Why It Matters
Given the uncertain future of payment mechanisms, we should create a health system focused on increasing quality for patients that will be successful in any payment model.
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4 Quality Fundamentals for ACOs and Beyond

By Jo Ann Endo | Monday, January 22, 2018
4 Quality Fundamentals for ACOs and Beyond

Ariadne’s Labs’ new Chief Medical Officer, Evan Benjamin, MD, MS, FACP, was previously the Senior Vice President for Population Health and Quality at Baystate Health. IHI recently talked to him about the lessons he learned while Baystate became one of the highest performing teaching hospitals for quality, safety, and accountable care in the US.

What do you say to health care leaders about ACOs and US health care’s transition from volume to value?

I try to move the conversation away from ACOs to talk about what would be helpful to our patients, communities, and health systems in any payment model. ACOs were designed to create risk sharing, and provide financial incentives to lower total cost of care for a population. That’s great, but given the uncertain future of payment mechanisms, I believe we should focus on value that will work in any payment system. There are four areas of importance to focus on:

  • First, total cost of care — Most systems don't really know the true cost of care. Our cost accounting systems are very complex. In a fee-for-service model, the true cost has been hidden, but understanding the cost of care in your institution, in your practice, is so important. Obtain the information on costs and move the finance team to support this. Also, begin to think episodically. Think about patients entering the system with an episode of care and try to understand the costs of care over an episode. Finally, think about transparently sharing the cost of care with patients and with providers.
  • Second, engage consumers — Our patients want transparency about the cost and quality of care. Begin to create avenues to share data on costs and quality. Also, begin to engage patients in shared decision-making about treatment. We’ve seen that shared decision-making leads to better outcomes, better patient experience, and is also less expensive. For instance, working closely with patients and families around end-of-life care is an example of a good area to focus on shared decisions.
  • Next, improve care coordination and physician alignment — Poorly coordinated care is much more expensive than care that’s coordinated well. Integrate care management into primary care for the most complex patients. Begin to create care models on common conditions between primary care physicians and specialists. Make an intentional effort to standardize care and decrease practice variation through care models and locally developed guidelines. Focus on the post-acute setting which is fraught with expense and poor coordination. To go back to the example of patients with serious illness, we need to do a better job of managing their care with a shared approach, with specialists and primary care coming together around agreed upon care models.
  • Finally, identify leaders and trustees who understand system transformation — The kind of leadership and governance we had in the past is not going to be enough to move us into the future. As health care systems get more complex — with mergers and acquisitions, more practices coming on board — we must leverage that complexity to improve care. Leaders and trustees need to leverage system expansion to improve care coordination, decrease the cost of care, and create better care models.

There’s a lot of uncertainty about where we’re going with payment models. Are we going to see the expansion of bundled payments? Will ACOs continue to exist? Will it be a fee-for-service with pay-for-performance incentives? But if we stick to these four fundamentals and create a health system focused on our patients, with improved coordination, we’re going to be successful in any payment model.

LEARN MORE: IHI Summit on Improving Patient Care, April 11–13, 2019, in
San Francisco, CA

How else do leaders and trustees need to adapt to face current health care challenges?

Our leaders need to move from thinking just about health care to thinking more about health. This shift is transformational in setting priorities. Organizations should embrace their role as citizens in a community, begin to understand the social determinants of health, and incorporate those into health care delivery. While the rest of an organization needs to be doing things like improving quality, coordinating care and decreasing overuse, their leaders need to think about the big picture, and ask, “How do we organize and drive all of this?”

How should organizations get started with these fundamentals?

A lot of people feel uncomfortable transforming care without data. Data is important, but if we wait for the perfect data systems, we’ll never move. While we’re waiting for the holy grail of the best enterprise data warehouse and predictive analytics, we need act on what we know and control as providers. We should think about who our patients are and create simple registries with what we have. Begin with some simple risk stratification of who’s sick in the practice, who is utilizing more services and who needs to be seen. Focus on these patients.

We don’t need machine learning and predictive analytics to start. You can often just ask the physicians who’s sick to get the information you need to get started. Begin with limited data to be proactive about care coordination, care management, and integrating behavioral health into practices. Begin to align the physicians and the providers together around what a new care model should look like. You can add the data in later to make it a full system, but don’t let the lack of robust data at the beginning slow you down.

How do these four fundamentals help to address health disparities?

We need to create a more accessible and comprehensive health system for all our patients. First, we need to identify the patients who are the sickest, be more proactive in engaging them, and give them better services and coordinate their care more. The fee-for-service model that just encourages waiting for people to show up has driven a lot of the inequities of our overall health system. Being more proactive ultimately improves the equity of our system. Secondly, we need to incorporate understanding and improving the social determinants of health of our patients. Creating a system to address these social issues will also improve outcomes of our most challenging patients.

Can the fundamentals you outline play a role in addressing the epidemic of clinician burnout?

Burnout is a complicated situation, but I believe that when we change the system to have physicians managing a population of patients, it may significantly decrease burnout. For example, a primary care physician, moving back and forth between two exam rooms all day, with the additional stresses of documentation, communication, insurance, and nursing homes etc., can get overwhelmed. But in a model where a physician is managing a population, and managing a team of providers — nurse practitioners, nurses, social workers, and other health care providers — based on risk stratification, who needs to be seen, and then distributing that work throughout a team, the work is much more satisfying.

I’ve seen improvements in the quality of life of physicians where I've seen this done well. These are situations in which primary care physicians have gone from taking care of patients in a fee-for-service mentality, to a practice that has integrated behavioral health, care management, and care coordinators, and created teams with physicians and advanced practitioners together. These physicians personally see the sickest patients and feel like they’re managing a team to do true population health management. They believe they are doing what they were trained to do. Not only is this a better system for our patients, but it may also lead to less burnout among our providers.

Editor’s note: This interview has been edited for length and clarity.

You may also be interested in:

Care Coordination Tips from a Pioneer ACO

No More ‘Shining Stars’: Why Teamwork Should Matter to Accountable Care Organizations

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