The Accountable Health Organization: Wave of the Future?

By Frederic S. Goldstein, M.S., and David B. Nash, M.D.

Reproduced from Healthcare Innovation News

The choice of words matter; they set the base and direction upon which thoughts and ideas flow forth, ultimately leading to structures and systems. One of the entrants into the healthcare lexicon is the accountable care organization (ACO). While there is much to like about ACOs and their proposed ability to improve health outcomes and efficiency while reducing unnecessary utilization and costs, there are some inherent flaws in the concept that will keep ACOs from achieving the results needed to create a sustainable healthcare system in the United States.

These flaws arise from the name and extend through the operational focus of ACOs. To better meet the goals of quality, costs and improved health outcomes requires a new organization with a broader constituency and a name that does not limit its structure to focusing on “care.” An expanded organization, an “accountable health organization (AHO),” would include the consumer as a central focus and extend well beyond the walls of the health system and the provision of care.

The Fundamentals of ACOs

With the passage of the Patient Protection and Affordable Care Act (PPACA), physicians, hospitals, health plans and even large employers are rapidly embracing ACOs as one of the newest approach to saving the healthcare system. They are meant to improve the coordination of care from within the system in order to improve health outcomes and reduce costs.

Kelly Devers and Robert Berenson (1) in their seminal paper1 proposed that an ACO should have the following three essential characteristics:

  • The ability to provide, and manage with patients, the continuum of care across different institutional settings, including at least ambulatory and inpatient hospital care and possibly post-acute care.
  • The capability of prospectively planning budgets and resource needs.
  • Sufficient size to support comprehensive, valid and reliable performance measurement.

While the ACO may be a fairly new name on the healthcare landscape, the concept is not that different from other structural approaches, such as physician/hospital organizations that were all the rage a few years ago. Many of these organizations accepted full risk or capitated contracts and were therefore accountable for the costs of the population they were managing.

The thinking behind the concept was that these models would ensure the efficient and appropriate utilization of services, resulting in lower costs and therefore a viable organization. Many of these organizations failed as they discovered that they were unable to manage the health cost risk.

As seen throughout the history of health reform, the vast majority of efforts have focused on the provider side and look at care and costs. Given the enormity of healthcare and the vast dollars, one would think that focusing on the supply side would make sense. There is much that can be done to fix the faults of fee-for-service medicine—inappropriate service delivery, fraud, tort reform and other areas. But this continual focus leaves out a basic but undeniably critical piece—the patient.

The Hippocratic oath includes these two lines: “I will prevent disease whenever I can, for prevention is preferable to cure.

“I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.”

As healthcare has evolved in the United States it has focused on illness; one enters the system for the most part when ill and that illness requires some sort of treatment. Then the person leaves the system to return to his or her community.

The problem with this approach is that patients and their interactions outside of the healthcare system have much to do with creating or degrading health. In fact, the major healthcare cost driver of the past two decades resulting from this behavior has been the increasing prevalence of chronic diseases, such as cardiovascular disease and diabetes, among others.

The Centers for Disease and Control estimates that 80% of cardiovascular disease, 80% of diabetes and 40% of cancers are preventable. The majority of these illnesses are the result of lifestyle, little impacted by the care system.

How will the three essential characteristics of an ACO have much of an impact on an individual’s health in places like the Mississippi Delta, where lifestyle and the community play such a huge role? Will ACOs prevent the growing incidence of diabetes, heart disease or obesity, or will they merely “care” for these conditions more effectively after they have occurred?

A Logical Expansion

True success in the United States will not come from an ACO, which places an overwhelming majority of its efforts on the provider system and the care they provide, but rather from an AHO that includes the patient and the broader community as an active and necessary partner in the structure, management and indeed financial rewards and penalties required to make this work.

How might an AHO take the basic structure of an ACO and integrate the patient into the process? There are tools that have been available for years in the population health management arena that should become a central component of the AHO model.

To be successful, the AHO must not only manage care efficiently, but it must also engage those that currently have little or no need for the “care” system of an ACO, except possibly for secondary prevention. These efforts are needed to reduce the incidence of preventable diseases such as diabetes, cardiac disease and the like.

An AHO will require the integration of two additional components: the patient and their communities. This new model will:

 

  • Seek to improve the health of all members, whether they have a current condition or not.
  • Use population based tools, such as health risk appraisals to adequately understand the health risks, as well as the health conditions or medical acuity of the population.
  • Place the patient at the center of the focus.
    • Assign appropriate accountability to the patient.
    • Provide incentives and shared savings if achieved.
  • Provide services of primary, secondary and tertiary prevention that go beyond those services provided by or within the healthcare system
  • Include the broader community in the planning and operations of the AHO to look at:
    • gaps in community services that lead to better health and
    • nutritional issues, such as access to healthy foods, school programs and the prevalence of unhealthy, fast foods, opportunities for exercise and physical activity.
  • Work with local and state governments to develop appropriate policies for the creation of health within a community.
  • Develop broader teams that include those from within the healthcare system, as well as those in the community.

