Haas, Sheila A

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Loyola University ChicagoLoyola eCommonsSchool of Nursing: Faculty Publications and OtherWorks Faculty Publications2013Accountable Care Organizations: Elements ofSuccessSheila A. HaasLoyola University Chicago, shaas@luc.eduThis Article is brought to you for free and open access by the Faculty Publications at Loyola eCommons. It has been accepted for inclusion in School ofNursing: Faculty Publications and Other Works by an authorized administrator of Loyola eCommons. For more information, please contactecommons@luc.edu.This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 License.© American Academy of Ambulatory Care Nursing, 2013.Recommended CitationHaas, S. "Accountable Care Organizations: Elements of Success." ViewPoint, May/June 2013.12 ViewPoint   MAY/JUNE 2013increased use of evidence-based protocols and to providecare in less expensive settings. Second, ACOs won’t auto-matically change patient behavior. Currently, many ACOslet patients choose their providers, including specialists.This has been done to avoid consumer dissatisfaction withuse of “gatekeepers” who authorize access to specialists orprocedures. Gatekeepers have been traditionally employedby HMOs to contain costs. Finally, “ACOs will not savemoney on a grand scale.... No dent in costs is possible untilthe structure of health care is fundamentally changed,”Christiansen and colleagues (2013) conclude.Christensen’s predictions are in line with the RobertWood Johnson National Commission on Physician PaymentReform Report (2013). They list the following factors thatare drivers of the high cost of U.S. health care (p. 2-3):• Fee-for-service reimbursement. Under this model, physi-cians are reimbursed for each service they provide. Payis not necessarily linked to outcomes.• Reliance on technology and expensive care. The federalgovernment and private insurers reimburse technolo-gy-intensive procedures at higher rates than servicesfocused on evaluating patients or managing the carefor chronic (illnesses.)• Reliance on a high proportion of specialists. The U.S. hasa high ratio of specialists to primary care physicians.The higher-intensity, higher-cost practice of specialistsmakes their care particularly expensive. The currentpayment system favors high cost procedures over timespent on evaluation or management of care.• Paying more for the same service or procedure when donein a hospital setting as opposed to an outpatient setting.For example, Medicare pays $450 for an echocardio-gram done in a hospital and only $180 for the sameprocedure in a physician’s office. While physician salaryand related expenses account for 20% of health carespending, the decisions they make influence an addi-tional 60% of spending. • Systemic issues. Specifically, the skewed incentives offee-for-service payment.Managed Care magazine did an interview with ClaytonChristensen in 2009. According to Christensen, three fun-damental investments are needed in health care:Investment in diagnostics, business model innovation,and the creation of a new system. Diagnostics that pre-cisely diagnose disease pay off very handsomely inaffordability down the road. The business model ofmedicine, such as the hospital and the doctor’s office,were put into place 100 years ago in response to con-ditions that existed 100 years ago. We need to replacethem with innovative business models that will do amuch better job of focusing the right resources on theright problem. And because health care is a systemicproblem, only companies that have the scope to wrapAccountable CareOrganizations: Elements ofSuccessAlthough much has been written about the PatientProtection and Affordable Care Act’s (PPACA) provisions toassist hospitals, physicians, and other caregivers to improveaccess, safety, and quality while decreasing costs of healthcare, there is much variability in the acceptance, strategies,and implementation of accountable care organizations(ACOs). On March 31, 2011, more than 2 years ago, theU.S. Department of Health and Human Services (DHHS)proposed new rules to assist with provision of better coor-dinated care for Medicare patients through ACOs. ACOsprovide incentives for teamwork and coordination of careacross settings including ambulatory care, acute care andlong-term care. “The Medicare Shared Savings Programwill reward ACOs that lower growth in health care costswhile meeting performance standards on quality of careand putting patients first. Patient and provider participa-tion in an ACO is purely voluntary” (DHHS, 2011).Although ACOs are supposed to decrease costs andincrease quality of care, the epicenter of their mission is thegoal that the ACO be a patient-centered organizationwhere patients and providers are true partners in care deci-sions. The ACA specifies that an ACO may include the fol-lowing types of providers:• ACO professionals (i.e., physicians and hospitals meet-ing the statutory definition) in group practice arrange-ments,• Networks of individual practices of ACO professionals,• Partnerships or joint venture arrangements betweenhospitals and ACO professionals, or• Hospitals employing ACO professionals, and• Other Medicare providers and suppliers as determinedby the Secretary (DHHS, 2011). Shared savings are also a major part of the ACO.Medicare would continue to pay providers and suppliersfor specific items and services, but it would also developbenchmarks for each ACO against which its performancewill be measured to assess whether it qualifies for sharedsavings, or should be held accountable for losses. Ambulatory care nurse leaders need to be aware of thechallenges and controversies that surround establishmentof ACOs, as well as expected performance parameters andoutcomes, so that they can assume leadership in planningand implementing ACOs. In a recent Wall Street Journalarticle, Christiansen (who developed the concept of“Disruptive Innovation”) and colleagues from Harvard(2013) argue