New program makes health care providers accountable

(Harrisburg) — Out of the ACA comes ACOs.

The federal Affordable Care Act has given Medicare the power to contract with hospitals and doctors to create Accountable Care Organizations.In an ideal world, they’ll cut costs, improve patient quality, and better coordinate care.It’s still early to answer that question, but Wellspan Health has put together its own ACO with Aetna, already up and running.

What’s an ACO?

It’s a collaboration between heath care providers, insurers (or Medicare or Medicaid), and patients.

“We’re going to essentially connect those providers to make sure that care is coordinated with a collaborative fashion between those different providers to that one members, and that’s been missing in the system in the past,” sayDan Day, market head of sales and service for Aetna Insurance.

There’s a batch of metrics health care providers will have to meet to get full reimbursement — things like hospital readmittance rates, avoiding preventable problems for those with chronic diseases, and better screenings.

The insurance coverage will include all Wellspan facilities, plus about 250 independent doctors that have partnered with Wellspan.

This is the first privately run Accountable Care Organization in the midstate, and one of the few in Pennsylvania.

Why an ACO?

“We believe these types of relationships help assure that care is coordinated, delivered in the most efficient fashion, and that the right care is delivered in a timely fashion,” saysCharlie Chodroff, senior Vice President at Wellspan.

Chodroff says the goal is for the coordination to go smooth it’s almost unnoticed. ACOs could prove to be a triple threat – lowering costs, keeping patients healthy, and improving quality.

What are the risks?

There’s the obvious risk to Wellspan and its providers – like failing to hit the metrics and getting paid less. Aetna says its risk is the standard insurance dilemma – making sure the plan’s enrollees are diverse enough to spread out costs.

All of this requires a bit of a dance.

“The main missing link is now, and it has always been, how to get doctors to work well with hospitals, given the differences in how they’re organized and the differences in objectives of the two groups,” saysProfessor Mark Pauly, who has studied the issue at the Wharton School at the University of Pennsylvania.

Primary care doctors aren’t used to having to come up with plans in partnership with hospitals, and vice versa.

These are often Type A personalities, after all.

“Wellspan has been working over the last couple of years to change the culture within their health system,” says Dan Day, of Aetna.

“To get the doctors to collaborate, to get the doctors to look at information and to drive towards better outcomes, to get the doctors to engage the patient, whether that be through a telephone call or reaching out to them through other means.”

Health care spending growth rates were reaching unsustainable levels, says Day, and calls ACOs a matter of survival.

As Charlie Chodroff with Wellspan says, “It’s changing the health system from reactionary to proactive.”

But, and this is a big but, even if this all works, in such a big, clunky and bureaucratic system like health care, it could be a while before ACOs become widespread, says Professor Pauly.

“I’m more optimistic about the thought that young doctors may be more able to cope with the system than older ones. It means we may eventually get there, but it also means that its gonna potentially be a long slog to get the changes that everybody thinks we need but nobody wants to do.”