Perspective
Achieving Accountable Care — “It's Not About the Bike”
N Engl J Med 2012; 366:e4January 12, 2012
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open through January 18, 2012
- Article
In his memoir It's Not About the Bike: My Journey Back to Life, seven-time Tour de France champion Lance Armstrong argues that winning the world's greatest bike race does not depend in the final analysis on sophisticated bicycles.1 Although advanced equipment is very important, winning depends more on athletes' riding skills, physical conditioning, and race-day effort.
Accountable care organizations (ACOs) are the bicycles of modern health system reform, attracting considerable attention as promising vehicles for achieving better care, better population health, and lower costs.2 Indeed, we have argued that health care delivery organizations do need new payment models3 like ACOs to improve their performance. Yet the success of ACOs — as they are defined by health care providers, private payers, and now the Centers for Medicare and Medicaid Services (CMS) — will depend on whether they can enable and sustain care delivery organizations (the analogue of athletes) to improve their underlying performance.
If an ACO were a bicycle, its wheels, spokes, and gears would be the criteria used by payers such as Medicare to determine providers' eligibility, the methods used to assign patients to a given ACO, and the manner in which financial bonuses are calculated. These and other key operational issues are important and have accordingly attracted close scrutiny in the past year. Yet the success of ACOs — like the usefulness of bikes — depends on whether they can compel and equip the athletes riding them to improve their performance. It's not merely about the bike.
Just as riding skills, physical conditioning, and race-day effort are critical to winning races, care delivery organizations will need to build a largely new set of core competencies in order to deliver accountable, high-value care. Unless careful attention is paid to these competencies, organizations meeting the administrative and operational definition of ACOs will nevertheless not achieve their potential.
The improvements that ACOs and other new care models aspire to achieve will require a clear vision of what optimal care looks like from the patient's perspective. This vision must then be operationalized by patients and clinicians across the spectrum of care in the shared design of scores of patient-focused care processes, or plans of care for individual patients based on the best available evidence, patients' circumstances, and other factors. These care processes — comprising the specific steps that must be consistently followed when patients are, for example, undergoing a particular type of surgery or transitioning from one care setting to another — should be convenient, efficient, and reliable.
Care processes will need to be based on the best available evidence regarding what care is most likely to be effective for which patients in which settings. For patients' convenience and for affordability, care processes will need to be managed far more efficiently than they typically are in the U.S. health care system. This will require the development and judicious use of health care–specific business-process-management systems and software to support the care of individual patients and entire populations.
Care processes will need to be adapted to the needs and preferences of individual patients. For instance, whereas a high-intensity intervention such as case management can substantially improve the quality of life and lower the trajectory of health care costs for patients with multiple serious illnesses who are receiving multiple medications, the same intervention might be intrusive and wasteful if it were applied to an entire population of patients, most of whom will have more limited needs. For these reasons, accountable care will depend on a care team's identification of and action on the specific needs and preferences of the individual patient, deploying the most relevant, tailored interventions and supportive services to address patients' specific needs, circumstances, and preferences.
Accountable care will also require the coordinated efforts of all the members of a patient's care team, including the patient and his or her caregivers, physicians, clinic and hospital nurses, case managers, skilled nursing facilities, home health agencies, pharmacies, community health workers, school nurses, call centers, and employers. Such coordination will be essential particularly for transitional care that spans multiple care settings. For example, to improve patient outcomes and reduce the rate of hospital readmissions, subprocesses such as predischarge planning, patient education, a check 36 hours after discharge, close coordination with the outpatient team, and an outpatient visit 7 days after discharge will need to be planned, supported by just enough information delivered in a timely manner, executed, and accounted for by a team whose members may work for different organizations and may never meet each other face to face.
Finally, care delivery organizations riding ACO bicycles must make judicious use of information technologies to support, continuously evaluate, and refine care processes. Cost-effective management of these processes will depend on the timely collection, normalization, analysis, and redistribution of actionable information among multiple members of the patient's care team. Critical sources of this information are patients (for example, through personal health records), clinicians (through the meaningful use of electronic health records4 and case-management software), and payers (through administrative databases). Useful and usable health information technology (IT) will need to be based on a deep understanding of the information needs of each member of the patient's care team and of the team as a whole. This understanding can then guide the development of a cost-effective information infrastructure that will include exchanges bringing together information from patients, clinicians, and the electronic documents created by various providers.
Federal Beacon Community grantees, supported by the Office of the National Coordinator for Health Information Technology, have designed information systems to support care teams in maintaining care processes and attaining performance-improvement goals. The Keystone Beacon Community in central Pennsylvania, for example, has created clinical extracts of the electronic reports that skilled-nursing facilities and home health agencies are required to submit to CMS (using Minimum Data Set 3.0 and Oasis-C, respectively). These extracts are transformed into standard electronic documents (C32) and automatically made available to the patient's care team through the Keystone Health Information Exchange, which permits the reuse of existing data to support care coordination. (The specifications for this extraction and transformation are being documented for public dissemination.)
