The Interface Between Accountable Care and Managed Care: Real World Insights and Innovations

Since 2010, the growth and proliferation of accountable care organizations (ACOs) has increased, and the rise of this collaborative care model is not without reason. Lack of consumer engagement, lack of competition, and misaligned incentives have made care less affordable. Underdeveloped quality measures, unusable information, and misaligned incentives have stagnated quality. Healthcare has also been made less accessible due to a primary care shortage, healthcare market complexity, and prohibitive costs. Integrated care, however, remains an exception to these challenges. ACOs have a proven impact on both healthcare cost and quality.

“Integrated care is better care,” said Thomas Merrill. “A common misconception is that ACOs represent providers, when in reality groups like Advocate Health rely on a collaborative relationship.”

Existing ACOs participate in a variety of organizational structures, payment methods, and risk-sharing arrangements. Some example model types include the small physician group ACO, the hospital-physician ACO, the hospital-led ACO, and the Medicaid ACO. There is high hope for the model, as the government projects that Medicare ACOs will save $1.9 billion between 2012 and 2015.

Robert Schoenhaus, PharmD, director, pharmacy benefits administration at Sharp Healthcare, adds that limited pharmacy services with ACOs can impact quality. To maximize pharmacy resources to support patients, physicians, and staff, professionals should look to “Path to Primary Pharmaceutical Care.” The steps for the path include: know the model and adapt, build the team plan for savings, build the systems, find the targets, and monitor and report your progress. Through commitment to this process, pharmaceutical stakeholders can leverage medical systems and position themselves for ACO quality improvement and shared savings. Dr Schoenhaus suggests pharmacists become engaged as “providers on the care team.”

There are challenges to replicating collaborative programs and services in different patient populations and demographic areas. Variances in geographic distribution and variability in governance structure are just 2 examples. Nevertheless, ACOs have found success in interventions that include a focus on pharmacy as they more effectively improve outcomes and reduce costs. Such interventions include improved care coordination between physician offices/specialties, discharge planning and follow-up for hospitalized patients, and identification and management of high-cost/high-use patients. However, the most successful interventions focus on readmission and pharmacy related matters. Dr Laura Happe, associate professor of pharmacy, Presbyterian College School of Pharmacy, says Geisinger Health System, for instance, utilized case managers to follow up with high-risk patients with phone calls. To reduce their workload, they implemented an interactive phone system.

“This interactive voice response system basically replaced the case manager’s time calling the high-risk patients,” Dr Happe explained. “It would ask the patients certain questions, and if they responded in certain ways, then it would flag them as being at a potential high risk for readmission and then they would move forward with an intervention They were able to reach a lot more patients because it reduced the case manager’s time, and so they had a very sustainable reduction of 44% in readmissions in 30 days.”

Trends suggest that ACOs will continue to demonstrate results over time as they strategically focus on preventable readmissions, pharmacy services, and case managers’ roles. Dr Rebecca Cupp, vice president, Ralphs Pharmacy, additionally noted that “Community pharmacies are untapped resources to aid in reducing readmissions, decreasing drug costs, promoting adherence, providing pharmacy-specific data, and disease management,” and that “Pharmacists are amply educated to serve on the care team in transitions of care,” especially in medication therapy management.