Accountable Care Organizations: Your Guide to Strategy, Design, and Implementation

As a new book author, I empathize with anyone writing about healthcare in a time of such dynamic change.  Before I review Accountable Care Organizations: Your Guide to Strategy, Design, and Implementation, by Marc Bard and Mike Nugent, I need to make a disclosure.  I know Marc Bard from a previous century when I was a surgical resident and he was an attending physician on the medical service at the Mount Auburn Hospital, Cambridge, MA.  I remember that Marc and his partner had one of the busiest practices and what a pleasure they were to work with.  They were not only pleasant but also available and clinically well-grounded. They knew what risks to tolerate and when to hold back.

I do not usually make the time to read 371-page books, but found myself showing up early to doctors’ appointments to arrange protected time to finish this book.  It is well-organized and contains a treasure trove of practical information for healthcare organizations at every level of readiness.  In fact, a table on page 153 shows key concepts and actions to consider for organizations that are considering forming an Accountable Care Organization (ACO):

  • Interested organizations should engage physicians in designing and managing integrated clinical functions, such as service lines, and in collaborations to improve operational efficiency, for example, reducing length of stay and re-admissions;
  • Engaged organizations should reward introduction of care pathways in common clinical areas and build physician management in the ambulatory environment
  • Committed organizations should focus on strengthening inpatient and ambulatory care coordination and implement medical home pilots in partnership with payers

I wrote a big exclamation point next to page 362, where the authors wrote:

While much attention will be paid to organizational structure, it is best to think of the structure like a sports arena.  It’s the venue, not the game.  Organizational structures do not ensure success, though an ineffective structure can make success much more difficult to achieve.

Those who read my post Collaborative Culture know that I also agree with the point the authors made on page 363:

While culture is often referred to as the “soft side” of healthcare, it is clear that the “hard” outcomes of quality, safety, patient satisfaction, and business performance are dependent on the “soft” elements of organizational culture.  Many leaders are quick to discount organizational culture because it is difficult to understand and even more difficult to influence.  But culture will ultimately be the difference between success and failure.

The authors encourage us (page 323) that there is no predictable timetable that will work for all organizations and to think of the process as a flywheel that gains acceleration.  Once it spins fast enough, the process will reach a self-sustaining speed and will generate confidence on its own.

I enjoyed the case study (p. 265-70) that described  the steps that a payer went through to move to value-based contracting:

  • The payer began by engaging individual specialties in conversations about trends in insurance premiums, administrative costs, utilization, and reimbursement
  • The data helped all parties address the objectives of maximizing value for patients and their families, the rationale for acting now based on trends of lowered reimbursement, demand for more cost-effective care, and the need to work together to achieve cost and savings targets without compromising quality and safety
  • The payers and providers established a set of ground rules that assured that all parties would have a voice at the table and that financial bonuses and direct investments to promote quality and efficiency would be made
  • In return for providing clinical resources to manage care transitions (case managers and infrastructure to support a patient-centered medical home) and administrative simplification, the payer expected providers to manage the total cost of care over time and to commit to achieving access, quality, affordability, and productivity targets in accord with multidisciplinary, evidence-based, team metrics
  • A year into the initiative, trust and transparency have increased, and momentum is building to support additional investments in improving the practice environment

I encourage all healthcare organizations to buy this book, make reading each chapter part of a monthly ACO journal club, and above all, to use the process to build a safe environment for reflection and learning that will improve care for our communities.

As always, I welcome your input to improve healthcare collaboration.

Kenneth H. Cohn

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