Accountable Care Organizations and Health Plans
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1 Accountable Care Organizations and Health Plans January 2011
2 What is the goal of an accountable care organization An ACO is a clinically integrated group of providers who seek to improve the health of a defined population and share resulting savings MedPAC (2009) A set of providers associated with a defined population of patients, accountable for the quality and cost of care delivered to that population ACA (2010) A group of providers of services and suppliers meeting criteria specified by [HHS] may work together to manage and coordinate care for Medicare fee for service beneficiaries Source: Fisher ES et al., Creating Accountable Care Organizations: The Extended Hospital Medical Staff. December 5, 2007, Health Affairs, Vol. 26, pp. w44-w577; MedPAC Medicare Payment Advisory Commission, Report to the Congress: Improving Incentives in the Medicare Program: Chapter 2. June 2009, Accessed 2/4/2010 2
3 Successful ACOs will require traditional competencies of health plans Successful ACOs will require different capabilities and relationships with the populations they are serving Examples Associated Health Plan Competencies Holistic View of the Patients Access to a holistic (360) view of patient data and use of technology platform Access to chronic disease registries of patients for keeping the physicians informed of their patient mix on a real time basis so they can better manage the population s health Technology and Decision Support Sophisticated technology platform allowing for longitudinal view of patient HIE Access to provider decision support at the point of care (e.g. referral guidance, patient risk) and refinement of information with emerging comparative effectiveness research results Ability to Measure Performance Risk Ability to summarize and explain population-level outcomes data Expertise in aggregating and analyzing quality and cost data Experience benchmarking providers against each other Care Management Support Inbound and outbound Call Center nurse telephone lines to help individuals deal with manageable health problems by phone and quickly identify and refer potentially larger problems Online portals for individuals to access a rich array of care and preventive programs and select medical information, such as lab results and consult with their physician and their team 3
4 The operational model is built to support this strategy Leadership & Governance Network & Physician Alignment Clinical Operations ACO Capabilities Finance & Risk Business Operations Infrastructure & IT 4
5 Example Core Competencies Any organization aspiring to provide accountable care will require a broad range of competencies; many of which are core competencies of commercial health plans Provider Contracting IT Medical Management Finance Marketing & Sales Internal Audit Quality Claims Processing Underwriting/Actuarial Legal Care Management Regulatory Mail Room Benefits Enrollment Note: List of competencies is not comprehensive 5
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