Accountable Care Organizations: The next level of health care

These two cases of outside-the-office health care are the direct result of a new trend in the way medical care is delivered: accountable care organizations.

While no two accountable care organizations are exactly the same, in broad terms, they take on the responsibility for providing care to a group of patients with a focus on getting and keeping them as healthy as possible while reducing the costs of care.

These groups of providers - ranging from primary care doctors to entire hospitals - are mostly treating Medicare patients, something encouraged by the Affordable Care Act. And as they reduce the cost of care and hit quality goals, they can, to various degrees, share in the money they save the Medicare program.

The accountable care model is coming to Cumberland County. Cape Fear Valley Health System was approved by the Centers for Medicare and Medicaid Services to set up such an organization starting in January.

The program will focus on the needs of its patients, said Bart Fiser, who is heading it up, but one thing he knows will begin right away is more patient engagement through people typically known as care coordinators or care managers.

Patients throughout North Carolina have seen the benefit of this increased one-on-one communication through accountable care organizations.

For Triad HealthCare, the woman who kept landing in the emergency room stood out from other patients when providers began to look at patient data, said Steve Neorr, Triad's CEO.

Care managers with Triad did a little digging to find out why. It turned out that the woman, who was diabetic and in a wheelchair, had no transportation to get to doctor visits and didn't have a refrigerator to store the medication and food she needed to manage her diabetes.

So when she needed a new prescription, she would call an ambulance to take her to a hospital emergency room - the most expensive kind of care and the most expensive way to get to it.

A care manager connected her with a transportation service and community organizations that helped build a ramp for her home and donated a refrigerator. She can now get to the doctor, store her medication and is no longer trapped in her home.

In the New Bern case, Anderson's diabetes has left him with legs so damaged that he can't walk without braces. A blockage in his neck pressing on his spine threatened the loss of feeling in his arms, as well. The 77-year-old New Bern resident has seen his health decline over the past three years, and his wife, Carolyn, has had to take on a large caretaking role for her husband.

As the couple navigates Anderson's complicated needs, Bostian - a care coordinator with Coastal Carolina Quality Alliance - is there to connect the dots for him and his wife.

Not only has Bostian, a registered nurse, provided Carolyn Anderson with advice about what to do during emergencies and help coordinate her husband's care among specialists, she's set the Andersons up with practical services, such as a program to refit their bathroom with grab bars and a walk-in shower so he can get in and out more easily.

Bostian's job came about after Coastal Carolina become one of the country's first Medicare accountable care organizations in 2012.

One of the reasons Coastal Carolina and other such organizations were founded, Coastal Carolina's CEO Steve Nuckolls said, was because the system helps doctors and other providers align their compensation with their mission to heal the sick and keep the healthy well.

Under the accountable care model, he said, "we can do well (financially) if our patient is healthy." But under traditional models, "we make more money if our patients are sick."

Fee-for-service system

The vast majority of the health care industry, including government-run health programs such as Medicare and Medicaid, runs on a fee-for-service model. Essentially, doctors and other providers are paid for each procedure they perform. The more services a patient receives, the more her providers can bill the insurance company or other programs.

Fee-for-service payments don't go away with the accountable care model. But the model does emphasize a move to payments based on quality of care delivered at an overall savings.

"It's an overlay over fee-for-service, rather than demolishing fee-for-service," said Cristina Boccuti, a senior associate of the Program on Medicare Policy at the Kaiser Family Foundation, a nonprofit focused on health-care policy.

Over the years, under the fee-for-service model, health care costs in the country have soared.

The difficult to contain fee-for-service payment system is unsustainable, said Hugh Tilson, chief operating officer of the North Carolina Hospital Association. "It's unsustainable at the state level; it's unsustainable at the federal level, it's unsustainable at the patient level, and it's unsustainable for the businesses that are providing insurance for their employees," he said.

ACOs and Medicaid

Some states are exploring accountable care models for their Medicaid programs. In North Carolina, state health officials and the governor have backed a Medicaid reform plan that makes use of ACOs. But efforts to move forward on reform got stuck last year as chambers of the General Assembly disagreed over whether to move forward with reform relying on ACOs or on private health-care management companies.

"Our top priority and focus remains on Medicaid reform," said Alexandra Lefebvre, spokeswoman for the state Department of Health and Human Services. "We believe the provider-led ACO model is the right improvement that needs to be made for our state," she said. "North Carolina currently has a Medicaid system that pays only for services, not for quality of care."

Tilson and the Hospital Association favor a solution for North Carolina's Medicaid system in which doctors and other providers can lead the changes to align care and reimbursement.

"A provider-led solution is better than an insurance-led solution," he said of potential Medicaid reform.

That way, he said, reductions in cost shared with providers can be reinvested into continued improvement of their system to deliver care.

But private insurance companies are exploring accountable care-based models, as well.

Blue Cross and Blue Shield of North Carolina has about five contracts with such organizations across the state, said Darcie Dearth, a spokeswoman for the company.

"Private insurers, we're obviously interested in paying for quality over quantity," she said.

With private insurance, the agreements are negotiated group to group and could contain different levels of reimbursement risk for providers.

