Much has been written about the potential virtues of accountable care organizations and clinically integrated networks in containing health care costs, expanding access to care and improving outcomes, but there has been less focus on helping organizations understand common challenges in the implementation process of this new model of payment and care. Certain core structural components are necessary for successful implementation of this new standard of accountability, and some of the most common issues likely to arise around these components throughout the implementation process are outlined here.
1 Physician leadership. Many organizations get tripped up early in the implementation process because they lack broad physician buy-in on the concept of population health. Mitigate this stumbling block through a proactive, coordinated effort of comprehensive education sessions to the physician community on the vision and value of population health, and be prepared to deliver this message on multiple occasions before comprehension and alignment are achieved.
The successful physician leaders for these transformative efforts will have not only the respect of their peers, but also be driven by the vision for the organization and unafraid to confront the inevitable obstacles related to both behavioral and payment changes. The organization must provide the training, exposure to external resources to fill knowledge or experience gaps, and an infrastructure that can deliver timely performance reporting to aid in providing feedback and education to participating providers. Be sure that there are also recognition and incentives in place to reward even the small but important wins. In this environment of constant change, recognition of movement in the right direction is critical to keep momentum and reinforce the vision and goals for the effort.
2 Delivery network. Effective clinical integration requires a strong primary care base and an aligned, broad delivery network of specialty services that cover the continuum of care for the target population, partnered with sufficient inpatient facilities and either affiliation or ownership of post-acute facilities and home health services. For many organizations, the full development of this comprehensive network will be a dynamic process. Focus initial implementation efforts on areas in which desired change can be quickly impacted in the network, such as strengthening primary care access through extended office hours, urgent care clinics and telephone triage services, then leverage existing relationships to build the remaining network over time.
Do not forget to engage specialists in the care model design and strategies for managing the care of the most complex patients. While the implementation of patient-centered medical home models can have a dramatic impact on avoiding emergency department use and hospital admissions, the engagement of specialists in the clinical "neighborhood" will be crucial for avoiding readmissions and improving outcomes for the highest-risk patients.
3 Care management. Thriving ACOs and clinically integrated networks have a systemwide commitment to care management along the continuum of care. Most care models evolve over time before being fully capable of managing that continuum of care, so jump-start the implementation process by building on programs that currently exist but are typically uncoordinated across the organization.
It is not uncommon, for example, for organizations prior to implementation to have multiple disease management programs across their network that are not coordinated and all target the same high-risk populations. Redundant programs can lead to confusion and frustration for both patients and providers when numerous teams pursue the same patients with slightly different programs. Identify, then standardize, the successful elements of each of those programs, and implement that restructured, coordinated program across the organization. This iterative approach will position organizations for faster growth in care model redesign.
4 Data analytics. Effective organizations possess robust information technology infrastructure and tools that deliver, track and document patient-centered, evidence-based care at the point of service and are able to disseminate actionable and meaningful data quickly and transparently. Similar to network development and care model redesign, IT infrastructure implementation is an iterative process, and rarely do organizations have a "fully baked" IT solution at the onset of implementation. Instead, plan early development of relevant metrics around currently available data, even if that means using claims rather than clinical data initially, and focus efforts on achieving the greater goal of developing provider comfort with access to and understanding of consistent data elements and measurement.
Prioritize those data points that are most crucial for managing the population, use reporting tools that are already required for quality reporting to Medicare (for example, Physician Quality Reporting System) and commercial payers, and expand as possible to focus on clinical areas or performance deficits that require the most improvement or have the greatest potential to impact cost. This is an example of "great being the enemy of good." The development of the perfect data system is far in the distance for many organizations and yet, there are still data available to be mined that can help in identifying risks and tracking performance.
Be sure that the data assembled are compiled in a reporting structure that provides clear tracking of performance on the "vital few," or most important, metrics. Too much data that are not well-organized or analyzed can simply create confusion and cloud the necessary focus required to impact population health.
5 Value-based payment models. Value-based payment requires new types of risk and a population focus. Meanwhile, many organizations are still dependent on fee-for-service payments for the majority of their revenue streams. Some organizations can get cold feet when the efforts to improve efficiency and effectiveness of care initially result in a drop in volume (and top-line revenue). This is where leadership again is required, as only those organizations with a steadfast focus on the transformation and who have communicated the long-term goal will be able to lead the organization through these initial rough patches.
Another obstacle is that while considerable effort will be asked of physicians and others in the organization, the financial rewards and incentives earned could be insignificant, particularly if the patient population involved in the initial effort is small.
To counteract the potential for this to derail efforts, be sure that the care coordination and tools provided to physicians actually help them in the delivery of better patient care. This is where the clinically integrated organization must invest in resources at the beginning to support care coordination, data mining and reporting so that the entire burden of change does not fall on the physician practices.
Another critical step is to be extremely transparent in the architecture of the funds flow to assure that participants understand what drives achievement of financial success and how any incentives earned are being distributed. Otherwise, there is a high likelihood that suspicions build that "the other guy or organization made all the money and left nothing for me." This value-based world means a whole new level of transparency for many organizations — sharing performance not just on quality, but on financial performance and funds flow as well.
Accomplished ACOs and clinically integrated networks have developed a culture of accountability, with both clinical and management leadership fully committed to the value of accountable care. These organizations have determined the key design characteristics that help to facilitate widespread effectiveness of population health management models. To implement clinical integration, health care organizations first must acknowledge gaps and likely obstacles to be encountered, then develop and communicate clear mitigation strategies for which there are clear structures for assigning responsibility and authority for carrying them out.
Laura Berberian, M.S.N., M.M., R.N. (lberberian@thecamdengroup.com), is vice president, The Camden Group, Boston.
