Innovative ACOs: Rebuilding chronic care management from the ground up

GandhiThe idea of integrating various aspects of patient healthcare, which is often needed for chronically ill patients, would seem to be in perfect accord with the mission of accountable care organizations (ACOs). However, according to Niyum Gandhi, partner in the health and life sciences division of Oliver Wyman, some of the more innovative ACOs are rebuilding their healthcare models from the ground up.

“A few ACOs are self-aware enough to recognize that the clinical model we have today has been built to provide fee-for-service care,” Gandhi says. “It’s about patient throughput, it’s about maximizing our reimbursement; it’s really not designed for managing chronic care, because nobody has been incentivized to manage chronic care. So these few ACOs are saying, ‘Now that we’re responsible for total cost of care, let’s start with a white sheet of paper, and if we’re building a new model that’s really patient centered and focused on the needs of the chronic population, what would that look like?’”

Closing gaps

Gandhi says he has generally seen two basic approaches to chronic care management in ACOs. The first, and more common, involves the enlistment of care coordination programs.

“Some organizations are looking at it and noticing that they have a lot of diabetics or patients with congestive heart failure, and so they built a care coordination program,” he says. “They hire some care coordinators and put them in primary care practices, and the coordinator is going to make sure the diabetics are getting their hemoglobin a1_c tests, their foot exams and their annual retinal exams. They’re going to look for bad medication interactions, and be on the lookout for avoidable hospitalizations.”

Such coordinators also provide follow-up, educational resources and periodic check-ins with chronic care patients, and will be focused on this population.

“They’ll have a ratio of how many care coordinators they need, maybe one care coordinator for every 5,000 patients, which ends up being one coordinator for every 750 chronic care patients,” Gandhi says. “Maybe the coordinator will be placed in the primary care practices, or maybe they’ll be bounced back and forth between a few practices.”

Gandhi said while he considers this the less comprehensive approach, it is nevertheless an improvement.

“It’s a much better and higher-touch model of what health plans do for their chronic care patients through their disease management, case management and care management programs,” he says.

Rebuilding from the ground up

The second approach, Gandhi says, is essentially an overhaul of the existing chronic care model.

“These ACOs decided that they were going to shift patient panels a little bit, because they believe that some physicians are better equipped to manage chronic patients than others,” he says. “Also, by concentrating more chronic patients in a couple of practices versus having every one of their 70 primary care physicians handling a couple hundred of them kind of brings it together a bit. Then we can invest the right resources in those practices.”

Some of these resources might include hiring a behavioral health specialist, a clinical pharmacist, a diabetes educator and other appropriate professionals.

“Rather than having four physicians who have panels of 1,800 patients, of which 300 are chronic, we now have a larger panel of chronic patients in one practice,” Gandhi says.

With this type of concentrated approach to chronic care patients, the ACOs can direct the necessary investments for chronic care into this block of the population.

“So when the patient comes in for their visit, it isn’t just the standard seven-minute examination where you get your weight and blood pressure checked,” he says. “Instead, they’ll actually have a 35 to 45 minute visit, where maybe they will see the physician for 20 minutes, then a diabetes educator or a nutritionist, or maybe a behavioral health professional-and they get all of that in one visit.”

In particular, he says, incorporating a behavioral health counselor or other mental health professional into a single visit is invaluable.

“When doctors refer patients to a behavioral health professional, 70% of patients never go through with the referral,” Gandhi says. “Maybe it’s a little bit of fear or embarrassment that’s stopping them. But also, patients who have chronic conditions are spending enough time in the healthcare system.”

When all of these services are included in one visit, it not only provides convenience for the patient, but also assurance that necessary care is being delivered.

“It’s addressing not just the patient’s physical condition, but their overall health,” he says.

Specialty clinics

The ACOs that have been investing heavily in this newer approach have begun to tailor their model to suit patients with specific chronic conditions.

“Some of these ACOs have said, ‘What about our patients with heart failure?’ Patients with heart failure typically get primary care from a cardiologist,” he says. “So this ACO actually built a heart function clinic.”

Furthermore, for this particular ACO, the first patient to walk through the doors of the heart function clinic in 2012 had been hospitalized for heart failure eight times in six months, according to Gandhi. 

“For the next 12 months after that, she wasn’t hospitalized at all,” he says. “So this is where you see an important difference. This was a patient who was in danger of not living very much longer.”

ACOs are exploring similar approaches to nephrology and oncology.

“A lot of cancer patients, for example, have other conditions; but once you have cancer, your primary care doctor doesn’t really get involved,” he says. “So what this group did-and it’s not necessarily right for everyone-is they hired an internal medicine physician and plopped them down in the middle of an oncology practice. They didn’t want to have a primary care doctor who was disconnected from all of this.”

While approaches like this are groundbreaking, they are difficult to put into practice.

“Very few ACOs are taking this approach,” Gandhi says. “It’s expensive, it’s a fundamental redesign and it requires a tremendous amount of physician buy-in. It also requires a certain level of self-awareness, which in this country is pretty terrible.”

He says the fee-for-service model has, to some extent, slackened the competitive spirit that drives innovation.

“In a normal industry, you have competition based on what is best for the customer," Gandhi says. "The people who innovate win, and the people who don’t innovate copy the people who do. I think we have taken that out of healthcare with fee-for-service, and some of these ACOs are looking at this and saying, ‘All right. We have to catch up on 30 years of innovation here.’”