The Affordable Care Act was created to increase the number of Americans with access to healthcare, but in order for that goal to be universally met, overall expenditures must be drastically reduced. One of the most innovative ideas in the ACA is the provision for accountable care organizations (ACOs) — groups of providers that work together to provide better care to Medicare and Medicaid patients at less cost, while sharing in the savings. Sounds good in theory, but where do you find those savings in an industry that is beset by runaway costs?
One astonishing statistic suggests an intriguing possibility: According to the HHS, a mere 5 percent of the U.S. population accounts for more than 50 percent of healthcare costs. Many ACOs are staking a lot on reducing the cost of healthcare for that 5 percent. Yet achieving this noble goal is not easy in practice.
"Out of 91 pioneer ACOs, only two or three had savings," said Robert Wergin, president of the American Academy of Family Physicians. It is not clear why many ACOs are struggling, but the ones that are making it seem to have at least one thing in common. They reduce inpatient admissions and outpatient procedures. Quite simply, keeping patients healthy enough to need less costly care saves everybody money in the long run. "It sounds pretty straightforward, but it's not so easy to make it work," Wergin added.
WORKING THE HOT SPOTS
This approach was around when the ACA was just a gleam in Obama's eye. It's called hot-spotting and it could be the answer for struggling ACOs. In the early 2000s, Jeffrey Brenner, a young physician practicing family medicine in Camden, N.J., borrowed some ideas from the police department and applied them to healthcare. By using data to identify and direct healthcare resources to those high-cost patients, patients he called super-utilizers, Brenner found that he could dramatically reduce the amount of hospital visits in this group. Brenner is now executive director of the Camden Coalition of Healthcare Providers, an ACO, and advises other practices around the country who are trying to make similar programs work.
Like most good ideas, with hot-spotting, the devil is in the details. Successful hot-spotting requires a combination of high-tech data use and old-fashioned care. Mr. Spock meets Marcus Welby.
Janet Steffen, director of nursing at Family Practice Associates in Kearney, Neb. and the clinic nurse coordinator for the practice’s ACO, says that capturing data is key to its hot-spotting program. "We run a lot of reports thanks to EHRs," she says. They might run a list of everyone who had a high Hb-A1C on the last visit, or a list of all children who didn't get their second round of immunizations. They will then call the patients (or parents) and ask them to come in for a visit. They also follow up with any patient who has been in the hospital or had a recent ER visit. "It's important to make sure the meds are correct after discharge," says Steffen. "We spend a lot of time reconciling meds."
Successful hot-spotters go beyond just tracking admissions and following up with patients by phone. Most super-utilizers have a range of problems that contribute to their health issues and impede their ability to stay on track with their healthcare plan. For example, say a patient's blood pressure remains high and you suspect he is not taking his meds. If you get to know him a little better, you may find that he has no way to get to the pharmacy to pick up his meds. This is not an expensive problem to solve, just not one you're likely to learn about in a typical 15-minute visit to check his blood pressure. Getting to know patients a little better, even visiting their homes, may be necessary. A patient is unlikely to tell you that she can't store the children's antibiotics in the refrigerator because the electricity has been turned off in their apartment.
This kind of medical care takes creative staffing. Care coordinators, social workers, and health coaches all play an important role. "It’s a team model," explains Wergin, who is in the same ACO as Steffen. "You have to let each person do what they do best. But it does require infrastructure. You have to pay the coach."