Accountable Care Organization – What is it and what does it look like?

By Marie Hooper

The current health care landscape is a complicated one but, when it comes to an individual’s health and wellness, it doesn’t have to be. Medicare has defined an Accountable Care Organization (ACO) as a group of doctors, hospitals and other health care providers who come together voluntarily to give coordinated, high-quality care to their Medicare patients. The goal of coordinated care is to ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors, according to CMS.gov (Centers for Medicare & Medicaid Services).

So you’re the patient, now what does this mean?

In the current fee-for-service system, if you receive care from different providers at different locations and you have tests or procedures repeated – whether you need them or not – you and/or your insurance company are paying for them. If the repeated test or procedure was not needed, that is a waste. Further, under our current system, a test done at your doctor’s office is reimbursed at a lower rate than that same test performed at a hospital/facility-owned provider. This means you and/or your insurance company are paying more for the same test because the larger facility has more costs and can charge more.

So now ask yourself, what matters to you when you think about your own health? What do you want for yourself, your children or parents when it comes to health? The answer probably does not include an ER visit or a hospital stay; rather we describe health as wellness, prevention and being able to live an active and productive life, even with a chronic disease.

Enter accountable care. You and your physician are back in charge of your health and the transition begins from a fee-for-service system to one of fee-for-value.

Now, if you live with a chronic disease, you likely see several different physicians but ultimately your primary care doctor coordinates your care. Your doctor might even refer you to a care coordinator who works with you to overcome the obstacles that may limit your progress in dealing with the disease. Each of your providers knows why you are there, what is expected to be accomplished at each visit and you leave knowing what you have to do between visits. All of the tests and reports are readily available to the next physician you see in the course of your treatment, so tests are not repeated, if not needed.

A group of northern Michigan physicians developed a new organization called Northern Michigan Health Network (NMHN), which is our area’s ACO and has initiated the transition to value. NMHN’s mission is to reduce waste and redundant work in order to 1) lower health care costs, 2) improve the patient’s outcome and 3) improve the patient’s experience. The network has invested in a community registry; a tool for physicians that, with your permission, allows for their health records to be shared among your doctors. Subsequent providers will have access to allergies, medications, lab tests and progress notes. The registry provides a complete view of your health record over time, which becomes available to your primary care doctor, allowing him/her to coordinate your care more effectively and efficiently.

Our communities of physicians have begun this work, however, they cannot do it alone. We as patients and ‘purchasers’ of health care must help. We need to own our health and wellness and to do that we must be engaged and informed. Instead of relying on our doctors to fix us when we are broken, we need to be accountable, as well, in order to help prevent illness or slow an existing one. It is learning about health, prevention and asking many questions.

As we look forward to 2015 and our lists of New Year resolutions, let’s include health and wellness among them. Let’s start owning our health and working with our community of physicians and other providers to start making a difference at the local level.

Marie Hooper is the executive director for Northern Physicians Organization and Northern Michigan Health Network. She is currently serving on the Michigan State Medical Society Executive Council and participating on the IHI (Institute for Healthcare Improvement) Leadership Alliance.

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