To succeed in an accountable care organization, practices have to dedicate resources to the high-cost, frequent utilizers of care.
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."
At this point, a natural question is how could this plan possibly save money? Reducing hospitalizations among the super-utilizers couldn't save enough to pay a team of experts to make home visits and hunch over computer printouts all day, or could it? There is not a lot of hard data on it yet, though clinical trials are in the works. People who are taking this approach are in fact seeing some savings. Natasha Dravid, senior manager for clinical redesign initiatives at the Camden Coalition said that many of the practices she works with are reporting success, in some places there is as much as a 20 percent cost reduction.
Savings come in unexpected places. The care coordinator in Steffen's practice routinely calls patients who have had a lot of no-shows. "If we find that they are missing visits because they don't have a ride to the clinic, we can help with that. Even if we have to send a taxi to pick them up, it saves us money," said Steffen.
Just having one or two care coordinators can make a demonstrable difference. A case study published in the AAFP’s journal, Family Practice Management in 2013 found that in a 340-member multi-specialty group with 100 primary-care physicians, that had two care coordinators to confirm visits, schedule preventive services, order labs in advance, reconcile medications and order refills, contact patients who were overdue for follow-ups, and call patients after discharge from the hospital, had fewer no-shows, higher visit volume, decreased hospital readmissions, and most importantly, increased revenue and improved outcomes.
While it doesn't take an army of social workers to see a difference, some attention beyond the consulting room is essential. "We must take into account the social determinants of health," said Dravid "We know that if we spend more on social services, we spend less on healthcare." We need to wait for the results of clinical trials to be able to point to hard numbers showing how much savings can be had from this approach, but one thing is clear already. This increased attention to patients' needs - both in and out of the clinic - makes for better patient care. "Economics is one side of things," says Wergin, "but for me the bigger issue is how to give better care to these patients."
SAVE ON PAYROLL, TOO
There are several ways of keeping staffing costs down when implementing a hot-spotting accountable care organization (ACO) program. Letting each team member work to the highest level of their certification and training can direct man-hours to the least expensive person on the team who can do that particular job. According to Janet Steffen, director of nursing at Family Practice Associates in Kearney, Neb, advanced practice nurses or nurse practitioners can order tests and medication refills, the front-office staff can make follow-up calls, and health coaches can work one on one with patients who need help understanding how to take their medications or have other problems that don't need to be dealt with by a nurse or a doctor.
Health coaches don't necessarily need healthcare degrees. In fact, people who come from the neighborhood the ACO is serving and speak the language fluently are often better able to work with patients than are well-trained outsiders. Robert Wergin, president of the American Academy of Family Physicians, says you can train these team members yourself and customize that training to suit the needs of your practice, patients, and community. Having people on staff who live in the neighborhoods you serve and know your patients (and their circumstances) personally can go a long way to establishing trust with your patients and giving you the information you need to provide them with the best care.
Natasha Dravid, senior manager for clinical redesign initiatives at the Camden Coalition points out that the team does not necessarily have to be embedded in the practice. Reaching out to other local agencies, social workers, and community health workers, and sharing resources can not only save money, but increase efficiencies in other ways as well. Many people are already working in the community; their experience and expertise can be invaluable to you as you implement a hot-spotting program.
Avery Hurt is a freelance writer based in Birmingham, Ala. Her work has appeared in publications including Newsweek, The New Physician, Muse, Parents, USA Today, and the Washington Post. E-mail her at email@example.com.
This article was originally published in the March 2016 issue of Physicians Practice.