Size matters

Large and small providers and payers enlist a variety of strategies to develop accountable care organizations and other value-based models.
ACOs made up of smaller providers essentially tip their toe in the water to get started on care coordination and risk stratification, while those comprised of larger providers have more resources with which they can conduct more comprehensive risk-based population management.
The smaller end of the scale is reflected by the three ACOs MedChi Network Services (MNS) is involved with. MNS is a firm that offers management services to physician practices as a subsidiary of MedChi, the Maryland State Medical Society. Craig Behm, MNS' executive director, said the three ACOs his group is involved with encompass 70 physicians and 25 practices.
"We started ACOs to avoid overburdening practices," he said. "Small independent physicians are constantly challenged with quality measures, care programs and measurement sets and standardization - things that they don't have time to do after they see patients for 10 or 11 hours."
Their care coordination model is similar to most case management programs - working with nurse managers in practices making sure standards and guidelines are being met, using data analytics and risk stratification tools to focus on a certain subset of population with the most to benefit from quality improvement, whether avoiding ER visits or avoidable readmissions. "It's all done from an IT system to enable data sharing, built onto proprietary systems and focusing on analytics," he said.
On the large end of the spectrum is Community Health Network, an integrated health system based in central Indiana. CHN concentrates on the commercial accountable care market. It created a jointly-owned entity, the Accountable Care Consortium, with two competing systems to cover all their accountable care initiatives, said Joseph Pollman, executive director, knowledge management, at Community Health Network.
"It gives us a tremendous amount of market clout, and in terms of the traditional fee-for-service way of measuring the market, it gives us 40 to 50 percent of the market," he said.
The consortium has chosen a full risk-based model, which presents the potential of losses in the first year, instead of the less-risky shared-savings approach.
"We think moving to full risk forces you to face issues that you generally wouldn't have the appetite to deal with effectively, particularly with the complexity of going to market," Pollman said.
"Health systems are not used to thinking of patients in terms of risk the way health plans have for a number of years," he said. "It's a different way of thinking."
Risk will vary by group depending on their demographics and makeup. Providers need to have tools in place to understand the risk they are assuming and to identify the patients that they need to pay attention to - the high-cost patients who may benefit from these initiatives.
"At the same time, we're discovering as we're moving into analytics that there are a lot patients who have symptoms of chronic health conditions but are not yet diagnosed," Pollman said. "We believe that's an opportunity to do a better job of identifying that cohort of patients to bring care management services to them and engage them before they become a cost to the system."
Increasingly, more accountable care programs are being evaluated for what works and how to do it at scale, said John Haughton, chief medical information officer at Covisint, a provider of cloud-based engagement platforms. Three functions that have shown to matter in population improvement and measurement are: getting the information to the point of care; measuring what you're looking at so you know how it's going - that means getting numerators and denominators; and distributing information in real time and close loops for feedback, he said.