 

ACOs may be a step in the right direction, but from their name, they are not focused correctly to truly impact a population and foster health at a population level. AHOs, which more deeply integrate the patient and their communities, combined with a “health” focus of comprehensive primary, secondary and tertiary prevention programs are the way to improve the health of all and thereby reduce the growing incidence of preventable chronic diseases and health expenditures.

 

(1) Devers KJ, Berenson RA. “Can Accountable Care Organizations Improve the Value of Health Care by Solving the Cost and Quality Quandaries?” Robert Wood Johnson Foundation and The Urban Institute. Oct. 1, 2009.

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Frederic S. Goldstein is president/founder of Accountable Health, LLC, and chair of the Board of Directors, Population Health Alliance in Washington, D.C. His email is fgoldstein@accountablehealthllc.com.

David Nash, M.D., is dean of Jefferson School of Population Health, Thomas Jefferson University, Philadelphia. He can be reached at david.nash@jefferson.edu.

 

 

 

 

Engagement, what was that again…and how do I know it when I see it?

By Fred Goldstein, PHA Executive Director 

Engagement has been on the spotlight for a while. In this new economy and ecology of companies invested in getting their clients to interact directly and constantly with the organizations and among themselves using various platforms, measuring engagement has become the angular rock of business. It has also become ever more elusive. Vanity measures – followers, likes – are no longer enough, and neither investors not customers are fooled by them.

If you are in the health care world, as I am, you know that engagement is paramount. You also know you would like to be able to define it, measure it, understand it, and figure out how it translates into better outcomes for your patients and employees.

It seems as if every organization reports on engagement in a different way, and the time for standardized metrics and homogenous methods has come. In order to define engagement, members of the Population Health Alliance have created a Workgroup on Engagement as part of the work of PHA’s Quality and Research Committee.

They are very happy to hear and receive continuous feedback from the organizations involved in worksite wellness, population health management, and others who are make strides to get engagement right. Get involved by contacting Karen Moseley, PHA Research Director, kmoseley@populationhealthalliance.org or just email me.

For PHA, 2014 is truly the year of engagement.

-       The theme of the annual conference, PHA Forum 2014, is Collaborate + Communicate = Engage.

-       Excelling in Engagement, an educational track at PHA Forum 2014, gathers presentations that discuss in depth engagement as an overall theme, including provider, engagement, health plan member engagement, incentive program design, and engaging the moderate risk population.

-       Engagement again! So, how do we do it?is the title of one of PHA Forum 2014 Walking Learning Labs of the Exhibit Hall, in which organizations will provide hands on demonstrations of how engagement works in real life.

Learn more about the PHA Workgroup on Engagement’s Charge.

PHA Executive Director catches up with the Population Health News Readers

Fred Goldstein, the Executive Director of the Population Health Alliance, serves as founder and president of Accountable Health LLC, in Jacksonville, Fla., which helps healthcare organizations implement health management programs and provides tools and techniques to engage patients and improve adherence, outcomes and control costs.

He combines his multidisciplinary experience—hospital administrator, general manager of an HMO, founder of a disease management company and president of a population health management company—to address healthcare issues, from operations and mHealth to product and network development.

Population Health News: What was the thought process in moving from a B.A. degree in zoology to an M.S. degree in healthcare administration?

Fred Goldstein: My father was a professor of medicine, but I was never interested in being a doctor. From a young age, the dream was to do shark research, à la Jacques Cousteau. In college during a summer internship at Mote Marine Labs in Florida, I discovered that funding for shark research had dried up so I finished up my degree in zoology and began looking at an MBA. Discussions with my father and others led me to combining science knowledge from the zoology degree with the business background in healthcare to make a difference.

 

Read Entire Interview: Catching Up With Fred Goldstein 

The Wait Is Over: PHA and HERO Release Core Metrics for Employee Health Management

For the past two years, PHA has partnered with Health Enhancement Research Organization (HERO) to identify and recommend measures and standards for the assessment of employee health management programs for the employer community.

The employer dashboard covers 7 domains: organizational support, health impact, participation, satisfaction, financial outcomes, productivity and performance, and value on investment. The recommendations have been reviewed by several subject matter experts and are currently under review by stakeholder organizations and public comment.

