t have to be immense.

For instance, panel sizes for physicians are important. Some say physicians need between 1,800 and 2,300 patients to balance risk in an ACO.

The size of the RWJ network was one reason RWJ Hamilton joined it a few years ago. ?It was visionary,? says Cimino. ?Our ability to connect with RWJ University Hospital by seamlessly transferring people within a 25-mile radius of their home is a very big advantage for us, versus the competitors, who aren?t aligned with big systems.?

While the hospital has been part of the system for years, each hospital in the past ?has done its own thing,? Cimino admits.

Part of a better future for his hospital, says Cimino, is the ability to clinically integrate with one of the top hospitals in the country, which allows residents in the Hamilton area to have care from a tertiary center without having to go to Philadelphia or New York.

One of the big advantages to the system, says Cimino, is its linkage to the Cancer Institute of New Jersey.

?We developed a satellite right here on the Hamilton campus,? he says, which provides cancer care as good as you can get in the major academic medical centers.

But at least as important as these links to the academic medical center at the heart of the RWJ system is the fact that community hospitals will have to deal with a far more competitive environment than they are used to, says Cimino. Critical to their competitiveness will be how they align with physicians and treat them as strategic partners.

At Hamilton, for instance, Cimino established a physician council separate from the medical executive committee.

?This is for strategic relationships and ensuring that we are dealing with and resolving those in partnership with physicians,? he says.

Technology?s role

One of the reasons many ACO supporters say that the ACO experiment will end better than managed care is the dramatic increase in useful technology to both coordinate care and choose the most appropriate care for patients.

?The pushback that happened with managed care in the past is why we?re seeing such important discussions on the medical home,? says Sachs, referring to a primary care physician who, in many cases, will be responsible for coordinating any advanced care the patient may need and serving as a clearinghouse for that patient?s electronic medical record. 

Sachs believes that today?s technologies can help better inform patients about the best course of action for treatment. In other words, those procedures that sometimes get denied in preauthorization aren?t necessarily good for you.

?This time, the pushback will be in the form of ?You did that procedure and I didn?t need it,?? he says. ?People want to get what they want when they want it, but since more is coming out of their pocket, they want someone who will be honest with them about need and risks.?

That?s a good point, especially with the commercially insured, who are seeing more of the decisions about treatment affecting their pocketbooks directly, with higher premiums and coinsurance meaning that decisions about expensive treatments and procedures affect the patient in more ways than just their health.

?A problem is there?s still so much fragmentation,? Sachs explains. ?Each doctor prescribes something different, but currently, they don?t realize or care about the chemistry experiment going on in your body. That?s the kind of thing that causes people to be admitted to the hospital. And if they find out why, it makes people really mad, and it should.?

People are looking for the primary care physician who can be the gatekeeper and manager of their care, especially patients with chronic issues, says Sachs, who contends change will happen slowly. 

?We still have a system designed for specialists. The problem is, that?s not what people want. They don?t want the managed care of old, but the managed care of today. That?s around managing the holistic experience for the patient. The organizations that can do that are those that have made investments in technology and a culture of integration.?

RWJ Hamilton?s CEO Cimino wholeheartedly agrees.

?That will be a big issue with us: delivering value-based medicine,? says Cimino. ?The hospital of the future, its foundation is IT.?


Philip Betbeze is senior leadership editor with HealthLeaders Media.
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1 comments on "In an ACO, Who's Accountable?"


Carol Stevenson (4/20/2011 at 1:26 PM)
Philip, kudos on a well-written article. This is one of the first articles I've read that really explains how ACOs are expected to work. Nicely done.