Accountable care will also depend on health IT to support reporting on process performance and patients' well-being to numerous internal and external audiences. Internally, care delivery organizations in ACOs will need to monitor and act on (both clinically and administratively) many quality and efficiency measures — as some are already doing. For external accountability, the same organizations will need to report results on hundreds of standardized quality measures (some of which will be directly reimbursable) to a variety of payers, accreditors, and regulators.
Ultimately, new approaches to provider reimbursement, such as ACOs, will make essential contributions to health system improvement, just as high-performance bicycles are essential equipment for cyclists attacking the Col de la Colombière on the Tour de France. For payment reforms to achieve their full potential, however, careful attention should be devoted to developing the organizational and technological competencies of the “athletes” that will use ACOs to achieve accountable, high-value care. These include the shared design of community-wide care processes that embody a patient-centered vision of optimal care, the optimization of roles and tools for people and organizations that contribute to a patient's care, and information systems fitted to the needs of patients and their care team.
Just as unprepared, out-of-shape athletes will not get very far even on the most advanced bicycles, care delivery organizations participating in payment-reform programs but not committing to the foundational capabilities for actually delivering accountable care will not achieve their full potential. Advanced equipment and advanced skills are mutually reinforcing — and both are essential.
Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.
This article (10.1056/NEJMp1112293) was published on December 28, 2011, at NEJM.org.
Source Information
From Geisinger Health System, Danville, PA (J.W.); RxAnte, McLean, VA (A.M.); and the University of North Carolina at Chapel Hill, Chapel Hill (A.M.).
- References
References
1
Armstrong L. It's not about the bike: my journey back to life. New York: Putnam, 2000.
2
Berwick DM . Making good on ACOs' promise -- the final rule for the Medicare Shared Savings Program. N Engl J Med 2011;365:1753-1756
Full Text | Web of Science | Medline3
McClellan MB ,McKethan AN ,Lewis JL ,Roski J ,Fisher ES . A national strategy to put accountable care into practice. Health Aff (Millwood) 2010;29:982-990
CrossRef | Web of Science | Medline4
Blumenthal D ,Tavenner M . The “meaningful use” regulation for electronic health records. N Engl J Med 2010;363:501-504
Full Text | Web of Science | Medline
- Comments (11)
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11 Reader's Comments
Steven Zeitzew | Physician | Disclosure: NoneJanuary 04, 2012The right answer to the wrong question
Sometimes getting the right answer to the wrong question is not as useful as asking and answering the right question. In the Tour de France one is required to ride a conventional bicycle, and some bicycles are better than others, but the Tour and other races have long since decided to disallow recumbent bicycles, a superior more efficient design better in many ways some of the time than the high tech bikes you refer to. Human Powered Vehicle speed records have been set on recumbent bikes, they are more comfortable and a less well trained athlete can sometimes ride faster than a more skillfull better trained and conditioned athlete limited by the requirement to ride a conventional bike. If the ACO is the bicycle then we are aspiring to be Lance Armstrong, an admirable but not a realistic goal. I would love to be as great an athlete as Lance, but nobody else is. I can easily purchase a recumbent bike more efficient than any he road in the Tour, however. Perhaps finding something better than an ACO will help physicians practice better medicine. Why not improve both the rider and the bike? I ride a recumbent, I don't race, but I am safer and faster than I was on a road bike.
ROGER WILGUS | Other | Disclosure: NoneJanuary 04, 2012Analogy Leaves Out the Vast Majority
It's always amusing to me to read the well-crafted, verbose descriptions of a proposed patient care system, most of which are written by academics with little or no experience in the real world outside universities and think tanks. In this piece there's one glaring omission in the analogy.
Consider that in today's populace about two-thirds of the prospective patients are overweight, and about one-third are obese. Add to that the fact that millions of Americans drink too much and smoke, and most don't exercise even moderately. This is the group that will eventually present as diabetic and/or cardiac patients, and in many cases whatever care they receive will be futile. Until more people choose to stop abusing themselves and opt for a healthy, sensible lifestyle, all of the laws, rules, regulations and theories for better care delivery are unlikely to have much positive effect.JAMES RICKERT, MD | Physician | Disclosure: NoneBLOOMINGTON INJanuary 03, 2012The Chance to make it Patient Centered
ACOs really can help make patient centered care a reality, or they could become nothing more than more paperwork. It all depends on whether financial incentives and regulatory requirements help create a model in which patients' assessments of their health care are measured. If this happens, patient satisfaction will go up and costs can go down. Furthermore, organizations with strong primary care will be rewarded.
KENNETH CROEN, MD | Physician | Disclosure: NoneWHITE PLAINS NYJanuary 02, 2012We can do better than this
Interesting that the authors should use an athlete and a sport whose reputation has been badly tarnished by performance enhancing drugs. Our medical group has been delivering high quality care to a very educated population of patients for 50 years. We engage in all the expectations of a practice that deals with patients going in and out of multiple centers of care. This is a challenging task made much easier with electronic records, patient portals, and improved support systems.
