Healthcare Revenue Cycle Management, ICD-10, Claims Reimbursement, Medicare, Medicaid

Why Patient-Centered Accountable Care Organizations Thrive

Accountable care organizations may have promise, but they have to keep evolving toward value-based, patient-centered care.

The patient-centered accountable care organization (ACO) is the new future of healthcare.

accountable care organizations value-based care

According to Mark Wagar, President of Heritage Medical Systems, when patients' voices are heard, they receive better quality care.

Wagar said his experience working with one of the largest Pioneer ACOs with over 30,000 physicians taught him about the importance of patient-centered care and advocacy.

“The key to our core business success and our ability to enter the Pioneer ACO – and stay with it – is an infrastructure we’ve built over the years,” he said.

“We've been developing and fine tuning how to make the most of physicians being in more control of more revenue earlier,” he stated.

“That's one of the keys to resourcing all the different things you can do in an accountable care environment.”

Avoiding expensive and preventable healthcare events with early care management access is a top focus, he said.

“ACOs have promise, but they have to keep evolving toward value-based care," stated Wagar.

Using upfront resources to learn more about patients’ personal lives is an effective way to prevent avoidable health emergencies within an ACO setting.

One of the most common preventable health emergencies involves the treatment of patients with congestive heart failure.

“In a matter of hours, they can start gaining weight through water retention,” he stated.

“But a simple adjustment in their medication and monitoring avoids an emergency department visit, an ICU visit, and a life threatening event.”

But focusing on the patients who are receiving care right in front of your eyes is only the beginning.

There also needs to be a greater focus on engaging those beneficiaries who opt out of care delivery entirely and never even set foot inside a physician’s office.

“Traditionally, we've built our medical system around what's paid for. You can be the best specialist in the world with the best facility, and you're just standing there, waiting for people to come in,” he asserted,

“You might intervene and help some of them, but intervention earlier or knowing about everybody who is at risk and needs to come see you is the other piece of the puzzle we're really needing," he said.

“A lot of older people reluctantly avoid visiting [the doctor] – particularly in an ACO environment,” he stated.

Many patients have good intentions to make appointments and receive care.

But oftentimes, simple external factors with an easy fix – such as an elderly mother not wanting to burden her busy son with taking her to and from various medical appointments – may keep a patient from receiving needed care.

Communicating openly with patients as soon as problems arise and offering simple resolutions is imperative. For example, perhaps this particular mother in need of transport could simply be driven to the doctor several times a week via a ride-share app like Lyft.

Wagar said these and other common communication problems often arise from a basic lack of sensitivity.

He especially advocated for more cultural and religious sensitivity when it comes to preventing avoidable health problems.

Oftentimes, a simple misunderstanding that can potentially be harmful to someone’s wellbeing can be very easily resolved, he stated.

“There have been patients over the years who end up in the hospital with big psych consultations because people think they're uncooperative when they won't eat after their surgery,” he said.

“They find out they have religious sensitivities and requirements. So they weren't eating the Jell-O because it contains things [that for] certain sectors of the faith are not edible.”

“You find some other mild substance for them to start eating and all of a sudden they perk right up,” he said. “They didn't really need a psych consult. They're not trying to be uncooperative.”

But learning more about patients’ medical conditions as they are receiving care within a hospital room is only the beginning.

Analyzing patients’ home environments and economic circumstances are also important steps that may prevent later health deterioration.

“We want to know their sister's name. We want to know if they're fighting with their family members and get depressed. We want to know if they live on a fourth floor walkup or a single level,” Wagar explained.

“We want to know everything about their circumstance and who the best people are to surround them with to get them to talk about their health and talk about other circumstances affecting their health," he continued.

“The light bulb goes on when physicians in an organized setting have the freedom to direct the resources whenever they're needed in the best possible way.”

Next Generation ACOs still pose RCM glitches

But maintaining high quality, value-based care is difficult when payment hiccups stand in the way.

Wagar said Next Generation ACOs are far from perfect models.

For instance, when patients are sent to an urgent care center for a bee sting instead of their usual primary care visit, this messes up revenue and cost calculations, he said. Consequently, this causes confusion and trepidation across the industry.

“Asking the delivery system to do a bunch of different things that are not billable events and cost money, and then maybe pay them, maybe not, 18 months from now is why you see a lot of people hesitating.”

“Our commitment is let's help prove the Next Gen can have as big a potential as we thought the first round would, and then keep showing the data so the government is able to keep involved in the payment model to really do it right.”

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