"The goal of this is to improve the care of all of our patients, not just those in certain payment arrangements," said Dr. Stephen Hippler, vice president of quality and clinical programs for OSF Medical Group.
Dr. Michael Weiss
Most of the ACO-related preparations at OSF have occurred in the primary care setting, expanding the breadth and depth of their patient-centered medical home. But Dr. Hippler said there also is a critical role for hospitalists. The health system has developed a number of projects aimed at improving transitions of care, from risk stratification at admission to medication reconciliation to creating a more robust discharge process.
Hospitalists also will have a significant role in guiding patients to the appropriate level of care after discharge, he said. Similarly, the Pioneer ACO at Monarch Healthcare in Orange County, Calif., asks its 25 hospitalists to think about transitions of care immediately after finishing their history and physical with a new patient.
Hospitalists are in a unique position because they exist at a point of care where many inefficiencies and redundancies occur, said Dr. Michael Weiss, a pediatrician and the medical director of quality and performance improvement at Monarch Healthcare.
"Hospitalists are an absolute key to this equation," he said.
Getting the hospital piece right is critical for any ACO to be successful, since about a third of the dollars in the health care system are today spent in the acute care hospital, agreed Dr. Ron Greeno, chief medical officer for Cogent HMG and chair of the public policy committee at the Society of Hospital Medicine.
"If you don’t control those inpatient dollars, it will sink you when you start taking [financial] risk," he said.
As a result, the demand for hospitalists is only going to grow, but so will the expectations in terms of the scope of care. "The bar is going to be raised," Dr. Greeno said.
One of the biggest challenges for hospitalist leaders preparing for the ACO world is that they are still operating mainly in a fee-for-service system that pays for more care, not necessary better or more efficient care.
And many hospital medicine groups simply aren’t prepared to make the leap to the coordinated care model because they haven’t laid the groundwork in improving discharge and transitions of care, he said.
To get ready, Dr. Greeno advised hospital medicine groups to take a series of steps that are simple in concept, but much more difficult to execute. For starters, the financial incentives have to be aligned so that hospitalists keep patients out of the hospital. Physicians also need to take a standardized approach to clinical functions and other nonclinical hospital processes. Additionally, the internal and external communications must be working well and hospitalists need to be able to track and interpret data.
Even though it’s early on in the emergence of new care delivery models such as ACOs, hospitalists must start to change their mind-set and realize that the hospital is a cost center, not a profit center, said Dr. Bradley Flansbaum, a hospitalist who blogs about health policy issues for The Hospitalist Leader.
In this new world, physicians should be doing everything they can to move patients out of the hospital efficiently. But exactly how their performance will be measured is unclear. While CMS and other payers use "rudimentary" core process measures to assess hospitalist care, there are real questions about whether these metrics are valid indicators of better care delivery, said Dr. Flansbaum, a member of the Society of Hospital Medicine’s public policy committee and the society’s representative to the American Medical Association’s House of Delegates.
"We have crude tools right now to really measure people," he said.
With those measures in flux, the best strategy for hospitalists is to focus on the areas that are sure to be important in ACOs, such as discharge planning, medication reconciliation, and communication, Dr. Flansbaum said.
Other than that, hospitalists can wait and see how the model develops and if the Pioneer ACOs are able to deliver on the promise of better quality at lower costs. The consolidation that is occurring in some ACOs could result in cost-saving economies of scale, but it also has the potential to drive prices up, he said. Another question mark is whether the model will catch on around the country. For instance, high-performing health systems with low costs, like the Mayo Clinic, may opt not to make changes.
"There’s a lot of folks who are questioning whether or not this whole ACO model is viable for every hospital and every place," Dr. Flansbaum said.