Our Senior Vice President Dr. Brian Silverstein was recently interviewed by Becker’s Hospital Review regarding his thoughts on accountable care organizations. 

1. This won’t be the 1990s all over again. ACOs won’t face the same problems capitated arrangements faced in the 1990s. Capitation failed in most parts of the country because incentives were not aligned, the technology was not in place and payors slashed rates for  physicians, expecting they would make it up on volume. “The country was not ready,” Dr. Silverstein says. But today the technology is better, more doctors accept the use of best practices, and rather than simply reducing rates, ACOs aim to reduce utilization and focus on quality, he says.

For the full article, please click on the link below: 
http://www.beckershospitalreview.com/hospital-physician-relationships/7-observations-about-acos-from-dr-brian-silverstein-at-the-camden-group.html

Accountable care organizations are the future of health care.  A five-step plan will prepare your organization for upcoming changes.

Click here for the full article written by Brian J. Silverstein, M.D. and Michael J. Randall.  It first appeared on July 12, 2010 in HHN Magazine online site.

Federal and state government incentives for physicians and hospitals to install and meet “meaningful use” requirements for information technology (“IT”) have created an unrelenting push to implement electronic medical records.  While meeting government guidelines is important, senior management leaders need to remember that to make healthcare systems more effective and efficient, these strategies must deliver better tools for caregivers.  Any of the strategies being employed to improve the quality of healthcare and reduce costs require the ability to manage, interpret, and coordinate information in real-time.  The tenets of pay-for-performance programs, medical home models, clinical integration (“CI”), and accountable care organizations (“ACOs”) are based on improving care delivery through coordination of the entire  continuum of care.  Here are the top ten questions senior leadership should discuss in preparation for this “new world.”

1.    Why should we consider CI or becoming an ACO?  CI has demonstrated results in improving quality and reducing costs – key goals to achieve in the path toward accountable care.  Organizations that meet the Federal Trade Commission’s (“FTC”) definition of CI achieve efficiencies by monitoring and controlling quality, service, and costs, selectively choosing physician participants, and making a significant investment of monetary or human capital in infrastructure.  An additional benefit for organized groups of independent physicians that become clinically integrated is that if these groups meet FTC guidelines, they will be allowed to jointly contract with payers.  In many markets, a majority of physicians are not in an employed group model; the CI structure allows them to provide better patient care as well as be rewarded by increasing the quality, service, and cost effectiveness of the care.  Ultimately, CI is an early stepping stone to becoming an ACO. 

2.    What are the keys to a successful information strategy for CI and ACOs?  Regardless of the organizational model (e.g., large multi-specialty group, IPA, PHO, or integrated delivery system), the information system should lead to higher quality, effective, and efficient patient care.  The system must provide the right information, at the right time, in the right form and be supported by an infrastructure to assure its security, maintenance, and use.  Providers must be able to make timely, personalized decisions for the individual patient at the point of care.  These decisions must be based on current, comprehensive information and patient history. 

3.    How will this information strategy improve the quality of healthcare, reduce costs, and provide the ability to manage, interpret, and coordinate information in real-time?  Real advantages and productivity gains are realized only if the caregivers have access to real-time information at the bedside, exam table, or through secure email exchanges between providers, staff, and patients.  Physicians and caregivers should easily be able to collect, visualize, and interpret information and compare it to network protocols, guidelines, and databases when it counts – that is, at the time of decisions.  The information strategy must avoid locking information into inaccessible “islands.” 

4.    Does the proposed strategy facilitate working toward the goals of quality, service, and cost reductions implicit in the new payment incentives?  Payment incentives rely on the ability of an organization to demonstrate and document care processes and the achievement of performance targets, including clinical and patient satisfaction metrics.  Some of these requirements can be met with relatively simple IT solutions, but more sophisticated and comprehensive systems are needed to drive improvements throughout the continuum of care.  The IT strategy must focus resources on assisting the caregiver in knowing not only what to do, but when to do it (i.e., real time alerts).  It must also indicate if their performance is getting better or worse. 