Read the Program Measurement Evaluation Guide: Core Metrics for Employee Health Management (Executive Summary)

Read the Program Measurement and Evaluation Guide: Core Metrics for Employee Health (Handout)

PHA Forum Logo Final-01Why PHM in the workplace is the new black?

A discussion and in-depth presentation of the core metrics for employee health management and the work of PHA and HERO will be a centerpiece of the Workplace Healthcare and Benefits Institute at the PHA Forum 2014.

Population Health Management (PHM) is changing workplace wellness for the better. The Workplace Healthcare and Benefits Institute, a preconference event of the PHA Forum 2014, will provide HR and benefits managers and employers across the spectrum a solid basis to assess their wellness programs, as well as, for newcomers a review of core metrics, engagement strategies, and comparison of emerging and existing trends in wellness, incentives and more.

Check PHA Forum 2014 Schedule of Events

Register for PHA Forum 2014

 

Want to Contribute to the Industry’s Discussion on Value on Investment?

By Michael Connor, Dr.P.H., Senior Vice President, Alere Health and Bruce Sherman, MD, Medical Director, Employers Health Coalition

The Population Health Alliance (PHA) Quality & Research Committee has identified Value on Investment (VOI) as a key initiative for this year. The goal of this work group is to empower purchasers of population health management (PHM) programs to adopt a comprehensive value proposition, which more broadly captures the business impact beyond healthcare costs.  Initial objectives include defining the scope of the VOI construct and determining a compelling rationale that is embraced by PHM purchasers.

The Health Enhancement Research Organization (HERO) and PHA led a collaborative effort to develop guidelines related to value domains and corresponding core metrics. The VOI model encompasses all of these domains as outputs as well as a broad view of investment or inputs beyond program vendor fees and incentive costs.

The domains are organizational support, participation, health impact, productivity and performance, financial savings and satisfaction. The Organizational Support domain addresses the degree to which an organization commits to the health and well-being of its employees. Participation recommends measures and definitions related to meaningful program interventions. The Health Impact domain covers measures associated with preventable health conditions.  The Productivity and Performance domain provides an employee continuum ranging from absenteeism through optimal performance at work. Financial Health Care Savings incorporates claims data and modeling estimates.  Satisfaction addresses participant and provider perspectives.

Initial reactions have been very positive related to both the domains and the VOI approach. Most stakeholders are intrigued with the concept, and some have enthusiastically volunteered to pilot the process. Others have suggested the need to develop a more compelling business case to discuss with purchasers.  There are clearly data implications related to a broader set of outcome measures beyond the more traditional and narrower focus of financial health care savings.

Work group discussions have questioned whether organizational support is an outcome or rather an input within the VOI framework. Additional considerations have raised the need for a greater focus on participant program engagement as well as assessing program impact on employee engagement at work and other business outcomes.

So what are your thoughts regarding …

  1. What are the barriers to a purchaser acceptance of a broader value proposition and how these can be addressed?
  2. What practical measures and methodologies best assess value components and will be readily adopted?
  3. How do the value domains align with purchasers’ (employers, health plans and government) strategic priorities?

Comment here or email us your thoughts at kmoseley@populationhealthalliance.org

 

DEADLINE EXTENDED for PHA Forum 2014 International Symposium Call for Papers – May 15

The Population Health Alliance has extended the Call for Proposals for the 4th International Symposium of Wellness and Chronic Care to be held at the PHA Forum 2014, December 10-12, in Scottsdale, Arizona. The theme is Collaborate + Communicate = Engage with a focus on best practices, outcomes and replicability of findings.  Find out more about PHA Forum 2014
 
This year, the call for proposals is very different… and exciting. Begin your abstract submission.
 
The International Symposium on Wellness & Chronic Care, held in conjunction with the PHA Forum, will facilitate a comprehensive exchange of information on wellness, prevention, chronic condition management and other population health strategies from around the globe. The primary presenter must live and work full time outside of the United States; proposals without an international representative will not be considered.
 
All abstracts must be submitted online through the PHA Forum 2014, by the EXTENDED DEADLINE, May 15, 2014. 
 
You do not need to be a PHA member to submit a proposal. 
 

Interview with PHA Executive Director: From CCA to the Population Health Alliance

Fred Goldstein, interim Executive Director of the Population Health Alliance was interviewed at the HIMSS 2014 conference, in Orlando, about the re-branding of the Care Continuum Alliance to the Population Health Alliance, the association’s research and advocacy priorities, and the annual conference, PHA Forum 2014.

Worth watching:

PHA Forum Logo Final-01

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