The PPACA of 2010 PPACA of 2010 brought many changes to the types of provider or

Question

The PPACA of 2010 PPACA of 2010 brought many changes to the types of provider organizations available. ACOs and PCMHs are two new organizations formed under PPACA. Using the readings this week, discuss the origin, structure, and purpose of the new organizations formed under PPACA. Using South University Online Library (for example, CINAHL) or the Internet, search any three articles from the list below and evaluate the challenges and opportunities facing payers and providers as ACOs and PCMHs are implemented:

•The patient-center medical home and managed care: Times have changed, some components have not (Baird, 2011). http://www.jabfm.org/content/24/6/630.long

•Patient-centered medical homes: Will health care reform provide new options for rural communities and providers? (Bolin, Gamm, Vest, Edwardson, & Miller, 2011)

•Accountable Care Organizations: The case for flexible partnerships between health plans and providers (Goldsmith, 2011). http://content.healthaffairs.org/content/30/1/32.abstract

•Payment reform for primary care within the accountable care organization a critical issue for health system reform (Goroll & Schoenbaum, 2012).

•Accountable care organizations, the patient-centered medical home, and health care reform: What does it all mean? (Longworth, 2011) http://www.ccjm.org/index.php?id=107937&tx_ttnews[tt_news]=365705&cHash=d55b4f7900d1d74fa228501c6932b035

•Implementing accountable care organizations: Ten potential mistakes and how to learn from them (Singer & Shortell, 2011).

Explanation / Answer

The patient-center medical home and managed care: Times have changed, some components have not challenges and opportunities:-

The medical home concept, which was originally developed in the 1960s, refers to the provision of comprehensive primary care services that facilitates communication and shared decision-making between the patient, his/her primary care providers, other providers, and the patient‘s family. The PCMH concept was included as a program in national health care reform legislation with components similar to joint principles developed by the American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), American College of Physicians (ACP), and the American Osteopathic Association (AOA):

Payment appropriately recognizes the added value provided to patients who have a PCMH.

2. Patient-centered medical homes challenges and opportunities

The PCMH model requires physicians to meet several objective criteria in order to participate and receive any financial incentives. These criteria include broadly:

1. Access and communication;
2. Patient tracking and registry functions;
3. Care management;
4. Patient self-management support;
5. Electronic prescribing;
6. Test tracking;
7. Referral tracking;
8. Performance reporting and improvement; and
9. Advanced electronic communication.

The patient-centered medical home (PCMH) model presents a unique opportunity for community health centers (CHCs) to improve the health of medically underserved communities and reduce health care disparities. Community health centers face ongoing financial and operational challenges, but are well positioned to adopt the PCMH. Health centers have experience collaborating on quality improvement initiatives and possess a strong organizational structure. The culture of CHCs emphasizes cultural competence, team work, and patient-centrism, and is well-aligned with the PCMH model.

A common challenge that these practices encountered was in making care coordination the top priority for the organization and gaining the strong commitment throughout the organization that is necessary to succeed. They each found that having strong clinical and administrative leadership overcame this challenge. All three organizations found that the cost of PCMH implementation was easier to recoup than expected. Through streamlined work flows and government/insurance incentive programs, all three practices were able to decrease costs and increase revenue.  

These practices also found that true care coordination, between primary care providers, staff, and other providers, was easily attained once all staff effectively learned to use the electronic medical record (EMR) system. An ongoing challenge facing these practices is the need to train staff, maintain that training, and retrain new staff. An internal handbook of PCMH processes within the organization was helpful in allowing current staff to look up any questions, and providing new staff with a tool kit to improve continuity of care. These solutions have helped each of these very different practices accomplish their common goal: to successfully implement a patient centered medical home, improve practice efficiency, and enhance the delivery of care to patients.

Each practice has found measurable improvements in patient compliance and health outcomes. These practices have benefited from reduced costs and increased revenues.   The initial costs of implementation were recouped relatively quickly. All of these practices found that they are significantly more efficient as a result of implementation of the PCMH model.

Opportunities:-

3. Accountable Care Organizations: The case for flexible partnerships between health plans and providers

--Despite the lengthening of the list of possible participants, hospitals are likely to dominate the ACO contracting process for two reasons. First, the largest avoidable Medicare costs are hospital related. And second, in many communities, the hospital is the only organized care delivery entity capable of executing the model.

--The ACO model presupposes collaboration between hospitals and physicians, but that relationship has a troubled history. In fact, in many communities in the southern and western states, the two groups have engaged in bitter competition for control of lucrative ambulatory services, such as advanced imaging, ambulatory surgery, and radiation therapy. The result has been much ill will and duplication of services. In some communities, physicians have controlled the lion’s share of ambulatory diagnostic and surgical cases, to the point of damaging the local hospital financially.

--The economic conflict between physicians and hospitals over highly profitable ambulatory services has left a powerful residue of mistrust between hospital managers and physicians. An essential ingredient of effective managed care is trust among the participants, including among physicians themselves. Sadly, that trust is absent in many health care markets.

--Another, newer problem is that about a third of physicians no longer bill for any hospital-related services, because their practices no longer require this kind of care. Hospitals have reduced their dependence on community-based practitioners by hiring hospitalists and intense visits—physicians who specialize exclusively in managing hospitalized patients. Physician communities are bifurcating into those who never or rarely come to the hospital and those who practice entirely within it.

--There are serious infrastructure constraints on the model of the accountable care organization that directly affect the hospital’s ability to bridge the gap between the in-hospital and nonhospital physicians.

--Although the ACO model seeks to blunt the “do more to make more” incentives of fee-for-service payment, the modest rewards that the model offers for cost restraint are unlikely to catalyze major change.

--Another key defect of the ACO model is the lack of any requirement for active patient involvement in joining the organization. Historically, managed care relied on voluntary enrollment by subscribers. The incentives for subscribers—employees and Medicare Advantage beneficiaries—to enroll in managed care plans included reduced patient cost sharing, more-comprehensive services, and less-complicated billing.

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