From the Consultant’s Corner 12/6/11

Clinical Integration: The Right Time, the Right Thing to Do

“Uncertain” doesn’t even begin to describe the future of healthcare in the US. We all know that the Patient Protection and Affordable Care Act is law, but it’s facing public resistance and an upcoming Supreme Court challenge. What’s more, there’s little doubt that ongoing budget talks in Washington will bring big changes to Medicare and Medicaid. We fully expect that the push toward performance-based reimbursement will only get stronger.

Now steps the just-released Accountable Care Organization (ACO) final rule into this already-confusing swirl step. The rule reflects the comments of thousands of physicians in provider organizations across the country, and is intended to empower them to join the trend toward clinical integration.

Although ACO participation is voluntary, most of the clients we speak with are convinced that this kind of system represents the future of medicine—and not just for Medicare patients under Medicare rules. Physicians—whether rural or urban, independent, or employed—will likely climb on board with the idea simply because it’s the right thing to do for patient care. Clinical integration across patient care settings is one of the best ways to enable providers to reach out to patients to offer better, more proactive services.

Under the new ACO rules, clinical integration can be accomplished in a number of different ways. Overall, the goal is to align providers and institutions with mutual, patient-centered objectives.

Though financial integration is one part of the picture, it’s definitely subordinate to the achievement of quality care. At their core, the rules require a commitment on both sides to the concept of aligning incentives for quality care—with the understanding that cost reductions will follow improvements in quality. They also require participants to recognize the undeniable role of IT in making it all happen.

Whether they’re headed by a physician chief executive officer (CEO) or a lay CEO, and whether they involve employed physicians or independent physician partners, all ACOs should share these four key characteristics:

• Common mission, vision and values
• Mutual respect and willingness to share risk
• Focus on the patient experience
• Commitment to quality care

Fortunately, some of the historical obstacles that have barred providers from working with large healthcare systems and payers are disappearing. For example, recent regulations released by the Centers for Medicare and Medicaid Services (CMS) significantly relax federal anti-trust laws. Everything is pointing in one direction: now, more than ever, is an opportune time for clinical collaboration.

For physicians, relationships with larger organizations make sense. They allow: easier access to the expertise inherent in the clinical programs of larger organizations; greater payer contracting experience; and the ability to leverage economies of scale. And let’s not forget information technology (IT) resources, which will play a huge role in the future of population management and coordinated care.

Clearly the pressure is on for providers and other healthcare stakeholders to align their mutual interests in order to cut the waste from our fragmented healthcare delivery system. With everyone on the same team, we can redefine the current ineffective, poorly coordinated, and unnecessarily costly healthcare system.

ACOs—together with other similar initiatives like patient centered medical homes, bundled payments and outcomes-based reimbursement—will become the foundation for delivering high-quality, cost-effective patient care for everyone. Ultimately, it doesn’t really matter whether ACOs start with Medicare or not. It doesn’t really matter whether the “ACO” moniker stays or goes. The concept of clinically integrated accountable care is here to stay.

So it’s up to providers to take the lead, developing clinically integrated organizations motivated by a common goal to improve access to quality, lower-cost care for all patients.

Brad Boyd is vice president of sales and marketing for Culbert Healthcare Solutions, a professional services firm serving healthcare organizations in the areas of operations management, revenue cycle, clinical transformation, and information technology.