As a top performer in Year 1 of the CMS Pioneer ACO program, the 2500-physician Monarch HealthCare is paving the way to accountable care with a foundation of patient- and provider-centered strategies that support Triple Aim goals.
Those goals – to improve quality, improve health outcomes and reduce cost, are detailed in Tactics from a Top-Performing Pioneer ACO: Engaging Patients and Providers in Accountable Care.
Colin LeClair, executive director of ACO for Monarch HealthCare, recounts how Monarch recast its Medicare Advantage (MA) care management program to target about 1,200 high-risk patients who have a similar constellation of issues.
“Monarch repurposed our Medicare Advantage (MA) care management program for the ACO,” LeClair said.
Monarch’s ACO care management team was designed to anticipate and prevent acute events and then to facilitate transitions of care for patients post-discharge, he said.
This interdisciplinary team is “comprised of a primary care physician who quarterbacks the team, and a care navigator, also known as a care coordinator, who performs most of the patient onboarding into the care management program and performs an initial triage of the patient’s needs,” LeClair explained.
The care manager is often a non-complex patient’s primary point of contact. The complex care manager is responsible for most of the complex cases, he said.
Then as needed, “we also deploy a behavioral health clinician, a community services coordinator, a clinic dietician and a palliative care nurse. The other resources may include a pharmacist or Pharm D to perform post-discharge medication reconciliation.”
Then, LeClair continued, “we have a team of medical directors, employed and contracted hospitalists, and employed and contracted skilled nursing facilitators (SNFs) to support us as well.”
The idea is that the team is tailored for the patient’s need at enrollment, and it can then be augmented as the patient’s health status changes, he observed.
This model scales best when you can target large patient populations with a fairly common list of conditions, which allows you to hire and assign clinicians with the appropriate expertise to each patient.
“For example, we can afford to hire and assign a registered nurse (RN) or a nurse practitioner (NP) who has experience in a dialysis clinic or a nephrologist office if we have enough renal disease patients to fill their case load,” LeClair said.
For more information or to order your copy of Tactics from a Top-Performing Pioneer ACO: Engaging Patients and Providers in Accountable Care today, please visit: http://store.hin.com/product.asp?itemid=4841
Managed care organizations’ adoption of accountable care goes well beyond the accountable care organization (ACO) initiatives of caring for the Medicare population.
Health plans see the potential of ACOs in terms of the quality of care and reimbursement models.
Among the managed care organizations partnering with providers to launch ACOs are UnitedHealth Group, Aetna, Humana, Cigna, Highmark and others.
For instance, Cigna is involved in 86 collaborative accountable care initiatives in 27 states. These programs encompass more than 880,000 commercial customers and more than 35,000 doctors, including more than 16,000 primary care physicians and more than 19,000 specialists, Cigna said.
The health plan’s goal is to have 100 accountable care relationships reaching one million customers in 2014.
UnitedHealth Group has ACO initiatives underway in eight states. And, $28 billion of the Continue reading
Will large numbers of physician organizations or physician groups develop an accountable care organization?
“No. Although an important component to a successful ACO, physicians will not have the infrastructure needed to develop an ACO,” a Regional Network Manager with a health plan told us in our Managed Care Leadership Survey.
“Physicians want to own healthcare but they have no infrastructure or expertise on the risk side of healthcare,” a consultant said.
“The emphasis on integration, EMR, quality and payment require a solid infrastructure which is beyond the capacity of most physicians per se,” said another consultant.
Said another respondent: “Most do not have the infrastructure, resources or expertise necessary to lead the development.” Few have the motivation.”
“We need provider buy-in and that doesn’t happen quickly,” according to a health plan manager of strategic growth.
Only a small number of physician organizations/groups “have the capital to develop an ACO without getting into the pockets of insurance companies,” said another senior consultant.
The survey is conducted by the Managed Care Information Center, which produces the National Directory of Physician Organizations Database.