Health reform reshaping medical practice

WASHINGTON-Patients who suffer from heart failure are getting a radical new treatment at Hartford Hospital aimed at significantly reducing their chances of readmission.

It’s doesn’t involve new medications or a cutting-edge diagnostic. In some ways, it’s a lot more complicated-entailing a more integrated way of practicing medicine that is being ushered in, in part, by the health care reform law.

Hartford Hospital’s new program for heart failure patients, which relies on intensive post-discharge follow-up, is one element of a larger effort to retool that institution and its affiliates into an “accountable care organization”, or ACO.

Some experts see ACOs as the linchpin of health reform-a way to bring down spiraling health costs while also improving the quality of care. But others are skeptical of their potential, and worry that Connecticut providers, in particular, will face unique difficulties in implementing this piece of health reform.

Under the health overhaul, ACOs are defined as a network of physicians, working across specialties and even at different institutions, who team up to provide a highly integrated continuum of care for their patients. If an ACO delivers quality care at reduced costs, its members will be able to share in any financial savings.

“What we’re talking about is a complete and total re-engineering of care,” said Amanda Forster, of Premier Inc., an alliance of hospitals and other providers that works on improving quality. Premier is helping Hartford Hospital and others prepare for the new ACO era.

Right now, hospitals and doctors are paid for every service they provide. So each surgical procedure, each test, each patient appointment translates into a reimbursement, whether from an insurance company or the government’s Medicare or Medicaid programs.

This fee-for-service system provides “a perverse incentive,” Forster says, because there are no rewards for keeping a patient healthy or for successfully managing a disease with minimal complications.

ACOs are designed to flip the system around.

Under the health reform law, a group of health care providers will be able to form an ACO if they can meet certain benchmarks, including the capacity to provide a full spectrum of health care services to at least 5,000 Medicare patients.

The providers in each ACO will still be reimbursed through Medicare on a fee-for-service basis; but if they are able to deliver quality care at a lower cost, they will split the cost savings with the government.

“Everybody agrees in the abstract that our health care system is wasteful and costs too much,” said Michael Millenson, a health care consultant and scholar at Northwestern University’s Kellogg School of Management. But few providers think their own systems have such inefficiencies.

The ACO model gives providers a carrot to find waste and root it out.

More broadly, it also sets up payment incentives for physicians to “step outside of their silos and their piecemeal approach to health care and to work across health care settings-and to be accountable across health care settings,” said Alwyn Cassil, of the Center for Studying Health System Change, a nonpartisan health policy research organization.

Take the Hartford Hospital example. Instead of discharging a heart-failure patient with some general instructions, the hospital is now aggressively working to connect with that patient’s primary care doctor and other providers to ensure the patient gets good follow-up services. The hospital staff schedules a nurse home-visit within 24 hours of discharge, and they make sure the patient sees his or her primary care doctor or cardiologist within 4 days of leaving the hospital.

“All of these efforts are to ensure that they don’t worsen and get readmitted,” said Rocco Orlando, the hospital’s chief medical officer who is overseeing the facility’s transition to an ACO.

“The ACOs represent one of the ways to link financial performance to clinical performance, by preventing disease and providing better care to achieve savings,” said Orlando. “It’s a very viable way to bend that cost curve.”

He noted that it’s part of a broader shift toward so-called “bundled payments,” under which doctors and hospitals would be paid for longer-term episodes of care, rather than individual tests and appointments.

The potential benefits to patients are immense, if not as immediate.

“If you are a diabetic with heart disease and high blood pressure, the payoff is over a 5-to-10-year period, you will have fewer complications and less illness,” Orlando said.

Even though the ACO provision doesn’t go into effect until January 2012, many providers across the country are already scrambling to form alliances. Orlando said Hartford Hospital and its affiliates are on schedule to form an ACO by this time next year.

“It’s amazing. Everyone is doing it,” Millenson said. “It’s been surprising how fast it’s caught on.”

Forster said providers from Pennsylvania to Illinois to South Carolina are laying the groundwork to move to an ACO model. Many of these groups are working with private insurers to set up cost-savings agreements, in addition to whatever savings they might reap from the health reform’s Medicare ACO plan.

But not everyone is so enthusiastic.

For one thing, the federal department of Health and Human Services has yet to write the regulations spelling out how the ACOs will work. And doctors and hospitals are worried about some legal barriers, such as anti-trust laws, that could impede collaboration.

“It’s not just add water and stir,” said Stephen Frayne, a senior vice president at the Connecticut Hospital Association. “There’s a lot of stuff that has to be sorted through.”

Frayne said it will take a lot of upfront investment, in terms of both time and money, to create the systems needed for such broad integration. ACOs will also have to dedicate resources to new technology systems that will help them track patients and health care outcomes, a key determinant of whether an ACO is successful.

Frayne and others also noted Connecticut’s health care system is not particularly well suited to move to the ACO model. That’s because nearly 80 percent of Connecticut doctors currently practice in small groups of four or less, rather than in larger networks.

“Unlike a lot of other states, we don’t have a lot of integrated health systems,” said Ken Ferrucci, vice president of public policy and government affairs for the Connecticut State Medical Society. “The biggest challenge in Connecticut will be … finding a way for physician practices to keep the independence they want and yet be integrated into an ACO.”

The reform measure could provide a needed impetus “to integrate the system more swiftly,” Ferrucci said. But for now, doctors and other providers are taking a go-slow approach, studying their options and trying to weigh the potential benefits against the required investments.

Forster said ACOs will probably look very different from one place to another, since the law is written broadly to allow for flexibility. But a move toward some new kind of new payment and care system is inevitable.

She said one of Premier’s alliance members framed the choice this way: “You can either keep doing business as usual, and die a death of a thousand fee-for-service payment cuts, or you can transform care and finally do the things that all providers have in their mission statements, which is to promote health and wellness.”