No matter how you slice it, accountable care is a model that pays more for providing less care. Patients will inevitably recognize this, and all shortcomings in healthcare performance will be blamed on the provider's profit motive. A new avenue for litigation will be created. The trust so critical to a successful healthcare environment will begin to unravel.
This model has been tested for 5 years. The savings were very small and half of the groups never reached the 2% threshold. Surely we can do better than this. Go ask Lance Armstrong.RICHARD WEISS, MD | Physician | Disclosure: NoneMARINA DEL REY CAJanuary 01, 2012Not Generalizable to Private Practice
Ae have no: PA, NP, RN, Social Worker, Health Coach or Coordinator. All three of our doctors in practice were trained before 1980. Expectations of a "new system," would require at least one year of residency. In general this applies to all doctors trained before 1980. Your expectations need re-education of patient practice, including HIT and more office personnel. Few articles in journals address this; they must think we are a bike to be built (how much training is that)?
Previous articles in the nejm concluded that ACO models after 2-3 years could not achieve all quality measures and satisfactory revenues. There were delays from the CMS to the ACO for guidance which led to unsatisfactory results.
Why are academic conclusions void of doctors in private practice? We now have MBA, PhD, DrSci...writing in most journals, highly educated men, with good ideas but limited experience in the difficulties in transforming any practice with old bikes.maggie honeycutt, MD | Physician | Disclosure: Nonewarrenton VADecember 29, 2011Patient Management Is Not Patient Satisfaction
As a physician for 26 years in the field of pediatrics and involved in the state AAP on behalf of pediatricians, it is disheartening to think clinic time which is already marginally compensated will now consist of paperwork ensuring compliance with HEDIS measures and other "measures of patient care." The culling of patient data from insurance data bases is not accurately reflective of patient care since patients change insurance carriers or drop insurance altogether. Our current documentation reflecting the highest standard of care does not guarantee a good outcome or patient satisfaction. What improves outcome and makes patients feel well cared for involves relationships, attentiveness to detail, participation in and appreciation of good team care, and knowing your limits. You cannot measure the makings of a good doctor. This is not, and never will be, a race. I am the bike. Without maintenance and care even a world class bike breaks down. With the addition of the paper weight and meaningless statistics about to befall us, I don't doubt there will be a major exodus from the profession. Medical home, yes. Accountable care organization, no.
SOPHIE LUKASHOK, MD | Physician | Disclosure: NoneATLANTA GADecember 29, 2011who is riding the bicycle anyway....
I was surprised by the authors' interpretation of the well trained athlete. Is not the well trained athlete the phycisian who cares for the patient,talking with the patient, performing streamline work-ups, treating the patient all the while engaging social services and delegating functions judiciously to PAs and NPs? What the authors call the well trained athlete is in fact the high tech bicycle. All of the software and programatization will be extremely expensive to implement and maintain, and my gut instincts, based on my past 20 years as a doctor, tell me that they will add nothing to the care of patients other than cost.
MARIANNE BEARD, DO | Physician | Disclosure: NoneARLINGTON TXDecember 29, 2011Tour de France -- by invitation only, and you have to want to compete.
I have been an independent family practitioner for 25 years, with a waiting period for new patients of about 6 months. If I gave copies of this article to my patients, there would be very little, if any, interest.
Look at the question from the patients' point of view. That is, after all, what matters: do they get better care, do they feel better, are they able to participate in their health care decisions, can they speak to a familiar person, when they have questions, concerns, fears and hope about their medical care?
When I served on the committee for "Utilization Review", and "Quality of Care" for our local hospital, we addressed the usual questions of financial gains and losses, repeat admits and accountability. We compared our statistics to the national average for length of stay and, according to our criteria, medical outcome. But I always wanted to ask each patient if they felt better, if their quality of life had improved, if they were participating in their own health care.
The 36 hour reevaluation always takes place in my office, or in the patient's home. This does not involve financial incentives, but it does matter to the patient. I hope this will never be lost.Sloan Manning | Physician | Disclosure: NoneDecember 29, 2011ACO's out of balance
Sadly, ACO's will organize and process to please payers. Patients will take the backseat and get healthcare de jour. Those with their own resources or with political connections will be able to obtain care that they prefer in a two-tier system that relegates those without to whatever evidence-based experts prefer, even though evidence lags invention and ignores patient preference.
RICHARD HEATHER, MD | Physician | Disclosure: NoneLOS OSOS CADecember 28, 2011only one person can ride the bike
Our profession has been turned into a collaboration that everybody wants to ride the bike. Even Lance can't ride with twenty people on his back. Organizations do not take care of patients, professionals do. It is never more efficient to have three chefs in the kitchen. Having layers of prior authorization does not make the bike roll. The whole system is flying down the mountain without brakes.
Not about the bike?
Interesting that the well-run offices of more-seasoned physicians seem not to shrug off these ideas as unnecessary. LIkely they already have systems and a staff in place that make their practice run well, kind of like cycling gurus have their bikes well-tuned and ready to go. For those of us who are just starting out, though, and may have to deal with a low-budget staff, these ideas are-- though esoteric-- definitely valuable.