5.     How can we incorporate independent physicians and small medical groups in CI?  Using CI tools, even small to mid-sized physician groups, in partnership with an IPA, PHO, hospital, or integrated delivery system, can use information technology to begin to impact the health status of their patients, meet the requirements of payers, and identify process improvement opportunities. 

6.    Does the technical infrastructure of this information strategy meet the requirements set by the FTC?  The technical infrastructure for CI must address two key components to meet the FTC definitions: “the use of common information technology to ensure exchange of all relevant patient data” and “the development and adoption of clinical protocols.”  The exchange of all relevant patient data requires a platform that can integrate data from multiple community sources (e.g., hospitals, physician offices, labs,) and store this data in a central data repository.  This immediate availability of trusted data is the key to patient care collaboration, the identification of diseases and corresponding care protocols, and performance monitoring at the provider, practice, and network levels.  The assembly of patient data from multiple sources requires careful consideration to ensure accuracy and completeness.   

7.    Does this strategy facilitate the integration of existing systems across the provider and service continuum?  Integration of existing systems across the provider and service continuum must be considered when designing a CI infrastructure.  Regional health information exchanges, hospital enterprise systems, electronic medical records, ancillary provider portals, and patient portals can all potentially be leveraged as part of the overall solution.  These solutions must be evaluated carefully as they alone will not guarantee that CI has, or will be, achieved.  Regardless of the solution chosen, at least one should be available to virtually every physician.  As the tools become more comprehensive, the ability to drive results increases dramatically.

 8.    Do the information tools meet the criteria and requirements in order to be successful in CI and accountable care?  To meet the functional needs related to the exchange of patient data, the technical support for CI must meet the following:

■     Provides immediately available clinical results to be viewed across service providers

■     Provides access to the established clinical guidelines

■     Provides a secure mechanism for provider communication

■     Allows providers to assign patient access to referring or consulting providers

■     Provides access to protocol adherence and measure quality outcomes at the provider, practice, and   network level

■     Allows electronic prescribing

■     Enables clinical decision support based on network determined guidelines including point of care alerts

■     Tracks physician performance against benchmarks and their peers

9.    What are the resources required and timelines for implementing an information strategy for CI and ACOs?

There are various methods to approaching the development of a successful long-term information strategy for CI and ACOs.  An evaluation of a build vs. buy scenario will determine the best approach with the greatest potential for success and, in many cases, a combination of the two will be the final solution.  Factors that may play into the decision include current internal resources, expertise, and internal systems, current vendor applications already in contract, vendor experience and satisfaction, desired timing of implementation, and cost.  There are pros and cons to each approach which can be generalized, but individual organizations should pay careful attention to the internal IT culture and history of IT implementations before choosing an approach.

10.  How will we know when the changes in information strategy have led to the desired outcomes for quality and efficiency, and how should we continue to support these ideas and capabilities?  The only way to be aware of successes or failures is to measure them!  When information is organized into a structured system, the focus must be on meeting the needs of physicians, providers, and patients’ care while decreasing errors, gaps, delays, and variation in practice.  What are the users’ satisfaction levels with the content, its ease of use, and its relevance to meeting their needs?  The strategy should create a highly flexible integrated system with tools that help each patient/member become healthier, leading to a healthier population while focusing on impacting cost, efficiency, and quality.  As with all work, it is never complete and will lead to the next iteration as the bar is raised.

For more information on clinical integration and accountable care organizations, please contact Jim Smith at 800.360.0603 x6108 or jsmith@thecamdengroup.com or Claire Heideman at 312-775-1703 or cheideman@thecamdengroup.com.

The Camden Group Announces Affiliation with Long Time Client GRIPA

Los Angeles, California, May, 26, 2010— The Camden Group, a national healthcare business advisory firm, today announced that it is now affiliated with Greater Rochester Independent Practice Association (GRIPA), a leading physician hospital organization (PHO).

The Camden Group sought the affiliation with GRIPA given the increased demand from healthcare clients to find ways to facilitate improved coordination of care and achieve greater integration in order to deliver greater value to healthcare consumers.  With its 812-physician membership, two community hospitals, and a medical management and IT staff, GRIPA is one of the first in the nation to achieve a favorable advisory opinion from the FTC on their plan for clinical integration.  Camden clients will now have direct access, including site visits, to GRIPA in order to learn and understand ways to deliver accountable care.

