Given today's fragmented and wasteful healthcare delivery system, most agree on the need for a coordinated care model that aims to deliver greater value to patients, providers and payers. But how do we get there? Many are turning to the federal government to provide a roadmap.
As the CMS prepares to issue the second round of the regulations for its accountable care organization initiative, known as the Medicare Shared Savings Program, healthcare organizations and political pundits are waiting to see if the many questions raised by the structure and risk described in the first round of draft regulations have been addressed. Without sufficient participation in these Medicare programs, it is not clear if government can drive a movement toward “accountable care” fast enough to meet the needs of our challenged healthcare system.
Reaching the goals of this new type of organization presents many challenges for physician groups, hospitals and other healthcare services. Atrius Health, an eastern Massachusetts-based independent alliance of five ambulatory medical groups, which is composed of more than 800 physicians caring for more than 700,000 adult and pediatric patients at over 30 sites, has been addressing these challenges for many years. Most recently, Atrius Health's focus has been on improving effectiveness, efficiency and patient engagement, with the engagement of our physicians as a critical underpinning.
It is not possible to change the way in which care is practiced without the active participation of the physicians and other clinicians. Efficient and effective care requires agreement about care delivery processes, medical protocols and roles and responsibilities within the care team. To engage Atrius Health physicians more fully in their work and to clarify what they need to consistently receive from their management team, our largest affiliate, Harvard Vanguard Medical Associates, has embarked on an ambitious process of building and implementing a leadership-physician social compact. The compact will set expectations for Atrius Health's management and physicians to support the many changes in the way in which physicians will need to work as part of an ACO.
The patient-centered medical home serves as the core of the ACO and as the locus of coordinated care. A PCMH is a primary-care setting in which each patient has an ongoing relationship with a physician who leads a team and an organization that takes collective responsibility for patient care. With the PCMH, patients are active participants in their care and the primary-care physician's team serves as the “home base” where patients go for the majority of their medical needs. Primary-care physicians, specialists and the patient all communicate and work toward the same healthcare goal through patient counseling, discussion of lifestyle changes and keen management of chronic conditions.
Most of Atrius Health's practices have been “medical home-like” for many years. In fact, four of the Atrius Health internal medicine practices have been awarded Level 3 National Committee for Quality Assurance certification for PCMH, and it is anticipated that all of Atrius Health's practices will be certified in the next six months.
A main challenge for ACOs is improving communication among providers about a patient's medical history and care plan. Historically, only a fraction of health providers across the country have utilized electronic health records. The meaningful use incentives will certainly increase the use of health information technology, which can play an important role in enhancing communication.
Atrius Health's experience with EHR began in 1969, and now all Atrius Health clinicians and patients share an EHR and a data warehouse into which we collect claims data about the continuum of care. The data warehouse allows for the creation of detailed patient registries used to drive proactive outreach across a range of conditions, thereby allowing Atrius Health to manage cost through a range of medical management activities. Furthermore, we are working with our many hospital partners to create the ability for clinicians to see into hospitals' EHR on a read-only basis for a patient who is shared across institutions. Additionally, patients have greater access to their own medical information through a robust patient portal.
Another challenge for ACOs is to reduce duplication and waste in delivering care. For the past three years, Atrius Health has been working with Simpler Consulting to adopt a lean operating platform. With the strong belief that if quality is improved, cost reductions will follow, we began a cultural metamorphosis focusing on governance, distributed leadership and local innovation. In addition to the benefits of reducing waste and improving quality, clinicians are beginning to free up time to use for increased access for patients, including by phone and through the patient portal.
There are many initiatives required to build an infrastructure that can support accountable care for multiple, and different, populations.
Moving toward the three-part aim of improving patient experience, improving the health of the population and reducing the per capita cost of care is an imperative for a nation that wants to be healthy. Whether you agree with the requirements of Medicare ACOs or not, the time to start moving toward better care is now.
Dr. Gene Lindsey is president and CEO of Atrius Health, an alliance of six physician practices in the Boston area.
