Potential Mistakes Line Path to ACO Implementation

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Whether allying themselves with the Centers for Medicare and Medicaid Services (CMS) or working with private payors, entities may, when attempting to form accountable care organizations (ACOs), make errors that impede
the success of their endeavors, write two health care policy experts.

In an article published earlier this month in the Journal of the American Medical Association (JAMA), Sara Singer, PhD, MBA; and Stephen Shortell, PhD, MPH, MBA, list 10 mistakes entities may make when forming accountable care organizations (ACOs) and describe strategies that must be implemented if organizations are to benefit from ACO participation. Singer serves as Assistant Professor of Health Care Management & Policy in the Department of Health Policy and Management of the Harvard School of Public Health, Harvard University. Shortell is Dean of the School of Public Health at the University of California, Berkeley.

Four common errors, Singer and Shortell say, comprise over-estimation of ability in the areas of risk management, electronic health record (EHR) utilization, the reporting of performance measures, and the implementation of standardized care management protocols.

Six additional areas center on failure to balance the interests of hospitals, primary care physicians, and specialists in creating governance and management processes to adjudicate differences; sufficiently engage patients in self-care management and self-determination; form contractual relationships with the most cost-effective specialists; navigate the new regulatory and legal environment; integrate beyond the structural level; and/or recognize the interdependencies and therefore the potential cumulative "race to the bottom" of the other nine mistakes cited.
Effective EHR utilization, according to Singer and Shortell, can be hampered by inadequate training and support from clinicians; disruption of practices during the early phase of implementation; and incompatibility of hospital and ambulatory-care systems. They claim the experience of pay-for-performance programs shows the difficulty of collecting, reporting, and analyzing performance data, but predict that this reporting capability will gradually evolve over time.

Moreover, the authors assert that the failure to achieve clinical integration could prove to be a death knell for some ACOs. They say health IT will be needed to map out processes of care and generate feedback on how the changes in care delivery are working.

While strategies for addressing each of these potential mistakes do exist, they are unlikely to be universally “generalizable”, the authors assert. Rather, they note, solutions will need to be adapted to local contexts and experience. For this to occur, organizations will require robust learning systems to help them avoid potential errors, learn from those that occur as quickly as possible to take corrective action, and anticipate future challenges.

Here, "two factors will be key,” Singer and Shortell write. Collective leadership by the Centers for Medicare and Medicaid Management (CMS), private payors, hospitals, physicians, and other health professionals to promote learning systems is one such factor; development of a mature performance measurement system to provide rapid feedback about what works in different local environments comprises the other.

“What is not measured cannot be managed, but what is measured must still be managed,” the authors conclude. “Management and measurement hold the keys to ACO success or failure.”
To read the abstract of the article or download the full text, click here: http://jama.ama-assn.org/content/early/2011/08/05/jama.2011.1180.full