For patients, depending on how their plans are structured, savings could potentially extend to their own wallets in the form of fewer or smaller copayments.

Dearth said she expects that over time, some of the shifts that are occurring now will create a more patient-friendly environment, which is "more convenient, more in tune with what their needs are."

In the past, health care choices often were based solely on the perception of quality by the patient, said Jeff Johnson of the Wilmington Health accountable care organization. Those perceptions came from word-of-mouth recommendations on everything from personality to the quality of the magazines in the waiting room.

"That is going to get moved to the margins for a while," James said. "What is going to move dead center for the next few years is cost and quality."

The conversation about a physician, he said, will go more like this:

"Is Dr. Smith a good doctor?

"Yes. I have diabetes, and Dr. Smith is ranked in the top 10 percent for (diabetes outcomes). Oh, and by the way, he never has old magazines in the waiting room."

Behind the scenes

Most patients may not even realize they're a part of an accountable care organization.

Much of the work happens behind the scenes: implementing new technology, opening lines of communication, forming new partnerships.

Patients are listed on an accountable care organization's roster based on where they primarily receive their care, though they are free to choose services from outside the network. But ACOs can encourage patients to see affiliated providers or counsel them about where to seek other services, such as radiology or laboratory testing.

"We spend a great deal of time educating people about where to have a service done," James said. "It makes sense to go where you can get the most value."

A common investment among North Carolina ACOs is technology to track patients from doctor to doctor or flag patients who are due for preventive services.

"We are constantly monitored for any intervention that might keep the patient well: preventive vaccinations, fall risks at home, keeping blood pressure, diabetes, cholesterol under control," said Dr. Martin DeGraw, who is in family practice at New Bern's Coastal Carolina Alliance.

The shift toward preventive care, he said, is aimed at keeping patients out of the hospital, or preventing the need for surgery, because those are where the big health-care expenses arise.

While there has been a shift toward more focus on preventive care, DeGraw said he doesn't think most of his patients would notice a difference.

And the medication management and various other work the care coordinators do outside of the office is important and doesn't seem to bother patients, he said. "I think the majority of our patients like the extra helping hand."

Dr. Jim Osborne, an internist who serves as chairman of the operating committee for Triad Health Network, said one tool has become so much a part of his day that he almost forgot it was new.

The Point of Care system, he said, dredges his electronic medical records and others it has access to and provides recent lab results, blood pressure readings, vaccinations, screenings or other preventive procedures a patient may be due for, and conditions for which they may be at risk.

"That is enormous in terms of what my day looks like," he said. Rooting out all of that information from a patient's record in his system would take much longer. Just remembering all the things that could be upcoming for a patient in a limited appointment time while dealing with whatever complaint brought her into see him in the first place can be a challenge.

"You start talking about a lot of things, and some things fall by the wayside," he said.

Occasionally the system, which provides Osborne with a simple piece of paper that he can review for each patient, is unavailable. At those times, he said, he feels like he's driving through fog when he sees patients.

"I thought I was a great doctor until I got a Point of Care tool," he said. "Looking at data is very eye-opening."

Neorr, Triad's CEO, said a lot of effort goes into identifying ways that providers can care for patients with common conditions such as chronic pulmonary disease in better ways, sharing best practices and creating best practices - all things that are behind the scenes for the average patient.

The more visible investment is the care managers who keep track of patients who need tests, who should be taking medications or who just need someone available to answer questions.

That's the role Bostian and her colleagues play at Coastal Carolina. Triad Health Network has the equivalent of 35 full-time care managers, Neorr said.

Triad's care management team has played a key role in removing barriers to care, he said, particularly for accessing the right care at the right time in the right place.

Neorr noted the woman who had been a frequent visitor to the emergency room for her diabetes.

"When you look at current system, this is how it happens," he said. "In the current system, there's no incentive to do anything about it."

At Triad, care managers have gone to hearings on government-subsidized housing with patients and have worked to help them get vouchers for medications.

"It is really a team approach to care," Neorr said. "It is the way most people would like the system to work."

Cape Fear Valley ACO

Cape Fear Valley Health System has been thinking about building such a team for years, Fiser said, but the system opted to jump in this year because of the movement of Medicare toward value-based payments and the possibility the state will incorporate accountable care organizations into its Medicaid reform plan.

"Medicaid is a huge payer system here," Fiser said.

And the health system will "be prepared for what the inevitable future is going to look like."

Fiser said Cape Fear Valley will step into the ACO model bit by bit. Trips to doctors will be largely the same for patients, but there will be a great deal more engagement with them outside the traditional hospital or doctor's office setting. This essentially means increased one-on-one communication with patients by care coordinators, whom Cape Fear Valley is still in the process of hiring, Fiser said.

Currently, he said, the health system is awaiting data about the patients who would fall under the accountable care model. When it comes, trends in that data will help drive the hiring process. For instance, if a high percentage of patients are diabetic, Cape Fear Valley may look for nurses with a background in diabetes care.

Data also will drive the first few waves of conversation around changes where providers can build programs that are most effective.

At first, Fiser said, only Cape Fear Valley employees will be part of the ACO.

"We're going to jump into it from a learning experience," he said, "but we're going to take it slow bringing people on."

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