Saying "we don't want to have organizations mess up the concept," the National Committee of Quality Assurance president last week announced that six physician-hospital networks are the first to receive accreditation that they qualify as true accountable care organizations.
"If we really want to maximize the chance of success of the ACO concept, we have to make sure everyone who is a player is capable of being one," said Margaret O'Kane. "We've lived through periods when we've had managed care backlash and so forth, and sometimes, it's because we had organizations that weren't doing the right thing."
The problem is that across the country, several hundred organizations now call themselves an ACO, but without some sort of vetted accreditation process, no one knows what that means, especially if an ACO is organized around private plan, non-Medicare patients.
"We're currently in a state where individual payers are setting their own standards and making their own arrangements, which makes life very complicated, and also creates a lot of waste," O'Kane said.
During last week's teleconference, representatives of the six organizations got a chance to talk about why they opted to undergo the rigors of accreditation, at a cost of up to $32,800, plus resources. And why they think other provider collaborations should, too.
The six accredited ACOs, all of whom agreed to undergo the process early last year, are:
- Billings Clinic, Billings, MT. This ACO has 320 physician and non-physician providers, a 272-bed hospital, and a 90-bed rehabilitation and assisted living facility.
- The Children's Hospital of Philadelphia Care Network. This ACO includes a 516-bed pediatric hospital and numerous providers.
- Crystal Run Healthcare, Middletown, NY, serving the lower Catskills and the mid-Hudson Valley. This ACO has more than 300 providers in more than 40 medical specialties, and is a certified Level 3 patient-centered medical home.
- Essentia Health, Duluth, MN. This ACO has 12,800 employees and physicians, 18 hospitals, 68 clinics, eight long-term care facilities and two-assisted living facilities. It serves populations in four states.
- HealthPartners, St. Paul, MN. This ACO serves more than 1.4 million medical and dental health plan members and includes a multispecialty group practice with 1,700 physicians, five hospitals, 50 primary care clinics, 21 urgent care locations, 21 dental clinics and numerous specialty practices in Minnesota and western Wisconsin.
- Kelsey-Seybold Clinic, Houston, TX. This ACO has more than 370 physicians covering more than 55 medical specialties at 21 clinic locations and cares for 500,000 patients a year, 40% of whom are covered through capitated plans including KelseyCare for employers with 50 or more employees.
NCQA measures the quality of each ACO on the basis of 65 elements, much the same as it measures quality for accreditation it gives to patient centered medical homes, employer wellness programs, and health insurance plans.
Organizations agree to measure certain quality metrics and report them, have sufficient specialists and primary care providers on the panel and available to see patients, must have the capability to provide urgent or emergency care as well as inpatient care, community and home-based services and long-term care.
Spencer R. Berthelsen, MD, chairman and managing director of Kelsey-Seybold Clinic, said the clinic's doctors chose to go for NCQA accreditation in part out of the belief that if purchasers know an ACO's verified capabilities, "it does confer a competitive advantage."
But choosing NCQA accreditation also was important, Berthelsen says, "because there was quite a bit of market confusion as to what an ACO is. It was only partially described in the ACA (Patient Protection and Affordable Care Act) as it relates to the Medicare Shared Savings Program. But those of us in coordinated care systems understand it's much more broad than that, and applicable to all of the delivery of patient care."
He likened that confusion "to the days when it was unclear what a doctor was," and why licensing standards emerged to identify who was a physician and who was not.
Hal Teitelbaum, MD, managing partner and CEO of Crystal Run Healthcare, said all aspects of his organization has transitioned to the ACO model. "We are all ACO, all the time," he said.
He acknowledged that there have been challenges making the leap from volume to value. "This has been like turning how medicine has been practiced in this nation for many, many years on its head," he said, adding that though his area is a predominantly fee-for-service world, "we're trying to push commercial payers, sometimes dragging them kicking and screaming, to reward us for outcomes, not for transactions."
Asked what advice he might offer other organizations seeking to create accountable care models, Teitelbaum said, "we would advise strongly against a schizophrenic approach. By that I mean we do live in this world where we have the value/volume dichotomy, where we're torn in different directions."
But if an ACO is to be successful, he said, "you can't say let's treat this group of patients, for whom we're rewarded on a volume or transactional basis, one way, and let's treat a different group of patients, for whom we're rewarded based on clinical outcomes, a different way. We believe there is only one way, and you have to embrace value from the first."
John Smylie, Essentia Health CEO, agreed. "You can't be in two camps," he said. "And you have to bank on internal learning to carry you forward because no one's written the script for this yet. We are on the leading edge."
Teitelbaum was asked how Crystal Run persuades specialist physicians to be enthusiastic about an ACO.
"You bring them into the tent, rather than treat them strictly as vendors or outside contractors. You get them to understand, as primary care physicians do, the concept of value (and you ask them) do they really want to get paid at the end of the day simply for doing a procedure, or do they want to get paid for the outcomes they help create for patients. It's an educational process."
See also:
Call Yourself an ACO? Prove It
NCQA Offers ACO Accreditation Review