My wish list for a perfect ACO

If you believe what most people are saying about health care reform and future practice models, you or your physician, will soon be part of an accountable care organization (ACO).

Health policy experts tell us that as physicians, we’ll be embarking on a wonderful journey that bears no resemblance to the HMO/managed care heyday of the early 1990s.  Of course, there’ll be similarities, like limited networks, top down implementation of health protocols, and the assumption of financial risk for the health of your entire patient panel.  But don’t worry, the acronyms are completely different.

For those of us who are still skeptical, we ask: if there are increased financial risks for joining an ACO, what then are the rewards?  What would make me, as a physician, excited about joining an ACO (or choose one ACO over another)?  Some say we’ll have no choice to join, but I can’t help but offer a “wish list” of things my new ACO can offer to sweeten the deal:

1.  No more paperwork. Do we really need to be spending our time doing disability forms, DMV paperwork, or prior authorizations?  The appropriate staffing should be in place to make sure doctors spend less time on paperwork, and more time on coordinating care.

2.  Immediate curbside consults. I want to press a button on my computer screen, and have a cardiologist pop up instantly so I can run by a clinical question with the patient still in the room.  No appointment needed.  Good for patient, good for doctor.

3.  Binding arbitration. This is a tough one, but because we’ll be explicitly rationing care based on protocols, guidelines, and community standards, we need some process in place to protect us and our patients when those protocols fail.  Kaiser has successfully implemented binding arbitration within their system, and it might be beneficial to follow their example. Binding arbitration can lead to quicker resolution (and settlements) for both patient and doctor.

4.  Access to pain management, disability evaluation, counseling, nutrition. Our patients should have access to everything that can get them better sooner.  These services are essential for good care.

5.  A great EMR. Obvious.  The less I spend on clicking and entering, the more patients I can see/email/call.  Which brings me to …

6.  Medical scribes. Think about how much time physicians spend on documentation.  Now imagine someone else doing it.  I want a medical scribe.

7.  Emailing patients. We need dedicated time to email patients.  If your ACO doesn’t want to spend money on having them come in for a visit, they sure as heck better have a good email system in place to communicate with patients. Oh, and I want a scribe to transcribe my emails.

8.  Physician unions. Since many physicians will be salaried employees under ACO/hospital arrangements, it’s only fair that we start to unionize as our colleagues in the nursing profession have done.  This should help mitigate concerns about compensation that will undoubtedly arise.

9.  Adherence coordinators. There should be a whole department dedicated to following up on labs, imaging, and making sure that people get their chronic disease labs and cancer screenings.  It shouldn’t be left solely to the physician to remember the countless things their patients need; we tried that system and it doesn’t work.  This is a team game now, and physicians need all the help they can get.

I like to think this is a pretty realistic list.  I’m not asking for an EMR that can read our minds, or to make a million dollars a year.  I just want to make sure we’re getting something for the loss of autonomy, the limited referral network and the additional assumption of risk.

I still want to have a meaningful connection with my patients.  I want them to be healthy and happy, and have access to affordable, quality care.  I know physicians have a hard time asking for help,  but if we’re going to jump on board this grand ACO experiment, we better be vocal about the tools and resources we’ll need to take care of our patients.

Keegan Duchicela is a family physician who blogs at Primary Care Next.

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  • rswmd

    ACOs are not about better medical care.

    They are about increasing market share to the point that they can demand higher fee schedules from insurers.

    Your list is great, but completely irrelevant.

  • NurseBob

    I couldn’t agree more with your wish list. As an RN with a very large HMO running a “best in show” EMR, I cringe every time I have to read about, or document patient encounters. That, coupled with how much data is still on paper (due both to old habits as well as regulation), leads to situations that manage to suck valuable time out of the day, and particularly, away from productive time with patients.
    Adherence Coordinators: While it’s not a perfect solution, systems integration of the lab and pharmacy with a well-conceived and managed EMR, can participate in keeping both providers and patients better informed and “in the loop” when it comes to maintenance, screenings, and important lab values.

    Time is always of the essence: Both top-notch scribes and time to email responses should be top priorities.

    Instant Consult: Why not??? I can skype to almost anyone I need to talk with, so why can’t a “world class” HMO offer that consulting Cardiologist on-call? Seems reasonable to me.

    Paperwork: When I participated for six months as an RN trainer for an inpatient EMR, we were told that the computerized system was not intended to be “paperless” but “less paper.” For the inpatient side, while the user interface is a nightmare for RNs, I have to admit, the min-chart is now only a few pages; no more three-inch thick chart that have to be thinned.

