What would an ACO would look like if it was truly patient centered?

Health care leaders are busy talking to attorneys and consultants about how to set up Accountable Care Organizations (ACOs). A recent Advisory Board survey found that 73 per cent of hospital finance executives said that creating such an organization was a top priority for their health system.

Last year my most popular keynote topic was patient-centered medical home creation; this year everyone wants a presentation on ACOs.

However not everyone has jumped on the ACO bandwagon. Bruce Bagley, MD of the American Academy of Family Practice was recently quoted as saying, “There are probably no experts about ACOs. It’s a developing concept.” And Jeff Goldsmith, PhD, of the University of Virginia stated at the same conference: “I think this is a stupid idea. Managed care without the risk – that’s like gin and tonic without the gin. How do you end up making choices if you’re not forced to make them?”

I started thinking about what an ACO would look like if it was truly patient-centered. What if we designed an ACO that gave patients what they say they really want?

Don Berwick wrote an article in Health Affairs in 2009 that examined what patient-centered should mean, and since he became the head of Medicare in 2010 it might make sense to start there. After all, Medicare is pushing the ACO concept by creating pilot projects and encouraging the shift from fee for service payments to global payments for medical care reimbursement.

In the Health Affairs article, Berwick defined patient centered care as “They give me exactly the help I need and want exactly when and how I need and want it.” Berwick said he was ready to move beyond words like partnership and have providers become guests in the lives of their patients.

Berwick went on to imagine that really embracing patient centered care would mean having no restrictions on hospital visiting hours, inpatients choosing what food and clothes they wanted, patients participating in rounds and the design of medical services, patients really owning their medical records, and patients and doctors universally using shared decision making aids so that patients could make wise choices knowing the inevitable trade-offs involved in picking a treatment.

Such an ACO would invest heavily in patient education and self-management programs. And these presentations would go well beyond the currently offered traditional wellness curriculum.

For example, a truly patient-centered ACO would offer technology support so their patients could harness their smart phones’ computing power, audio, video, motion sensors, and GPS modules to explore new ways to self-manage their health and wellness. There are smart phone applications for fitness and weight control, diabetes management, sleep hygiene, stress reduction, and hearing and vision assistance. An ACO that partnered with their patients to fully utilize such technology could keep their clients healthier and out of the hospital. Such a strategy makes a lot of sense if your organization is accepting global payments where hospitalizations are not incentivized.

I could even imagine a truly 21st century ACO expanding their primary care team to include physicians, advanced nurse practitioners, physician assistants, and even robots and avatars. Dr. Joseph Kvedar of Harvard’s Center for Connected Health believes that we will need to embrace emotional automation and use robots and avatars to meet the manpower needs of taking care of all the retiring Baby Boomers. In a YouTube video he states that one Boston hospital has already found that hospital patients prefer a robot for discharge planning to a real life person. The robot has all the time in the world and does not make the patient feel stupid when they ask the same question over and over again.

At first, I had a hard time getting my head around this emotional automation concept, but reading MIT’s Sherry Turkle’s book Evocative Objects: Things We Think With has convinced me that humans have already formed trusting relationships with technology. “We think with the objects we love, and we love the objects we think with.” How many of us talk about love when we discuss our iPhones or iPads that have really become extensions of our brains? Admit it, do you sleep with your smart phone?

The health system that designs an ACO that is truly patient-centered will be highly successful. In addition to consulting attorneys and payment reform consultants, I would suggest that health systems think about how the new disruptive technologies (smart phones, tablet computers, avatars and robots, video games, haptics, and artificial intelligence) could be used to better manage a geographically defined population of patients.

Kent Bottles provides health care leadership consulting and blogs at Kent Bottles Private Views.

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  • Barbara Hummel

    The only thing I would add to ACOs is to include mental health services and language assistance.  Those seem to be forgotten…

  • Kia LaBracke

    Need to change the title – you have two “woulds” here! Great article.

  • Newton

    Speaking from the perspective of someone working within this supposed continuum of care between the hospital and needs of patients at home, I can imagine several very real challenges of creating an ACO that truly operates with the patient in the center. First is geography, because many of the younger patients are highly mobile and do not want their healthcare to be constained to a single health system. This brings in the issue of access to critical information within the medical record, privacy laws making this very difficult for patients and providers. Second is often a real lack of clinical expertise on the part of the patients, who often are not willing to get invested enough in their care to seek an adequate level of usable knowledge on their conditions and treatment. Western medicine has often encouraged an attitude of instant gratification, patients wanting results before and above understanding. Elderly patients still hold onto the notion of doctors as gods with powers to heal at will, and they seek that magic bullet for that purpose. The third issue that a truly patient-centered ACO faces is the all-too-often sense of entitlement patients feel over an understanding of clinical need and efficacy. When patients are pushing the buttons of busy physicians, advocating for this drug or that piece of equipment as is often the case with prescriptions today, there is a real danger of the tail wagging the dog. Physicians and other providers walk a thin line between guiding patients and being guided, the potential result of conflict being the loss of that patient to another provider. Therefore, incentives for patients to make choices that align with acceptable clinical practice must reach across the lines of geography and provider groups, so that they are as accountable for these decisions as their caregivers. None of these are necessarily insurmountable challenges, but all will be important factors for consideration in the implementation of any ACO model of care.

  • Anonymous

    Frankly, the thought of another poorly designed health care delivery model is enough to make me run screaming from the room.  Patient ownership of their own health, disease management, decision making and the related financial obligations is not a situation I envision working for the vast majority of people in this country.  Specifically in my home state of Kentucky, I see numerous socioeconomic and cultural roadblocks. How do you engage patients who don’t own the necessary technology to participate in this model?  Or who have limited ability or no interest in learning how to manage their health or with working cooperatively in partnership with a provider?  And just who is accountable to whom?  How are noncompliant patients handled?  Can they be dismissed from the ACO for nonperformance or is the ACO at fault for not properly educating and motivating patients toward expected outcomes?  How will ACOs be monitored for quality of care standards?  What are the expectations for providers and how will those be evaluated and remunerated?  Will ACOs or patients be incentivized for meeting goals?  Are those goals care-based or financial?  My own experience leads me to the conclusion that patient care and outcomes has either stagnated or worsened since the advent of HMOs into the field.  And I’m certain that no matter the outcome of this or any other care delivery model, patients and providers likely won’t be the ones celebrating large quarterly bonuses.  And I wouldn’t be surprised to find that third party payers are already planning ways to spend those windfalls.  It just won’t be on patients, doctors or services.

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