Accountable Care Organizations: Early Results

At the beginning of 2011, as the health care industry was gearing up for the changes mandated by the Patient Protection and Affordable Care Act (PPACA), we reported here on a brand new care model known as the accountable care organization (ACO), in a four-part series. By now you’ve probably heard quite a bit about accountable care, but here’s a quick recap of our series:

Part one introduced the concept of the ACO, as a network of doctors, hospitals, and ancillary providers that will share the responsibility of providing care to all the patients enrolled with them – while accepting bundled payments for a set period of time (rather than fee-for-service) as an incentive to keep patients healthy and out of the hospital.

Part two quickly ran down some of the potential problems that were projected as potential pitfalls for this new model of care.

Part three covered the ACO goal of better discharge planning, in order to reduce unnecessary hospital readmissions – those defined as occurring within 30 days of a discharge and being directly related to the original complaint.

Part four described the ways in which case managers can contribute to ACO success. With their mandated goals of cost containment and improved outcomes, ACOs will likely need case managers to strategically manage services for all patients, even those in ambulatory care. Tomorrow’s case managers will have to consider clinical, financial, and patient advocacy functions simultaneously, as they balance competing interests.

Where do ACOs stand now?

So now, nearly two years later, what have we learned about ACOs – and how have they fared at reducing costs and improving outcomes?

An extensive article in the December issue of Health Affairs titled “Many Accountable Care Organizations Are Now Up And Running, If Not Off To The Races” reported that there are more than 300 ACOs now in existence, some chartered by Medicare and others formed by private insurers, and that some of them have yielded early results that are promising – even though the overall picture may be inconclusive.

Here’s what we know, according to the report, which is available for a fee:

  • The transition to ACOs is an ongoing process that will take many years – despite the pressure to get results quickly.
  • While hospital systems are the main backers of ACOs, physician groups are also becoming surprisingly active in forming ACOs. Large insurers like Cigna have launched their own pilot ACOs, with good early results.
  • The first challenge is engaging physicians and other providers, which must happen before the care process can be reorganized to make it more efficient.
  • Patients must also be educated about the new concept, in carefully crafted messages – and some new ACOs have been challenged by the process of obtaining patient consent for their data to be shared with CMS.
  • Another early challenge was finding that many people covered by the ACO lacked a primary care physician, so the first step was connecting them with one.
  • Several of the new ACOs reported that they were able to achieve cost savings by improved discharge planning that makes readmissions less likely, or by using “care navigators” to help patients manage complex or chronic conditions.
  • Often, when a medical group becomes an ACO, the financial investments it must make in electronic records or additional case managers cause it to lose money at first.

As issues like accountable care have become hot topics in health care, the field of case management in particular is expanding. In fact, it’s been said that case management, with its current emphasis on complicated cases, needs to evolve into care management, with a focus on wellness, prevention, and patient advocacy. It comes as no surprise then that the Bureau of Labor Statistics, in its 2010 Occupational Outlook Handbook, identifies case management as a field projected to grow faster than other job categories.

The perfect way to build the skills you need for case management is through American Sentinel’s online RN-to-MSN program with a specialization in case management. American Sentinel University is an innovative, accredited provider of online nursing degrees that can empower you with knowledge and help you reach your career goals.

 

 

 

 

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