    Prior to entering Nursing several years ago, I was a software engineer for 15+ years. I had such high hopes when I heard our company was going to computerize the entire hospital, which were dashed when I saw what we were being saddled with. In truth, there are many benefits to the implemented system, but I know from experience, and from my own anecdotal surveys in the ICU and on the floor, charting on the patient takes longer now.
    Who loses? The patient!

  • http://twitter.com/glevin1 Gary Levin MD

    ACOs are not about patient care. They are another intrusion into the doctor-patient relationship. tIt will take at least several years for them to become functional and then more to develop statistics which may or may not be meaningful. How are hospitals and doctors going to serve competing and multiple ACOs? Are you telling us that if an ACO in Cleveland is better based on some statistics, patients and insurers and/or medicare will send patients from Cinncinatti? Someone is not firing on all their cylinders here.

    • http://primarycarenext.blogspot.com/ Keegan Duchicela, MD

      “Are you telling us that if an ACO in Cleveland is better based on some statistics, patients and insurers and/or medicare will send patients from Cinncinatti?” Not really.

      I think Closecall hit the nail on the head: I was looking at it from the perspective of a private physician or new residency grad who was actively being sought by these newly formed ACOs(many of them spearheaded by hospitals).

      In my geographic area, we have about 3-4 different entities actively looking to form ACO-like organizations, including a local academic institution and a handful of hospitals and their associated non-profit foundations. There is healthy competition for our family medicine graduates. That’s a good thing.

      The point being: Where physicians have a choice among whom to affiliate themselves with, they should pick the setup that gives them the best tools to succeed… and hopefully improved job satisfaction.
      Thanks for the comment.

      • rswmd

        If you have competing ACOs in your area, eventually some will be winners and some losers. Docs are just overhead to the suits, and, if your ACO is losing, they’ll start cutting expenses. Doctors will be fired, left with nothing but a non-compete clause.

        Just be careful. I don’t think the future looks too bright for doctors who tie themselves to an ACO. There are many risks.

  • DavidBehar

    “Accountable” is lawyer code for “cheap,” but mostly for “controlled by lawyers.” Violence in the defense of clinical care is the sole recourse, since the lawyer controls the three branches of government, and there is no legal recourse.

  • Close Call

    Disregard the obvious about ACOs and their ability to demand higher fee schedules from insurers. Of course that’s going to happen.

    The author’s point is that because hospital “foundations” are itching to buy up physician practices to expand their referral base, a physician might have more than one ACO to choose to affiliate with (and the same goes for new residency grads). Especially in areas with more than one hospital.

    Will the newly minted FM grad choose the ACO that gives them the tools to survive (or at least make their life a tiny bit easier)… like webvisits, scribes, and binding arbitration? Or will they choose one with a crappy EMR, uncompensated email time and no protection for the physician? This is something doctors need to start thinking about. We have no right to complain about our working conditions if we are unable define what constitues our ideal working conditions.

    And this is a pretty good list, regardless if you work in an ACO or not.

  • lissmth

    The biggest advantage for physicians will be the potential boom in the concierge market. As a medical care consumer, I’d never be forced into an ACO. ACOs are nothing more than capitated HMOs on steroids. We all saw how well they did.

  • http://twitter.com/macobgyn MacArthur Obgyn

    Easy solution. Don’t join and dont believe the hype.

  • IntMed2.0

    As someone who has worked in academic, small group practice, and now in a large group practice setting (Kaiser Permanente) I can honestly say that though I am not sure the ACO model will create the best care across the nation across all markets (That is up to the execution) the ACO model itself, as it is based off the intergrated/prepaid model used by KP for decades, does work. I have never seen populations as well as individuals get care as consistently as when I have joined KP 2 years ago. In terms of the writer’s “wish list”, here is my commentary:

    1. No more paperwork. All paperwork including disability forms, DMV paperwork, or letters are directed by my staff to my medical secretaries of my medical center. They have access to my EMR and if I have logged a basic disability form – they fill in everything else and are expert enough to peruse my electronic notes to fill in 95% of the forms. They get sent to me to sign. They are logged and tracked so nothing is lost — or if it is, it can easily by found. They also will write draft letters for me and for patients that I can review and edit to where I am ok signing them.

