The U.S. healthcare system is undergoing a dramatic transition as the industry strives to achieve the goals of the Affordable Care Act (ACA) to improve an inefficient, unsustainable system. Physicians, insurers, pharmacists and other players in the patient care arena are shifting roles and forming more collaborative, coordinated networks to fill the gaps in care and reduce practice redundancies.
What are the key changes in this new healthcare scenario? Part two of this seven part series discussed challenges of healthcare reform. In part three of this series dedicated to the emerging role of the pharmacist in the healthcare ecosystem, the topic of new models of patient care is discussed.
New Models of Patient Care
New models of care have emerged to remedy these issues, supported by the goals of the ACA, signed into law in March 2010. The ACA aims to improve the quality of care and affordability of health insurance and reduce costs to individuals and the government. To meet these goals, many healthcare team players across the country have already transformed how they deliver care.
The fundamental component to reach the ACA’s goals is coordinated, integrated, accountable, patient-centered care with a focus on value, not volume. In this team approach, patients are part of the decision-making process of their care, and members of the medical care team connect with each other to manage patient’s care, providing more comprehensive, coordinated care with a focus on patient outcomes. The primary care physician, who develops a patient’s care plan, is the hub of the medical team and should be easily accessible to other players. Another key component of this new model is shared risk, where every health care provider on the care team has a gain or cost share dependent upon achieving quality and cost targets.
There are several types of coordinated care networks, and they are based on one of two strategies:
A consolidated network is a single system that “owns” patient care, such as Kaiser Permanente, who employs all members on a patient’s healthcare team, from doctors to surgeons to pharmacists. About 70% of hospitals are consolidated networks, which provide all care throughout a patient’s lifetime under a single umbrella following specific protocols. These systems enforce efficiency and have system-wide protocols and processes.
Collaborative networks involve smaller players who create informal, flexible relationships and health information exchanges, but do not own other entities in the network. These powerful collaborations generally do not have contracts or risk and reward systems. They are community-based, tied to a local neighborhood, and founded on personal relationships and trust. For example, five key pharmacies in a local community may collaborate with a local hospital. Collaborative networks establish common processes, technology platforms, registries and health information exchanges. They depend on advanced health information technology and, particularly in metropolitan areas, informatics. Their level of healthcare penetration in the community depends on the local ecosystems.
Consolidated and collaborative networks are similar in concept. Both are about improving outcomes and quality while lowering costs. Consolidated networks have a more formal organization structure, focus on accountability with responsibility for costs and care delivered, and most have a shared savings program with defined shared responsibility. Consolidated networks typically have a better data system and better analytics than collaborative networks, but are not closely connected to the local community. Collaborative arrangements depend on meaningful, personal relationships between the care team members and patients. Community care managers establish a relationship with local pharmacies and typically, patients receive conveniently located, personalized service from a pharmacist they know.
Accountable Care Organizations
Accountable care organizations (ACOs), a type of consolidated network, are groups of doctors, hospitals and other healthcare providers who come together voluntarily and work to provide coordinated, high-quality care to their patients. ACOs are usually hospital-based or physician owned. Medicare ACOs were formed by the Affordable Care Act of 2010, with Medicaid and commercial ACOs following suit.
ACOs are designed to promote accountability and affordability, shared risk and savings and improved health outcomes for a defined population. The organizations are designed to hold providers and their payments to value metrics, quality of care endpoints and reductions in the total cost of care. These entities become accountable for the quality, cost and care of the Medicare fee-for-service beneficiaries assigned to them. Some may also take Medicaid and dual-eligible patients as well as patients on the state and federal health exchanges.
ACOs have a formal legal, management and leadership structure that includes administrative systems. They have integrated, interoperable healthcare information technology systems and analytics to gather the right data for patient care and effective reimbursements. Focused on continuous process improvement and a strategic allocation of resources, ACOs save the costs of redundant, outdated practices and are designed to improve profitability and provide better, more efficient patient care.
Primary Care Medical Home and Medical Neighborhoods
A Primary Care Medical Home (PCMH) is a type of consolidated care network driven and possibly owned by physicians. This model is rapidly gaining momentum as an innovative approach to primary care. There are more than 6,037 PCMH sites in the U.S., according to the National Committee for Quality Assurance (NCQA).3 A PCMH aims to strengthen the physician-patient relationship by replacing episodic care with coordinated care and a long-term healing relationship. Each patient has an ongoing relationship with a personal physician who leads a team that takes collective responsibility for patient care, providing for the patient’s healthcare needs and arranging for appropriate care with other qualified clinicians.
PCMHs are expanding to include the entire care continuum, known as a Medical Neighborhood, which includes: a PCMH (with physicians, pharmacists, hospitals, payers, etc.) plus a constellation of clinicians, community and social services, long- term-care facilities and state and local public health agencies. They have strong community links, a patient-centered focus, clinical data-sharing, a clear agreement on each player’s role and carefully managed transitions in a patient’s care.3
Other Types of Networks
Other new and emerging healthcare arrangements to provide primary care include clinics at pharmacies and retail chains, such as Target. Large employers are contracting with hospitals, ACOs, pharmacists and other healthcare entities to provide primary care for their employees. Regardless of the model, all healthcare networks require timely, integrated and relevant shared data, transparent coordination of care among players and more efficient use of resources to manage patient wellness effectively.
Part four of the series will discuss the Emerging Roles for Pharmacists
Previous Articles in Series:
Part 2 – Challenges of Healthcare Reform
3. Squires D. The U.S. Health System in Perspective: A Comparison of Twelve Industrialized Nations. July 2011. Accessed at: http://www.commonwealthfund.org/~/media/Files/Publications/Issue%20Brief/2011/Jul/1532_Squires_US_hlt_sys_comparison_12_nations_intl_brief_v2.pdf