The Affordable Care Act (ACA) is a major driving force in reshaping the healthcare industry today. In addition to greatly expanding healthcare coverage and mandating participation, ACA provides the guidance for the creation of accountable care organizations (ACOs) and their participation in the Medicare Shared Savings program. The purpose of ACOs is to bring healthcare organizations to coordinate care for a defined population with the goal of improving quality and reducing costs. This will have broader implications for not only providers, but also health plans and consumers beyond the Medicare population as all of these parties will be expected to work together to coordinate care with the goal of improving health outcomes and reducing costs.
The T2C Difference
Developing and implementing a successful coordinated care strategy can be one of the most challenging endeavors attempted by a healthcare organization. In the past, providers and plans focused on a division of financial and care responsibilities. But in a world of coordinated care, plans and different providers must collaborate to recreate the value chain. This requires a thorough reassessment of what of their value creating activities—their “secret sauce.”
T2C is well positioned to advise healthcare organization across the value chain from providers looking for coordinated care initiatives to health plans looking for new ways to compete in this changing landscape.
ACOs and Other Coordinated Care Initiatives:
ACOs are not entirely new. Past and existing efforts to pay providers for managing costs and improving quality include capitation and share risk payment models, bundled payments and pay for performance programs. However, whereas these arrangements are paid and directed by health plans, the ACO model allows providers to set their own standards and administrate their own program. The significant shift requires ACOs to:
- Develop clinical science (e.g., disease management and population care) and uniform clinical practices
- Design and executing organizational strategy and governance
- Achieve buy-in and committed participation by providers
- Implement systems and processes that support coordination of care across the care continuum
- Create data reporting to support financial reimbursement
- Develop outcomes research to support ongoing clinical and process innovation
The Affordable Care Act has also required significant changes by health plans, which must respond by reducing its administrative costs and managing its medical cost. In addition to this, ACOs may assume some health plan responsibilities in the areas of care management, disease management, pharmacy management, network management, provider management and financial reconciliation. How should health plans respond to cost reduction requirements and threats to its value proposition? What is its future role in providing coordinated care for consumers? In answering these and other critical questions, health plans may consider the following insights:
- Achieving administrative cost reduction is not enough; health plans must continue to differentiate themselves to consumers by providing better services and clinical care networks
- At present, ACOs are regional; health plans must evaluate each region individually when they conduct their assessment and develop strategy
- Developing and maintaining systems and capabilities to support coordination of care requires significant scale and capital and health plans can leverage their capabilities and creatively partner with providers to support coordinated care
- Collectively, ACOs will collect invaluable information; by providing a common platform for the sharing of clinical and outcomes data with ACOs, health plans may develop a major strategic asset used to evaluate its strategy and develop innovative programs
Consumers are absorbing an increasing share of total healthcare cost. As a result, they are increasingly looking for affordability and value when they make healthcare decisions. The introduction of health insurance marketplaces will further improve the ability of consumers to compare offerings by health plans. In addition, consumers are becoming increasingly informed and are demanding greater transparency from health plans and providers. Working with an increasingly sophisticated and demanding consumer presents challenges and opportunities for plans and providers:
- Health plans must rethink their consumer strategy to build intimacy and engage a more connected, motivated and informed consumer
- Providers will need to engage consumers to manage their health and make the right lifestyle decisions
- Health plans and providers need to invest in capabilities that enable consumers to view their personal health information, manage their care and understand the financial impact of care decisions at the point of care
Are you ready for the ACO revolution?
We’ll help you get there. Partner with T2C today.