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Insights from ACO Pioneers (Part Four: Patients)

How can healthcare organizations that were built on volume adapt to the arrival of a value-based reimbursement system?  To help answer that question, we’re continuing our four-part series of posts based on a new white paper by Allscripts Chief Medical Officers Doug Gentile, MD and Toby Samo, MD exploring the unique perspectives of pioneering Accountable Care Organizations.

In this fourth and final part of the series, Drs. Gentile and Samo explore how ACO’s manage their relationship with patients, and conclude with some parting advice from the pioneers. 

To read the white paper in its entirety, go to 




Key Takeaways:  

  • Invest in the sickest
  • Ensure social media informs physicians first
  • Patient Mobility Improves Customer Service 

For many, the Achilles’ heel of the ACO concept is consumer involvement. Healthcare is the only industry in which the consumer has an indirect connection to the cost of the services they receive because of insurance coverage.  As a result, consumers with insurance are “cost insensitive,” with little incentive to reduce unnecessary services. Under new ACO value-based payment models, ACOs are financially accountable for their patients’ health.  This requires a new level of engagement and partnership between patients and providers. Their task is complicated by the free choice of patients covered by Preferred Provider Organizations (PPO), who can choose at any time to find another provider in another network.

Against this backdrop, the participants expressed their struggles to find ways to engage patients in their own health and build loyalty. The suggestions in this section were accompanied by a lot of disclaimers and expressions of doubt. It was clear that, for these organizations if not for all American providers, patient engagement is very much a work in progress. As Sharp’s Hrountas put it: “It’s going to be up to us to develop new models to engage the patient in a different way than we’ve had to do in the past since they’re not restricted from going elsewhere.”

Invest in the Sickest

This may seem obvious but it is the foundation for any patient engagement strategy. According to an Advocate study, 11.4 percent of patients in their ACO account for 52 percent of the costs. These are the sickest patients, many of whom have chronic diseases. They represent the ACO’s best opportunity to produce savings (profit), and Advocate and the other participants have all heavily invested in engagement and care management infrastructure to better manage these patients.

Advocate has made the boldest effort, hiring 60 nurse practitioners as outpatient care managers to support disease management across the ACO. Pioneer ACOs Genesys and Sharp expect soon to receive historical records on their ACO members from Medicare, enabling them to identify patients for referral to case management. Mining data from commercial payers may be more difficult in some cases. Hrountas said it has taken over a year to get one commercial payer to correct file format issues so Sharp can access historical claims information on their PPO ACO patients.

Ensure Social Media Informs Physicians First

All of the participants said they were using patient portals and, to some degree, social media to engage with patients. Sharp has iPhone and iPad access to its portal. Scripps monitors Facebook for trends. Huntington Hospital uses a patient portal as well as Facebook for disease management, encouraging patients to reach out to staff to get more information about chronic disease. But Huntington’s Armato cautioned that the speed of social media can work against providers.

“Our biggest fear is that the federal government or some other force around consumer engagement will put clinical information in the hands of patients before we can get it to their doctors,” she said. “We’re afraid that would cause a massive number of patients calling doctors about results out of norm but not enough to make it quickly significant. So we’ve said yes to a portal but we make sure to get the data in the hands of doctors before they notify patients.”

Patient Mobility Improves Customer Service

As we mentioned, one of the common complaints about ACOs in general and the Medicare Pioneer program in particular is that enrolled patients can elect to change providers. But according to James, that free-market approach is at the core of improving healthcare.

“Every time I hear that (argument) I’m sort of amazed that in healthcare we feel entitled to having patients locked in for a period of time regardless of the quality of our customer service,” he said. “A patient seeking care elsewhere is not by happenstance. I think not having them locked in is a good thing not a bad thing, because it forces you to look at yourself very hard in the mirror and try to analyze why patients would not use your service in individual service lines. I believe that requirement is going to make healthcare better, not worse, and arguing that it shouldn’t be there is ignoring how our marketplace works. That’s old thinking in a new delivery system.”

Conclusion: Working Together to Build a Common Culture

The participants in this paper agreed on one thing above all: Changing today’s healthcare paradigm requires ACOs to build a new, common culture that supports a value-based system of care.  This can be challenging when you’re talking about bringing together a diverse set of organizations with a history of divergent interests – multi-specialty medical groups, independent practice associations, and hospitals with a culture devoted to keeping beds full.

Create a Shared Identity and Values

In its attempt to create a culture of engaged physicians, Advocate decided to appeal to their physicians’ sense of pride, commitment to excellence and competitive spirit. They set a high bar for physician membership in Advocate Physician Partners, with over 20 requirements ranging from IT connectedness to performance. Physicians receive public recognition for quality and efficiency. Transparency plays a big role in this creation of a “membership” culture. All individual physician performance results are available for all internal providers to view and compare.

“It’s the few and the proud,” explained Shields. This exclusivity comes with the prospect of loss if expectations are not met. “Every year we remove physicians, and I’ll tell you, when you remove a doctor for performance reasons that sends a very important message.”

Appeal to Providers’ Best Instincts

In developing its Pioneer ACO, Sharp struggled for consensus among the three parties that make up the legs of its stool – the hospitals, the multi-specialty practices and the affiliated independent physicians. “We had to appeal to everyone’s interest in providing the best care to the patient,” recalled Hrountas. “It required lots of conversation and data and quelling the fear factor of the ‘what ifs.’ But the structure of our limited liability company where all three parties have equal say was one of the strong determinants to make it successful.”

Shields noted that the scale of the ACO and its focus on working as a team to provide superior care for entire populations appealed to Advocate’s physicians. “Our physicians realized they can accomplish things on a much greater scale than just their own panel,” he said.

Taken together with the participants’ insights on physicians, hospitals, payers, and patients, their comments on culture point to the significant strategic shift required of healthcare organizations that seek to create successful ACOs. It’s a change that cannot be accomplished by technology alone, by better incentives alone, or by any one of the necessary ingredients in isolation. 

As Shields put it: “Culture pretty much trumps everything else.”

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