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How digital technologies can address 5 sources of health inequity. Discover What is the World Economic Forum doing to accelerate value-based health care? Show more. Primary data collected through site visits to four private sector ACO s.
The importance of shifting organizational culture from volume to value was emphasized across sites and interviewees, particularly when defining an ACO ; describing the shift in organizational focus to value; and discussing how to create value by emphasizing quality over volume. Value was viewed as more than cost—benefit, but rather encapsulated a paradigmatic cultural change in the way care is provided. We found that moving from volume to value is central to the culture change required of an ACO.
These policies have spurred a significant health care delivery reform, yet substantial progress in achieving the triple aim of better quality, lower cost, and improved population health remains elusive Keehan et al. Accountable care organizations ACOs serve as a prime example of the difficulty in creating significant change. ACOs have proliferated, and over Medicare, Medicaid, and private sector ACOs now cover over 32 million lives, making them one of the largest efforts to reshape delivery systems Muhlestein, Saunders, and McClellan However, evidence remains mixed about the success of this strategy in delivering higher value care McWilliams et al.
The evidence on private sector ACOs is less clear, but a recent comparison to the Medicare ACOs shows that they are more successful with cost and quality improvements Lewis et al. Overcoming these barriers is critical for an ACO to be successful; yet examining each issue in isolation may miss the broad cultural change being pursued as organizations implement the ACO model. Consideration in the academic literature of the overarching transformation necessary for the ACO model generally focuses on operational change management, with culture change as a side note Burns and Pauly ; Larson et al.
This paper thus aims to move beyond the current research that explains how ACOs can succeed with operational changes and explores important considerations about the concomitant cultural changes necessary to be successful.
The evidence we present will be useful for ACOs attempting to advance the new delivery model within their organizations. Because the definition of an ACO or ACO contract in the private sector is not as well defined as a Medicare ACO, we identified key eligibility criteria that organizations in our study had to meet in order to be considered an ACO and participate in the study.
Second, the organization had to assume responsibility for both cost and quality of a defined population. Third, the contracts had to assume some level of downside financial risk, that is, penalties in addition to shared savings.
Our study ACOs differed along several dimensions: geography, organizational age, and populations served pediatric vs. Information about our study sites is included below. Additionally, a sister publication from the parent study includes a table with more details about each site McAlearney, Hilligoss, and Song The ACO is associated with Advocate Health Care system—a large regional health system—and has global capitation arrangements with multiple commercial payers and serves a patient panel of , through commercial plans and , through Medicare Advantage.
The Children's Mercy Pediatric Care Network PCN , launched in , is an integrated delivery network comprised of Children's Mercy Hospitals and Clinics, employed physicians, community pediatricians, and other health care providers in the greater Kansas City area. Data were collected from each ACO through a combination of key informant interviews, document collection, and review. We then worked with a contact person at each ACO to identify the most appropriate individuals to interview.
Across the sites and visits we interviewed a total of 89 individual informants, 51 administrative i. No informant approached for this study refused to participate. We used two standard guides available upon request to conduct interviews to ensure consistency in data collection.
One version was tailored for administrative interviewees and another for clinical interviewees. As our original study was designed to improve understanding of private sector ACO development, the interview guide domains covered history, implementation, consumer involvement, population impact, quality and cost measures, and challenges and facilitators of ACO development.
There were no specific questions about the shift from volume to value. Interviews lasted 30—60 minutes, depending on the key informant interviewed. The vast majority of our interviews were conducted in person during site visits. All interviews were recorded and transcribed verbatim to permit rigorous data analyses. Throughout the analysis process, we used an iterative approach that involved reading interview transcripts, reviewing the literature, and discussing findings among investigators as the study progressed.
With the original study data, a coding team, established by the lead investigator, first created a preliminary coding dictionary defining broad categories of findings from the transcripts.
Coders met periodically throughout the coding process to ensure consistency and review any new codes or themes that emerged, consistent with a grounded theory approach Glaser and Strauss We used the Atlas. Although it was neither a question domain, nor a focus of the study, the concept of shifting the organization's culture from volume to value was mentioned across sites and interviewees.
