August 25, 2011

AC-Oh No

Through some twisted events of fate, I have found myself at the cataclysmic intersection of three worlds: emergency medicine, health information technology and accountable care organizations (ACOs). I was asked a few years ago to be the CMIO for the Palmetto Health Quality Collaborative (PHQC), an ACO established by Palmetto Health in Columbia, S.C., and it has been quite amazing to realize the interrelatedness of these worlds.

As our emergency department medical director says, “In the ED, we are uniquely positioned to sit like a raven and look over the valley of chaos which is our health care system.” In any discussions about our health care crisis, the state of emergency departments is the sine qua non of why we have to change our health care delivery system. If there’s another option to accomplish this besides the fundamental principles of an ACO, I have not heard of it.

But let’s be clear, the concept of an ACO that I refer to here is NOT the proposed Medicare ACO system. In fact, the disdain for the general principles of the proposed regulations has made most of the early adopters reluctant to even utter the letters “ACO.” From sitting on a steering committee with a dozen of our state’s hospital CEOs, I can promise you that if these letters were uttered, their faces read as if there is a horrible and painfully familiar stench in the room.

So, many organizations and transformative health care leaders have started to come up with other terms for ACOs like PHQC’s “clinically integrated” program, a “transformative health solution” or a “patient focused care network” to name just a few that I have heard. Call it what you want, but I doubt many can argue with the general principles that I think of when I hear the letters “ACO.”

With my emergency medicine hat on, I see the dreadful conditions of access, and not simple access to care. I would argue that everyone has that ˗ it IS our EDs. I mean access in terms of coordination of care or availability for follow up or access to primary care after 4 p.m. Hardly a shift goes by that I don’t have to admit someone for something that could be handled the next day in a primary care provider office. It isn’t always a funding issue, it is value over volume from a population standpoint. I feel this everyday as well, albeit it isn’t as palpable to me as it certainly is to the payers that reimburse our hospitals and doctors. It’s better quality. Through the many analytics and reporting projects that we are now working on, I have been amazed at how shining a little light on something makes providers realize that they might not have been providing bad care, but they certainly can provide better care.

I see the pitfalls as well, like overreliance on hitting a specific number and the resultant gaming and the negative changes implemented in our clinical workflow just to document something that has never been scientifically proven to improve outcomes. We rely on claims data as an indicator of quality care, and any provider will quickly tell you that these are not synonymous. We have to improve quality, but this will not always directly translate into decreased cost and vice versa.

I noted in a recent discussion with the largest insurer in our state, that I am often quite conflicted and in serious disagreements with myself. However, I still come back to a few generalizations that I relate to the foundations of what an ACO is to me:

  1. We must improve coordination of care.
  2. We must radically change the structure and delivery of our primary care system.
  3. We have to decrease costs and improve quality.

Tripp Jennings, MD, FACEP, is CMIO at Palmetto Health Quality Collaborative and the immediate past president of the South Carolina College of Emergency Physicians.