ACOs Begin with Clinical Integration: MGMA

Thinking of starting or joining an accountable care organization (ACO)? Better make sure the organization in question is already fully clinically integrated and that the physicians within it have developed a culture of holding each other accountable to outcomes.

So argued Mark Shields, the senior medical director of Advocate Physician Partners (APP), a group of 3,900 physicians affiliated with Advocate Health Care hospitals in the Chicago area, on Tuesday at the MGMA11 Conference. Shields said that a fully clinically integrated network of physicians across all specialties is "the chassis on which to drive other activities, such as an ACO, or bundled payments, or a robust network of medical homes." Physician groups and hospitals can’t begin their clinical integration efforts with an ACO, because such organizations are essentially contracting groups that take advantage of the efficiencies they've built to win contracts that recognize those efficiencies.

"It's a next logical step on the road for a clinically integrated organization," Shields said. "But it's not the place to start. You gotta walk before you can run."

Yet the concept of genuine clinical integration is not well understood, he added. And getting there requires years of painstaking attention to clinical and other physician performance benchmarks, data collection, and physician incentives. For example, APP has identified 147 performance benchmarks in five domains: clinical outcomes, efficiency, technological infrastructure, patient safety, and patient satisfaction. Of the benchmarks, only those appropriate to each physician's specialty is counted toward that physician, Shields said - as many as 40 and as few as 17, depending on the specialty.
Benchmarks are selected by committees of APP physicians; physician-level results are reported widely, and physicians hold each other accountable to them at the local hospital or practice-site level, partly because more incentive dollars are available to physicians working in groups that meet benchmarks. In 2004, APP paid out $12.4 million to its member physicians in performance bonuses; last year, the payout was $50 million. It's all part of developing what Shields called a "culture of engaged physicians," which he said is the backbone of any successfully integrated clinical organization.

"If you don't have the culture right, you'll have unintended consequences," he said. That's why physicians, and not hospital administrators, dominate the committees that select clinical-outcome benchmarks. "Physicians aren't along for the ride," he told the audience, which was split about equally between managers of hospital-owned and independent groups. "They drive the whole process. They pick the clinical measures, they credential each other, and they're very tough."
Transparency about the benchmarks is important, too, he said. Not only are the benchmarks themselves clear and selected by the doctors, but physicians' performance is individually reported to their colleagues. Physicians can look up the scores of doctors they're considering referring to, for example. Physicians who know each other are better able to hold each other accountable, which is why accountability is most effective at the site level.

"If a physician gets a memo from me, the senior medical director, it gets thrown directly in the trash without being read. But if the medical director of the hospital comes up to someone in the hall and says, 'Hey Joe, I noticed that your prescribing of genrics is awfully low. Let me tell you why we think that's so important, and how prescribing generics increases patient adherence,'" that message, Shields said, is likely to have an effect.

Only organizations that have done that kind of meticulous work can move successfully toward creating ACOs themselves, he said, and few have. APP is looking hard at the government's shared-savings program, and has been working with private payers on ACO-type contracts for some time now. Shields said payers are acknowledging, for the first time, the reality that they are, alone, powerless to control the growth of health costs yet reaching a point where they can no longer continue to pass the increased costs on to employers. Something must change, he said.

"It's a new day. We're moving away from silo-ed care and toward integrated care management, and you can only do that by partnering with physicians across specialties and integrating with hospitals," Shields said. "We, unlike insurance companies, are well positioned … to reduce the waste in the system. Working together with doctors in our network, we can eliminate waste. And much of the savings comes back to us in the form of value-add payments."