“We are thrilled to have this unique opportunity to be affiliated with such a groundbreaking organization – one that we have worked with for several years,” said Steve Valentine, president of The Camden Group.  “Healthcare is changing, and it’s moving in a very clear direction.  GRIPA embodies the future of healthcare and achieves the core objectives defining this new age in accountable healthcare –  greater clinical quality, improved cost effectiveness, and superior patient experience.”

In addition to The Camden Group’s affiliation with GRIPA, the firm announced earlier this year its hiring of GRIPA’S former CEO, James Smith, FACHE, as senior vice president.  Smith is heading up The Camden Group’s advisory services in clinical integration and the development of accountable care organizations.   Eric Nielsen, M.D., the current CMO of GRIPA, also recently joined The Camden Group as Medical Director for the firm.

“This collaboration brings great exposure and expertise for both our organizations,” said Gregg Coughlin, president of GRIPA.  “Healthcare is revolutionizing at an incredible pace, given the anticipated impact of healthcare reform.  Together, we’re dedicated to innovating the industry to make healthcare work better – for everyone.”

This latest news follows the recent announcement by The Camden Group that it has added Robert A. Minkin, former CEO of Exempla Saint Joseph Hospital, to serve as senior advisor to the firm.  Minkin is a leading national expert on bundled payments.  Under Minkin’s leadership as president and CEO, Exempla Saint Joseph won the bid to participate in a three-year CMS Acute Care Episode (“ACE”) demonstration project to “bundle” payments to hospitals and physicians.  Exempla Saint Joseph is one of four hospitals with cardiac programs to participate in the pilot demonstration.

About The Camden Group

The Camden Group provides a vast array of consulting services on areas ranging from hospital operations improvement, strategic, financial and business planning, and physician group advisory services. Since its founding in 1970, The Camden Group has advised more than 1,000 hospitals, medical groups, outpatient facilities, and other healthcare organizations nationwide. For more information, please visit www.thecamdengroup.com.

Contact:

Sarita Choy, Marketing/Communications Coordinator

The Camden Group

310.320.3990

schoy@thecamdengroup.com

www.thecamdengroup.com

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There is much to debate in drafting healthcare reform legislation:  who to cover, how to cover them, how to pay for it, and who will pay.  But one thing seems clear:  the current provider payment model that is based on a fee-for-service chassis is going to have to change.  The inherent incentive to do more than may be necessary coupled with inadequate accountability for the quality of care or health outcomes are two major reasons for rethinking the nation’s dependence on the fee-for-service model.  Accountable Care Organizations (“ACOs”) are being proposed as part of Medicare payment reform and are also being considered by some commercial carriers as a mechanism to shift responsibility to networks of hospitals and physicians for “bending the cost curve” and improving quality.  Is your organization (either hospital or physician group) ready for a world of ACOs?  Regardless of the organizational model selected, here are the top ten questions to discuss among senior leadership to assist in identifying action items to prepare for the “new world.”

1.  Do you have the ability to aggregate clinical and financial data from community physicians as well as hospital(s), pharmacies, and independent diagnostic centers? 

Changing and uncertain reimbursement methodologies are a cause for concern with most hospital boards.  A focused discussion of specific performance improvement efforts designed to manage costs and quality will open dialogue between management and governance, identify perceived versus real opportunities, and establish targets/accountabilities.  Key areas of focus must include labor cost management, productivity, clinical protocols, revenue cycle, patient throughput, and emerging models of care coordination.  Specific institutional performance compared to best practice benchmarks will foster board conversation.

2.  Do you have a culture and discipline to measure and enforce clinical and service standards?

This isn’t just a “brush-up” on traditional medical staff peer review.  This means creating a discipline that is less forgiving about inconsistent application of established standards and protocols.  It requires timely information (e.g., “report cards”) as well as timely feedback loops and education.  It also requires enforcement of sanctions if expected behaviors/outcomes are not being met.  This will apply to physicians, clinical staff, and administrative leadership.

3.  Do you have a culture that embraces and encourages a relentless pursuit of improved quality and efficiency in care delivery?

