An emerging health delivery system that rewards doctors and hospitals for working together to improve quality while controlling costs may lead to better end of life care and advanced directives.
That is the hope of a growing number of medical providers that are testing a popular new model known as “accountable care organizations,” or ACOs, that coordinate medical treatment in hopes of improving outcomes and lowering the nation’s total health care cost.
The ACO model is in sharp contrast to the now predominant fee-for-service medicine in which doctors, hospitals and other care providers are paid for each service to each patient in a system. Fee-for-service medicine can lead to potentially excessive treatment. End of life care can often be a time when patients get the most care, and it is known for not being coordinated or effective.
“ACOs can provide a strikingly better experience for end of life patients and their families,” said Dr. Donald S. Furman, senior director of health management services at consulting firm Oliver Wyman. “Traditional healthcare providers have really limited tools for organizing care, so end of life patients are subjected to arbitrary decision making, poorly executed handoffs between doctors and facilities, and lack of continuity. It’s stressful and confusing, it causes fear, and in my experience, it leads to unnecessary medical crises that are devastating for families.”
In an ACO model, end of life planning starts well in advance, Furman says, and includes “policies, procedures, and training to make all of the pieces work together for the patient and the family.”
A team approach to health care delivery is key to the ACO, according to Reid Blackwelder, president-elect of the American Academy of Family Physicians, which is supporting various team approaches to primary medical and accountable care.
“You call people, you touch base, you work as a team,” Blackwelder told more than 200 journalists at the Association of Health Care Journalists Health Journalism 2013 conference in Boston this March. “You work within the community.”
In an ACO, doctors and hospitals are rewarded for improving quality of care and patient outcomes while at the same time controlling rising costs. These entities, though largely invisible to the consumer, contract with private health plans or Medicare to provide services to populations of patients.
The ACO model is intended to have doctors and hospitals take responsibility for managing the care of Medicare beneficiaries, and providers would be financially rewarded for improving care and saving dollars. The ACOs contract with private insurance companies or Medicare, adhering to more than 30 outcome and quality measures. If the providers in the ACO achieve better outcomes, they divvy up money saved with the health plans.
In January, the Centers for Medicare & Medicaid Services reported that as many as four million Medicare beneficiaries will be receiving care from more than 100 ACOs that have signed on to participate in the “Medicare Shared Savings Program,” an initiative under the Affordable Care Act. Private insurers are also contracting with ACOs, and Oliver Wyman research shows that about 14 percent of the U.S. population is now in an ACO or similar health care delivery system.
Providers that are incorporating end of life care and advance planning into their ACOs say most end of life care puts all the medical providers on the same page so the entire team knows what the patient wants and needs.
“We look at the ACO as an opportunity to provide higher quality palliative care and hospice services to Medicare beneficiaries,” said Dr. David DiLoreto, chief medical and innovation officer at Presence Health, a large Catholic operator of hospitals in Illinois.
“We do know that a higher degree of care coordination eliminates redundancies and repeat testing, and it allows for patients’ wishes to be understood at the end of their lives,” DiLoreto said.
Often when patients near the end of life, they have several health issues and are seeing multiple health care providers. While they could have a primary care physician for much of their lives, they tend to have an array of specialists that might not even know the patient’s history, let alone whether they have an advanced directive.
“Each doctor does not seem to know what the last doctor is doing,” DiLoreto said. “In an ACO, we are increasing the availability of these teams. Patients are assured that there is a team and that they are working from the same play book.”
At Presence Health, doctors and hospitals report they are advancing patient care through a “digital patient engagement strategy” incorporated through its ACO that uses technology to “engage patients in a new way,” DiLoreto says.
The digital strategy was incorporated into Presence’s application for an ACO, which was approved earlier this year by the Centers for Medicare & Medicaid Services.
A growing number of health systems see the ACO as a way to improve outcomes for patients at the end of life through better care coordination.
Though it is unclear how end of life care would work in each ACO nationwide, studies have shown care coordination is needed in end of life care. The British Medical Journal reported in 2010 that “a coordinated, systematic model of patient-centered advance care planning” leads to better identification of a patient’s wishes, improves care and “diminishes the likelihood of stress, anxiety and depression in surviving relatives,” authors concluded.
“You can make investments in care coordination capabilities,” DiLoreto said. “It’s the right thing to do.”