Accountable Care Organizations and the Collaboratives Mantra by Jim Bloedau of Information Advantage Group

It was my first time at American Health Insurance Plans (AHIP) last week in San Francisco and although it is the leading conference for the health insurance industry, attendance was rather small, when compared to HIMSS, and didn’t seem to have much energy that went past their keynote speakers which included Tim Pawlenty and Tom Daschel. 

The agenda was surprisingly shallow.  For a time when collaboration is the current mantra of this side of the healthcare industry, it didn’t include any providers talking about what they needed or offering perspectives – content was pretty much the basic blocking and tackling of the insurance/reimbursement process.

A couple of insurance executives and former provider cohorts now working the payer side I spoke with characterized the overall industry’s demeanor as being more than a bit concerned about what reform is going to do to them –“How much will the government take away?” was the common fear.  They also though that most of the sessions were “the same old stuff” when I asked about what was exciting or new at the conference…not very positive.  Here are my major observations.

Collaboration:

Collaboration the “NEW Way” was clearly an understated theme by speakers and confirmed by all senior management that I spoke to at the conference as the only recognizable offering that would qualify as the buzzword of the conference. 
This notion that collaboration within the payer/provider/consumer continuum is the emerging model of the healthcare insurance industry’s conversation flavored a number of sessions that I attended, but I wouldn’t call it the “hot sauce” of the conference…there just wasn’t any.   The recognizable flavors of this strategy were: 

·         Collaboration with the patient during the entire “episode of care.”  This would not just take the form of reacting to a “disease crisis” that calls for admission to an acute care facility and is common to the fee-for-service model.  It is a continuance of care management  until the conclusion of the “disease episode “ that eventually ends at home with a cure, stability or may become chronic and continues on until end of life - a major tenet of the burgeoning value-based, shared-saving models of reimbursement.

·         Collaborating with the patient/consumer to promote health and wellness.  This flavor of collaboration seemed to be a competitive design to meet a reported call by customer companies and consumers to move past patient completed Health Risk Assessments (HRAs) which are very subjective.  HRAs have been around for some time and BC/BS stated that they are hearing from their customer that they want to move past subjective assessments to biometric data collection - a plus for the mobil, hand-held and participatory healthcare advocates. 

Both of these are measures that could be seen to be part of promoting coordination of care or better outcomes and may fall under HHS’s plan and definitions of “activities that improve health care quality” under Medical Loss Ratios (MLR) rules that include efforts to: 

·         Improve health outcomes

·         Prevent readmission

·         Encourage wellness  and prevention programs

·         Improve safety and reduce errors

·         Use health IT  for quality improvement

BUT, these are the early days and all are doing their best to figure out when and how reimbursement will flip from fee-for-service  to quality-base episodic reimbursement with shared savings.  Certainly all realize that an increased level of cooperation between payer, provider and patients is called for.  The big challenge will be creating this level of trust in an environment that will include FFS for some time and after decades of payer-provider antagonism. 

Accountable Care Organizations:

Shockingly, only one session had “Accountable Care Organization” in its title and was mentioned in passing in several others I attended and sparsely on the exhibit floor.  The one session that did was hosted by Deloitte which cleverly included a real-time survey of the attendees using texting.  The survey of session attendees showed: 

·         What was causing their interest in ACOs:  56% stated premium rates and margins, 40% outcomes - it’s about money first and then the "care" thing.

·         What was the best way to stand up an ACO: again, 56% thought medical home, 32% thought an Integrated Delivery System and 27% diagnosis (CHF, diabetes, etc.) specific or boutique ACOs was the way to go.  Early pilots of medical home have been very positive in controlling costs - again, it’s about money first.

The host of this session clearly and wisely encouraged the reality that the tighter the analytics the more competitive you can be.  No mention of the complexity of the infrastructure required by the provider, many whom will be virtually starting from scratch, to do so was heard. 

With physician consolidation, ICD 10, EHR, MU, HIE and now ACO/Medical Home infrastructure filling the plates of providers, seeking collaborations that fosters better data analytics, reimbursement dissemination and qualifying for MLR rules may be problematic.  Combine this with the notion of building trust in the face of an adversarial history between payer and provide and we can expect some spectacular failures by payers trying to merely “collaborate.”