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How Physician-Led ACOs Can Overcome Four Major Implementation Challenges

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We are pleased to announce the release of a new resource: Adopting Accountable Care: An Implementation Guide for Physician Practices. The toolkit, which provides resources and advice for physician-led ACOs in all stages of development, implementation and practice, is the product of a year-long effort on behalf of an ACO Learning Network physician-led workgroup.

The Critical Role of Physician Practices in the Accountable Care Movement

Physician-led organizations now account for more than half of the ACOs in the Medicare Shared Savings Program. Early results suggest that these physician-led ACOs have been able to improve the quality of care delivered to patients and, in many cases, reduce total health care spending. In fact, we believe that physician-led ACOs are uniquely positioned to help transform accountable care across the country. However, more work is needed to continue this momentum. The purpose of this toolkit is to explore the four major barriers to success and help these organizations develop strategies to overcome them effectively.

Physician-led ACOs are an integral part of accountable care precisely because they are unique in comparison to their hospital-led or integrated health system counterparts. Physician-led ACOs are commonly comprised of one or more independent primary care physician group or practice association and on average provide care to fewer patients than hospital-led ACOs. These ACOs are primary care-dominant, but are also increasingly engaging with specialists and others across the care continuum. The centrality of primary care within their organizations may give physician-led ACOs a comparative advantage at improving outcomes, reducing unnecessary hospitalizations and ED visits, and lowering costs—all essential elements of accountable care. Their smaller size and leaner operational structure can allow them to be more nimble and make quicker decisions about launching quality improvement initiatives or adopting new clinical processes and technologies.

Addressing Key Challenges for Physician-Led ACOs
However, physician-led ACOs also face significant challenges. Most lack the infrastructure and support of their larger counterparts, which may inhibit their ability to hire necessary staff and providers, purchase new health IT systems, secure technical assistance or develop patient outreach strategies. Oftentimes, smaller ACOs are unable to recruit an adequate support staff to manage the operational demands of ACO transformation, or a clinical staff that is experienced in population-based care management. Nonetheless, a growing body of evidence suggests that physician-led ACOs are often able to achieve better health outcomes in low-cost community settings by leveraging the strong relationships that exist between primary care providers and their patients.

In recognition of the unique position of physician-led ACOs in the evolving accountable care landscape, the ACO Learning Network convened an Innovation Exchange to explore the greatest barriers to success. This working group convened bimonthly calls with approximately 20 physician-led ACOs and external experts to share best practices and discuss next steps for accountable care. From these interactions with workgroup members and other thought leaders we identified four topics to cover in this toolkit: (1) identifying and managing high-risk patients (2) developing high-value referral networks (3) using event notifications and (4) engaging patients. The toolkit includes chapters on each of these topics, as well as appendices and other resources for physician-led ACOs.

Chapter 1: Identifying and Managing High-Risk Patients: This chapter includes a discussion of analyzing claims and clinical data, use of risk-stratification algorithms and selecting which patients would most benefit from care management approaches. We also discuss team-based care strategies, such as the role of care managers, appropriate training, and the role of health IT for population health management.

Authors

J

James Colbert

Consultant, ACO Learning Network; Instructor of Medicine, Harvard Medical School; Hospitalist, Newton-Wellesley Hospital

Mark B. McClellan

Former Brookings Expert

Director, Margolis Center for Health Policy - Duke University

S. Lawrence Kocot

Former Brookings Expert

Principal and National Leader, Center for Healthcare Regulatory Insight - KPMG

Chapter 2: Developing High-Value Referral Networks: This chapter discusses how ACOs can collaborate with specialists and other providers who are not formal members of the ACO. We provide an overview of developing care coordination agreements with specialists and outline expectations for communication and disease co-management. We also highlight approaches for effectively engaging with post-acute care providers, and identify ways to identify specialists who are more likely to deliver high-value care.

Chapter 3: Using Event Notifications: This chapter emphasizes the role of data as a critical tool for managing patient populations. We discuss ways that ACOs can set up automated notification systems to receive real-time alerts when patients are admitted and discharged from the hospital or transferred to a post-acute or long-term care facility. In addition, we provide an overview of care coordination interventions that can be set up to respond upon receipt of such notifications.

Chapter 4: Engaging Patients: Our final chapter addresses key competencies for ACOs on how best to engage patients and their families in accountable care. This chapter covers strategies for informing and engaging patients in accountable care, as well as partnering with patients for improved medical decision making and management of chronic disease. Additionally, the chapter discusses ways to strengthen the connections between patients and ACOs, as well as opportunities to involve patients in ACO governance and decision-making.

The ACO Learning Network continues to work with ACOs and other stakeholders to provide practical solutions that encourage the widespread adoption of accountable care strategies. We look forward to engaging in dialogue around these issues, sharing provider experiences and identifying actionable next steps to ensure the success of physician-led accountable care.

Our future efforts will focus on two areas: (1) developing sustainable financial models that account for organization needs and capabilities; and (2) developing strategies for clinical transformation that use advanced primary care and team-based approaches. For more information, click here.

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