For the ACOs we studied, the importance of shifting from volume to value was emphasized across sites and interviewees, and this was evident in three areas in particular: 1 using the concept of value to define an ACO ; 2 describing the need to shift organizational focus from volume to value; and 3 noting that creating value requires an emphasis on quality and not volume.
Below we describe each of these areas of emphasis further, and we provide additional evidence showing the importance of this volume to value shift in Table 2. First, a variety of interviewees defined an ACO in the context of delivering value. It's kind of like the Triple Aim all over again. Second, a commonly mentioned goal for each of these ACOs involved an attempt to shift organizational focus from volume to value. And … that takes moving the ship, which is already what we've been doing with the PCN [primary care network].
So it's enough that people are really paying attention … and then we'll be moving to 15 percent next year …. Third, interviewees noted that creating value requires an emphasis on quality and efficiency, with volume only relevant to the extent that it affects cost.
And when we can do it at a lower cost. So it's really all about that paradigm: higher quality at a lower cost, and that's what I think an ACO is really striving to achieve. Across the ACOs studied, explaining how the goal of value is being achieved was an important topic of many interviews. We next describe these themes, with additional supporting comments provided in Table 3. So we're kind of having to turn that switch on, and the medical system and the provider is too, you know.
That's our job! We're accountable for them. That's what this is all about. In the old world, the patient shows up in the emergency room because they can't make it to the dialysis center because they don't have cab money.
And they get admitted. In the new world, we pay for the cab fare, arrange for ongoing transportation. So right care, dialysis center, right?
Right time schedule, you know, right place: … outpatient versus inpatient. You know, it's all, but only, the necessary care to drive the best health outcomes. The next mechanism enabling a shift to value involved focusing on population health management PHM for a patient panel. We are managing the overall health and wellness of individuals. PHM efforts directed toward the patient panel included wellness registries, gaps in care analyses, and care coordination outreach see Hefner et al.
Finally, each of the ACOs studied noted specific efforts to engage physicians as a critical part of their mission to shift to a focus on value. Below we explain each of these issues in greater detail, and we provide additional evidence about these challenges and potential solutions ACOs are pursuing in Table 4.
As one executive explained,. People buying insurance need to have a choice. That they're joining a closed panel like an ACO. We believe they need to have a choice, not just be attributed by government, and now being attributed by their commercial carrier.
Because they come into the exam room, the physician can be their advocate to guide them through the scary system and give them to our preferred specialist panel and everything. But they don't have to come to us, because they're not selecting a primary care in their products. You know, it's not just a gatekeeper to find out where you're sending someone.
It's a gatekeeper on making sure they're getting all of the care, the kids are getting the care that they need to be healthy in their communities. You're sort of forced to really collaborate and make sure. You're looking at the patient from physician practice, hospital, SNF [skilled nursing facility], transition of care, home health. The issue of retrospective review was a second common challenge noted. So that makes it a little tough. If you make a change, you're not sure whether it made a difference or not.
For instance, by creating reports with metrics that could be obtained in near real time, ACOs were reportedly improving their ability to manage the health of their populations. Given the aforementioned issues with attribution, interviewees noted that patients did not typically understand that they were part of an ACO.
If you go to some other hospital, where I'm not on staff, I don't know that. So the time to educate is now, before they need to go to the emergency room.
Calling patients. Making patients aware of the existence and role of the ACO may be the solution to the challenge of a lack of patient understanding, and a critical step on the pathway toward patient engagement.
The concept of a culture shift from volume to value has supported several health policy initiatives, including the development of ACOs, yet research to date has overlooked how ACOs interpret and translate this concept to support culture change.
Rather, investigators have focused more on contractual, implementation, and performance issues. Similarly, in our larger parent study, we questioned ACOs about topics such as implementation, quality and cost metrics, and challenges and facilitators of ACO development. Thus, it became clear that this emergent issue required further analysis.