that ACOs will fail because they are foundedon three “untenable assumptions.” First of all, ACOs can-not change physician behavior. Physicians need to move toView health care reform resources online at:www.aaacn.org/health-care-reformWWW.AAACN.ORG   13their arms around the whole system are going to beable to change it. A few institutions, IntermountainHealthcare, Kaiser Permanente, Geisinger HealthSystem, and a few others like these, are integratedfixed-fee sorts of providers that are really building onwhat HMOs originally were. They have the scope torethink the creation of new systems that have disrup-tive business models (Managed Care, 2009).In a WSJ article, Christiansen and colleagues (2013)build on the ideas expressed in the 2009 interview andoffer several suggested reform solutions:• Consider opportunities to shift more care to less-expensive venues, including, for example, “MinuteClinics” where nurse practitioners can deliver excellentcare and do limited prescribing. New technology hasmade sophisticated care possible at various sites otherthan acute-care, high-overhead hospitals.• Consider regulatory and payment changes that willenable doctors and all medical providers to do every-thing that their license allows them to do, rather thanpassing on patients to more highly trained and expen-sive specialists.• Going beyond current licensing, consider changingmany anticompetitive regulations and licensurestatutes that practitioners have used to protect theirguilds. An example can be found in states likeCalifornia that have revised statutes to enable highlytrained nurses to substitute for anesthesiologists toadminister anesthesia for some types of procedures.• Make fuller use of technology to enable more scalableand customized ways to manage patient populations.These include home care with patient self-monitoringof blood pressure and other indexes, and far morewidespread use of “telehealth,” where, for example,photos of a skin condition could be uploaded to aphysician. Some leading U.S. hospitals have createdsuch outreach tools that let them deliver care toEurope. Yet they can’t offer this same benefit in adja-cent states because of U.S. regulation. Christiansen and colleagues (2013) have apparentlyread and accepted recommendations made in the RobertWood Johnson 2010 Report: The Future of Nursing: LeadingChange, Advancing Health.ReferencesChristensen, C., Flier, J., & Vijayaraghavan, V. (2013, February 18).The coming failure of ‘accountable care.’ The Affordable CareAct’s updated versions of HMOs are based on flawed assump-tions about doctor and patient behavior. Wall Street Journal.Retrieved from http://online.wsj.com/article/SB10001424127887324880504578296902005944398.htmlManaged Care. (2009). A conversation with Clayton Christensen, DBA:Network-model health plans may be tomorrow’s dinosaurs.Retrieved from http://www.managedcaremag.com/archives/0901/0901.qna_christensen.htmlNational Commission on Physician Payment Reform, The (NCPPR).(2013, March). Report of the National Commission on PhysicianPayment Reform. Retrieved from http://physicianpaymentcommission.org/wp-content/uploads/2013/03/physician_ payment _report.pdfU.S. Department Health and Health Services (DHHS). (2011).Accountable care organizations: Improving care coordination forpeople with Medicare. Retrieved from http://www.healthcare.gov/news/factsheets/2011/03/accountablecare03312011a.htmlSheila A. Haas, PhD, RN, FAAN, is a Professor, Niehoff School ofNursing, Loyola University of Chicago, Chicago, IL. She can be con-tacted at shaas@luc.eduInterest Group (SIG) networking and the sharing of infor-mation. What is a CoP? It is a group of people who share aconcern or passion for something and interact regularly tolearn how to do it better. The Leadership SIG, their AdvisoryGroup, and past Chair Kathy Mertens agreed to pilot thisnew concept and the technology that goes with it. A spe-cial session at the annual conference was held to educateand demonstrate the capability of the CoPs to leaders andmembers of the other SIGs, committees, and task forces topromote the use of this interactive tool.In addition to the CoPs, the AAACN Web site(www.aaacn.org) has an entire new look and functionality!If you haven’t been there lately, I encourage you to visitand try out some of the enhancements for yourself.Research and evidence-based practice will be high-lighted in a new toolkit soon to be added to the resourcesavailable on the Web site. In addition, plans for an ambu-latory nurse sensitive indicators task force are in progress.Strategic Goal #2 – Expand Our InfluenceAAACN has become a member of the Nursing Alliancefor Quality Care (NAQC) – a bold partnership among thenation’s leading nursing organizations, consumers, andother key stakeholders to address the disparities and ineffi-ciencies in health care quality and safety. Thank you toEileen Esposito, who will serve as our representative to thisimportant group.Strategic Goal #3 – Strengthen Our CoreMembership and member retention are the highestever in 2013! We are pleased to have over 2,600 members.Thanks to all our members who are committed to AAACNand who are working to invite new members to join us asthe organization that encompasses many settings and mul-tiple roles in one unifying specialty of ambulatory care.Looking AheadDuring the next year, I plan to use this column to keepyou informed of the progress of our strategic goals and ini-tiatives. However, we can’t accomplish them without you,our members. Opportunities to volunteer are plentiful – ifyou find something that “speaks” to you and your practice,join in! You’ll be glad you did.Thank you for this opportunity to serve as theAAACN President this year!Susan M. Paschke, MSN, RN-BC, NEA-BC, is Chief Clinical andQuality Officer, Visiting Nurse Association of Ohio, Cleveland, OH.She can be contacted at spaschke@vnaohio.orgPresident’s Messagecontinued from page 2

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