Achieving the types of cost savings likely to be demanded will require rethinking traditional ways of delivering patient care.  This starts at the physician office and includes every component of care along the continuum.  It truly begins in the patient’s home, where efforts to engage patients in taking responsibility for their health and self-care will be ever-more important.  The way that most patients interact with our healthcare system hasn’t fundamentally changed in 50 years, despite advances in technology and changing demographics.  While there are some models that may hold promise (e.g. medical home, wireless technology), the successful ACO will continually promote innovation in search of “a better way” to delivery clinical care.

4.  What is the depth of physician leadership to assist in driving this change?

Clinical integration, care delivery redesign, development of clinical guidelines, and reporting – all necessary components – require a deep bench of clinical leaders.  Today there is too often a dependence on a few physicians who are continually relied upon to drive change.  Developing emerging leaders through education and empowerment will be critical steps to be accomplished sooner rather than later.  This includes physician leaders as well as other members of the clinical team such as nursing, pharmacists, social workers, and educators – and yes, even administrators. 

5.  How do you currently interact with your community?

As providers, generally we prepare ourselves for the times when patients come to us for care or advice.  But in an ACO world, we will need to think more about the general population in our community – how do we reach out to them even if they do not need medical care right now?  What kinds of opportunities for electronic communication, home monitoring, or other forms of interaction have we implemented?  How robust is our patient web portal?  Do we really live our mission statement (which in many cases is to “improve the health of the communities we serve”)?

6.  How honest are you in assessing what you really do well (and not so well)?

In today’s world, the incentive is to provide as broad an array of services and capabilities as possible in an effort to capture as much volume (and revenue) as possible.  But in an ACO world, it is likely that you will want to take a much more objective view of what kinds of services you should be offering versus those that you should contract with others in the community to provide – who can deliver better outcomes more efficiently.  This is the time to truly evaluate, for example, whether you should be providing open heart surgery or whether another community provider is really more capable of delivering the outcomes and efficiencies required in a global payment environment.

7.  How close are you to having a “care management” culture to address the continuum of care?

Do your case managers work closely with hospitalists and other physicians in assuring that the most efficient care is delivered both in and outside the hospital (e.g. follow-up appointments, alerts for repeat admissions, etc.)?  Do your primary care physicians have mechanisms to identify problem signs in patients with chronic disease (e.g., ED activity, specialty referrals required, etc.)  Case management, where the focus is on managing patients who present with complex problems, needs to evolve to care management, where potential problems are identified before they result in expensive care.  Ultimately, this will require the capability to do predictive modeling to identify both individual patient risks as well as more general trends that impact health status of a population.

9.  Does your approach to capital decision-making include consideration for the potential of the project or equipment to improve efficiency or enhance quality ‒ or both?

Traditional ROI models that assume a consistent revenue stream based on today’s payment structure could lead to decisions that may be appropriate in the short-term, but fateful for the long-term.  Assumptions should weigh the risks of a rapid change in payment structures.  And leadership must weigh the pros and cons of investing in the future (i.e., IT and care management infrastructure) versus investing in the present (e.g. more imaging equipment).

9.  What incentives are built into your compensation structures?

Productivity models (e.g. wRVUs for physicians) work well in a fee-for-service environment, but if payment requires efficiency and quality outcomes, is your incentive structure going to facilitate achievement of the desired behavior and results?  Also a review of incentives for administrative leadership may be warranted – do the incentives reward “silo” performance at the expense of system-wide performance?

10.  How informed is your board, medical staff, and middle management?

Moving toward systems of accountable care requires all oars moving in the same direction, at the same time, and with a consistent effort.  That won’t happen unless everyone knows that the rules are changing.  The change in mindset and definitions of success will not happen overnight, and in fact will likely take years.  Assuring that all participants have a view into the future will facilitate effective change.

The concept of ACOs requires an organizational culture of mutual accountability based on individual responsibility – with a focus on optimizing the health (not just the medical care) of all patients – are you ready?

For more information on preparing your organization for ACOs, contact Laura Jacobs, MPH at 310.320.3990 or ljacobs@thecamdengroup.com.