Based on our research, we purpose that this ultimate objective for ACOs is to shift organizational culture from volume to value. If the ultimate objective is in fact to shift from volume to value, culture change throughout the ACO is necessary to support the sustainability of the ACO model and other future delivery models rewarding value rather than volume. Viewing the ACO narrowly as a new payment plan ignores the concurrent shift that benefits consumers and helps to ensure a sustainable competitive advantage for ACOs Macfarlane This study adds to the current understanding of previously identified operational factors i.
Interestingly, though not asked specifically about this shift, it was repeatedly discussed by interviewees who held a variety of jobs and also across diverse ACO sites.
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|What are changes happeing in healthcare that will change value for volume||You're looking at the patient from physician practice, hospital, SNF [skilled nursing facility], transition of care, home health. Indeed, quality of care remains variable across health care settings with ongoing unnecessary utilization, low rates of compliance with recommended care, and inequities in health and health care. By Shubham Singhal and Neha Patel. By MarchAnthem will stop paying for MRI and CT scans performed in hospital settings in 13 states unless they are medically necessary. Patients with low back pain call one central phone number SPINE read article, and most can be seen the same day. Disappointment with their limited impact has created skepticism that value improvement in health care is possible and has led many to conclude that the only solution to our financial challenges in health care is to ration services click to see more shift costs to patients or taxpayers. Those with serious causes of back pain such as a malignancy or an infection are quickly identified and enter a process designed to address the specific diagnosis.|
|What are changes happeing in healthcare that will change value for volume||So we're kind of having to turn that switch on, and the medical system and the provider is too, you know. The range of outcomes measured remains limited, but the Clinic is expanding its efforts, and other organizations are following suit. Specifically, we can compare how culture is changing in private and public sector ACOs, and potentially link this evolution to changes in care delivery and outcomes. The program is in its infancy, but visit web page are that Hppeing and other large employers healthacre expand such programs to improve value for their employees, and will step up the incentives for employees to use them. The vast majority of our interviews were conducted in person during site visits. At the individual IPU level, numerous providers are beginning efforts. Simply co-locating staff in the same building, or putting up a sign announcing a Center of Excellence or an Institute, will have little impact.|
Adding to the challenge of moving from volume to value is the fact that these laws often overlap one another, yet have different interpretations, centers of authority, and requirements. Stakeholders have often thought to reform one law without addressing the interplay of these requirements.
Too often providers are confused or concerned about the consequences, resulting in undermining the rapid and permanent move to a value-based system. To address these issues, we need new value-based exceptions and safe-harbors to more clearly promote the rapid transition from the fee-for-service environment to a value-based model.
New care models — where all contributors to health care can share accountability for achieving clinical outcomes and share responsibility for the total cost of care for a patient or population — should be encouraged. Stark and anti-kickback laws are a remnant of the fee-for-service world and harm the very patients they are supposed to protect by deterring more comprehensive patient-centered, coordinated care.
While well intentioned, these laws have not been sufficiently updated to reflect the transformation in health care payment and delivery or account for the rapid emergence of new treatments and innovative technologies.
In addition, changes should consider incorporating new technologies into value-based arrangements. These laws need to recognize that services might be bundled with a product to more effectively address costs and quality.
However, while progress is being made, we are still far from achieving our goal. We need a combination of legislation to provide greater clarity and to make exceptions permanent, and to revisit regulations, safe harbors, exceptions and guidance to allow for holistic value-based solutions, more explicitly recognize new reimbursement models such as accountable care organizations, as well as better acknowledge how medical technologies and pharmaceuticals aid in the move from volume to value.
The goal of better patient care while reducing health inflation is a shared mission. To assist in continuing the progress that has been made, CMS recently released a formal Request for Information RFI , calling for ideas on Stark reform, and in a recent speech HHS Secretary Azar said a similar request related to anti-kickback reform would soon follow. We were also pleased to see the House Ways and Means Committee announce that it will hold a hearing soon on the issue of Stark reform.
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