    2. Immediate curbside consults. We have both “econsult” where we can directly send a request for patient to be seen, “tconsult” where we can setup a telephone appt with a specialist to call the patient (for example routine low back pain, but they demand a 2nd opinion, if they have imaging and no red flags, the specialist can review the imaging and symptoms over phone or webex and schedule an in person eval prn). We have “pconsult” where I can, with the patient in the room or even later after I receive a followup email from them, call a specialist who is available 8:30am to 5:30pm and the designated specialist carrying a special phone will answer immediately 95% of the time, unless they are already on a call. Then they will call back. I had a patient show up in my office with painless jaundice. I spoke to the GI specialist immediately, had a RUQ u/s and lab done in 2 hours, appt with GI the next day, EUS done in 1 week, and he was in the OR for a whipple 2 weeks after seeing me — the hold up only being the meeting with the surgeon and the OR schedule.
    3. Binding arbitration. Not sure we have binding arbitration, but we have arbitration.

    4. Access to pain management, disability evaluation, counseling, nutrition.
    We have multiple case management chronic pain programs as well as auxillary emotional/physical conditioning programs. We have a narcotic harm reduction pharmacist and team that educates each patient who is given a new narcotic about harms and benefits, and if they hit a certain threshold of daily dose or duration of treatment, there is a whole other set of protocols and education that kicks in to help them manage pain while minimizing drug effects from narcotics and other scheduled drugs. We have electronic DME that has a concierge function where a DME nurse will order anything I or patient needs — I just need to fill in a blank online form – they deal with the formulary and specific orders if I want them to. We have the largest and health education departments of any organization I know of. Every medical center has a chief of patient education and a fully staffed dept that runs emotional, physical, lifestyle support and internvention classes and services.

    5. A great EMR. Epic is world class and now being adopted by Partners in Boston, UCSF etc. KP basically made Epic the most succesful and deployable enterprise EMR that exists and is integrated with PACS, eprescrbing. I can be in San Francisco and if a patient is in Fresno and smashes their foot with a brick, I can order and xray and ibuprofen/vicodin and they can walk into an xray/pharmacy in 60 seconds and get an on demand xray, pickup meds, In 1 hr the xray is read and the result sent to me and if not fracture I can email him the report and tell him to RICE it up.

    6. Medical scribes. Still have to type. No magic there.

    7. Emailing patients. Epic and we have hundreds of macro phrases that can be used for common patient emails. If I’ve types the same email twice, it goes into my macro list and I never have to type that email again (for example, pro/cons of bisphosphonates, toenail fungus home treatment, how to refill meds directly from pharmay, etc). If you can type and can think conceptually about your high volume email interactions, you can be super efficient and take care of many problems without an in person visit. I can also train my dedicated medical assistant to answer most or all emails that do not have explicit clinical issues (how to get records, how to self schedule mammogram)

    8. Physician unions. We don’t need a union. We are the dedicated medical group for the “KP ACO” Each region has a dedicated group. It’s better than a union.

    9. Adherence coordinators. We don’t explicitly have “adherence coordinators” but we have clinically specialized care teams. There is a centralized anticoag clinc that managed all warfarin and if you tell them someone is going to goto the OR and needs a bridge with lovenox, they handle it 100% once you tell them. If you prescribe a new abx and the INR might get wonky, you cc them on the office visit note and they will monitor the INR for you and adjust it using their sophisticated algorithms. There is perioperative clinic so I don’t have to do preops. There is the most robust cardiovascular risk reduction program in the nation called PHASE that will drive every patients LDL, hga1c, bp etc down to clincial goals. They have decreased the # of fatal MIs in northern california down 30% compared to the population of non Kaiser patients in the same socioeconomic and geographic area.

    http://xnet.kp.org/newscenter/pressreleases/nat/2010/101310dmaaaward.html
    http://www.news-medical.net/news/20120918/HSS-recognizes-Kaiser-Permanente-Colorado-as-a-2012-Hypertension-Control-Champion.aspx

    At KP, it is recognized that adult and family medicine physicians are the keystone to high quality, cost effective, convenient care. It is a great place to be a family physician.

    • http://primarycarenext.blogspot.com/ Keegan Duchicela, MD

      Thanks for the comments.

      Funny how the wish list sounds a lot like what’s going on at Kaiser =) And I agree, it’s a great place to be a family physician. It doesn’t hurt that they’re paying new FP grads up to 20% over what other local medical groups are offering and with amazing benefits too – or at least that’s what I’ve seen in the bay area.

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