NATIONAL HARBOR, MD. – Accountable Care Organizations are designed around wellness with primary care physicians at the center, but hospitalists still have a major role to play by improving quality and decreasing costs, according to Dr. Emily Mallin.
A look at the 33 quality measures that Medicare requires ACOs to meet shows how integral hospitalists are to the success of these new care delivery models, said Dr. Mallin, a hospitalist at one of the Pioneer ACOs approved by Medicare in 2012. Hospitalists are involved in nearly half of those quality measures, from preventive health to care coordination to the treatment of at-risk populations.
"While ACOs seem to be population based and outpatient based, the truth of the matter is that [hospitalists] are involved in this," Dr. Mallin, medical director of the academic medical service at Banner Good Samaritan Medical Center in Phoenix, said at the annual meeting of the Society of Hospital Medicine.
Dr. Mallin is part of Banner Health’s Pioneer ACO, a Medicare program that allows mature ACOs, usually located at integrated health systems, a chance to share in the savings generated through better-coordinated care. But this isn't the only type of ACO model.
"ACOs come in all shapes and sizes," Dr. Mallin said.
Officials at the Centers for Medicare and Medicaid Services have also approved more than 220 organizations for the Medicare Shared Savings program, which offers organizations the chance to share in savings only or to take on financial risk but potentially reap higher financial rewards. A third Medicare ACO model, called the Advance Payment Model, allows some small physician-run ACOs to receive up-front, monthly payments to help invest in care coordination. There are also several private payers that have been forming ACOs around the country.
Regardless of the specific structure, all ACOs are designed around the concept of making health care providers accountable for the quality, cost, and overall care of patients.
Photo by Mary Ellen Schneider
Dr. Emily A. Mallin (left) and Dr. Edward J. Merrens (right)
While the idea of taking on financial risk for the total care of patients sounds similar to the HMO heyday of the 1990s, Dr. Mallin said there are key differences: For instance, the move to HMOs was driven by insurance companies whose sole goal was reducing costs. With today’s ACOs, there is a greater attempt to involve physicians and other health care providers. And while there is a definite focus on reducing costs, ACOs are paid for outcomes, quality, and value. Another key difference, she said, is that there are now significantly more data available at the point of care to help coordinate care.
In the developing ACO world, hospitalists are considered "specialists," Dr. Mallin said. As specialists, hospitalists can participate in more than one ACO at a time. They are also entitled to share in the savings generated by the ACO but exactly how that is done depends on the where they work and how their ACO is structured, she said.
At Banner Health, hospitalists are taking on some new roles with the goal of better care coordination in the ACO. For example, they have an inpatient transitionalist physician who sees patients in the hospital before discharge and then follows them for 30 days after they leave the hospital. He makes house calls and follow-up phone calls to make sure they are receiving adequate care in the community and prevent them from bouncing back to the hospital. "He is extremely patient centered," Dr. Mallin said.
Banner also has a "triage-ist" who is stationed in the emergency department of the hospital and helps in deciding if patients should be admitted, Dr. Mallin said.
The biggest thing to keep in mind about the hospitalist role in ACOs is that this is evolving, said Dr. Edward J. Merrens, a hospitalist and the chief medical officer at Dartmouth-Hitchcock Medical Center in Hanover, N.H., one of the Medicare Pioneer ACOs.
"We don’t have it all figured out yet," he told attendees at the SHM meeting. "This is a new endeavor."
But hospitalists should start to think differently about the care they provide, he said. For instance, ACOs are reversing some long-standing ideas about health care costs, turning hospitals from "profit centers" to "cost centers," he said.
Under the ACO model, ordering an MRI is now a cost to the ACO, not a way to generate revenue for the hospital. Medicare is applying that same principle to hospital readmissions, by penalizing hospitals for having excess return hospitalizations. Dr. Merrins said hospitalists need to start thinking about admissions that way too and trying to prevent them in those patients who return frequently to the hospital for multiple reasons.