What can ACOs learn from Europe?

Accountable care demands continuity of care
By Mike Miliard
09:23 AM
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Earlier this spring at HIMSS15 in Chicago, HIMSS Analytics Executive Vice President John Hoyt led an education session about the Continuity of Care Maturity Model he and his colleagues helped devise.

During the session, the audience was asked how many hailed from outside the U.S. "Two out of three hands went up," says Hoyt.

Accountable care and care continuity are not the same things, of course. But they have a whole lot in common. And the former pretty much depends on the latter.

[See also: ACOs hamstrung by poor data exchange]

"The rest of the world," says Hoyt, is "more into continuity of care than the Americans are."

Launched in 2014, the eight-stage CCMM puts a focus on interoperability, health information exchange, patient engagement and clinical and business intelligence – all necessary components of care coordination for population health.

ACOs and other value-based initiatives have been pursuing these goals in earnest these past few years. But in many parts of Europe and elsewhere in the world, care continuity has been the byword for sometime.

In single-payer Europe (or, in the case of the Netherlands sextuple-payer: "there are six insurance companies that all have to provide the same level of benefits, like six companies offering Medicare"), "they're very attuned to continuity of care," he says. "They're more holistic in their view of healthcare than we are."

In the U.S., of course, attitudes and incentives are very, very different.

"We have so much of a competitive environment in our healthcare that it's disjointed," says Hoyt. "That's why we built this CCMM. Because that really is the next big thing."

The model was not explicitly developed with accountable care in mind. But driving efficiencies within big health systems and across their spheres of influence was a big motivator – as was a vision for a truly global strategy for coordination. In fact, says Hoyt, much of the input as it was created came from European stakeholders, from Germany, Italy, Scandinavia and the Netherlands.

I ask Hoyt what Europeans think of America's fairly recent – and sometimes halting – pursuit of the ACO model. Having embraced value-based ethos for decades, do they think it's … cute?

[See also: Europe sets goal of EHR interoperability by 2015]

"Yeah," he says. Hoyt recalls a recent conversation with a public health official from Sweden: "You Americans are too focused on hospitals," he paraphrased. "They're a big cost center. You're focusing on something we don't want people to use, and you should focus on the bigger picture."

"She's right," says Hoyt. We need to shift our emphasis toward ambulatory care, just as they have in Europe. "They just have that as part of their culture: Sweden, Finland, Norway, Denmark, the Netherlands and maybe the NHS."

But European countries hardly have everything figured out. And in some respects the States' post-HITECH push these past few years has left us ahead of the game. "The truth is they still have gigantic holes in the electronic medical record in the acute care world. They lack a lot of cohesion inside the hospital because there are so many best-of-breed type hospitals. Like we were, before the late-'90s."

At the same time, says Hoyt, "you can criticize the fact that they're missing pieces in the hospital, but that which they have, they openly share, because they are very, very oriented to the whole continuum of care. They want people to get healthy, stay healthy, use services that are not expensive, stay out of hospitals."

So we have them beat on the technology side but they're much further along with the philosophical ethos of sharing. Sounds about right. But we're getting there on the latter point – if only because the Centers for Medicare & Medicaid Services, with its ambitious new goals for the transition to value-based care, is helping force the issue.

Just this past month, CMS announced that, despite some early struggles, despite some dropouts, the ACO program has realized some very encouraging savings, and it will be expanding the program.

"Ages and ages ago, we started HMOs, federally funded, but hospitals lost money and got out," says Hoyt. "So we've had some ACOs get out too. But there's still staying power in some of the big ones."

But from the point of view of Northern Europeans, it should never have taken so long to get to this point. "I think they look at ACOs and say, 'Well, yeah. That's what you should do. It's kind of what we do,'" says Hoyt.

He points to one of the few HIMSS Analytics Stage 7 organizations in Europe, Hospital de Dénia-MarinaSalud, in Alicante, Spain, which is also a HIMSS Davies Award winner.

"They're really an ACO. They don't use the term, but they are. They're paid by the Valencia government on a per capita, per month basis to maintain health for the people who live in a certain geographic area. That's an ACO. So there are other places in the world who are doing this."

In the states, despite some early roadblocks, "we're coming along, getting out of our shackles."

Consider a success story like Boston-based Atrius Health. It's "thriving," says Hoyt. "Their costs are lower than the average ACO."

So where would an Atrius sit, theoretically speaking, on the CCMM?

"This is not your typical HIMSS Analytics thing where we collect data and give you a score," he explains. "There are several areas in which we measure you: policy, analytics, IT support for continuity, governance support for continuity – governance includes your own system as well as your regional government and health authority: for which our country has low scores – and clinical informatics."

What's more, "in each of those pillars there's a set of questions that derive a score," says Hoyt. "You could get Stage 5 on analytics and Stage 2 on governance, or something like that. It's a more complex structure, but it's intended to be a benchmark. In a year or two you can do it again to see how you stack up to your peers."

So an ACO would be judged on a multitude of factors, in other words, and some might be stronger than others.

For clinical analytics, they may be very good. And they may be good – but not great – on IT. Because of course there's more involved with care continuity than just having an EMR and a patient portal.

"What about public health? What about long-term care? Are they getting an electronic medical record for that patient over the whole continuum? That's just not a strength in the U.S.," says Hoyt.

Put another way: Even the providers who are embracing ACOs in earnest could be scored pretty low on the CCMM.

"I think they're going to be low to medium," says Hoyt. "We have to counsel people: The vendor comes and says, 'They're going to score great!' I can pretty much just ask the vendors a few questions, like, 'What do they do for long-term care?'"

It's yet another argument for the fact that leaving long-term and post-acute care out of meaningful use may have been a big mistake if accountability and care coordination really are the goal.

"Interestingly enough, we've had some conversations with some providers on helping us build an EMR Adoption Model for long-term care," says Hoyt. "I am all for it. Collecting the data is a whole 'nother subject, but there's no reason we can't do it."

Back to Europe: Hoyt mentions EMRs he's seen in Helsinki that aren't merely "medical" record, but are essentially "a social support system," he says. The data they track goes far beyond weight and blood pressure to "economic indicators of health: Can you walk to the grocery store and get fresh vegetables? That's the kind of stuff they want in the patient's record. Find me a physician in the U.S. who collects that in the EMR."

But such a shift – to prevention rather than treatment, to ambulatory rather than inpatient – is coming.

"It has to," he says. Luckily, the trend lines show acute care "shrinking" in the U.S., he says. "In our database, the average hospital is under 150 beds. That's strikingly small compared to a lot of places in the world. So we are making progress. Ambulatory and continuity of care is the future."

Meanwhile, ACOs still have a tall order when it comes to connecting data from different care settings. The nirvana of continuity would include "the patient's record from primary care, specialty care, urgent care, inpatient care, post-acute, long-term care, hospice, public health," says Hoyt. "One continuous record for the patient. That's the goal."