Q&A: Expert points to IT power of ACOs

By Bernie Monegain
09:32 AM

Dogu Celebi, MD, is chief medical officer, payer and government solutions at OptumInsight (formerly Ingenix). Before joining OptumInsight, Celebi developed disease and care management programs for CIGNA. He spoke with Healthcare IT News about the role of health information technology in supporting accountable care organizations (ACOs).

Are ACOs a “back to the future" to managed care?
I don’t know that I agree with that, partly because a lot of people use that in a negative connotation. I think ACOs are the beginning of the future. There are a lot of lessons learned with the system’s experience in the ‘90s and early 2000s, in the context of either managed care or capitation – both good lessons and bad lessons. I think a lot of the lessons are incorporated into the concept of ACOs. ACOs are really, in a way, the market’s transition from silos to a well-coordinated and aligned system of care, where care is centered around the patient and delivered by effective delivery systems. I think people refer back to the experience as it particularly relates to gatekeeper models and capitation models. But, I don’t see ACOs as back to the future.

[See also: CMS extends application deadline for ACO pioneer project.]

What is the biggest challenge in creating an effective ACO?

Both from the perspective of where the delivery systems have been, as well as what their focus has been, if you look at the past 20 years, and if you look at delivery systems that are transitioning or planning to transition into ACOs, what they’ve been concentrating on and what they’ve been investing in, the biggest challenge is coming from the healthcare information technology perspective.

They have made significant investments in workflow systems in automating and optimizing clinical workflow and delivery settings, but if you look at the ACO concept and particularly concepts around coordinated and collaborative care, what’s required is very effective information infrastructure both from an analytical perspective as well as decision support perspective. A lot of them have either not invested in those types of capabilities or they do not have experience in implementing analytical informatics capabilities. Another challenge is really connectivity, from an IT perspective again. Developing an effective information technology infrastructure that will enable collaborative and coordinated care is a key missing ingredient in a lot of these organizations.

[See also: New ACO at work in Tucson.]

What is the biggest advantage of an ACO to the clinician? The patient? The payer?
One of many advantages that comes with well-coordinated and collaborative care is the patient is at the center of that care delivery model. Not that delivery is organized around the patient’s needs, but also delivery is organized around the fact that patient needs vary from medical condition to medical condition and when they’re healthy versus they’re in acute need of care. The system is not able to adjust to those varying needs. At the end of the day the system does not really deliver collaborative and coordinated care.

So, from a patient’s perspective, (an ACO) is almost a customized delivery system. From a provider perspective, these new models give a provider the ability to concentrate on patient quality and outcome rather than a traditional way of looking at care delivery, which is designed to maximize encounters because that was the incentive provided by the fee-for-services model. Ultimately, if you ask any clinician, they would agree that their number one priority has to be patients and patients’ wellbeing, not necessarily maximizing the number of encounters they can squeeze into a day. In a sense, potentially this type of delivery re-organization has not only financial benefits for physicians or caregivers, but more importantly from a personal and professional satisfaction and quality perspective, that has positive implications as well.

From a payer's perspective, traditionally what has been a mix of responsibilities for an insurer or payer – and I’m referring to managing financial risk as well as clinical risk – this gives payers an opportunity to concentrate on what they’re really good at, which is managing financial risk and letting providers or care teams, who are experts in managing clinical risks, manage that risk effectively and produce a lot more desirable outcomes, both financial and clinical.

What critical role does healthcare IT play in an ACO model?
The role of health IT is probably broader under the ACO model than under any other healthcare delivery organization. One of the reasons for that, if you look at some of the core capabilities that are critical to the success of this model, whether it’s provider network strategy – meaning incentivizing providers to do the right things as well as providing information to do the right thing, integrated care delivery models, care coordination and various new payment methodologies and also enabling collaboration among different team members – these are all concepts that require a great deal of information technology solutions as well as analytical and data solutions because in order to coordinate care effectively you need to know what the patient needs, what has happened to the patient and what might be needed in the future.

In order to create that type of delivery system, you have to be connected. All the parties that have participated in the creation of the ACO need to be connected. All the systems that are in place, or the future systems that are going to be put in place, need to be interoperable. In order to achieve collaboration and cooperation, the clinical portfolio needs to be automated. In order to be automated, you need IT solutions. On top of this automated clinical workflow you need analytical intelligence where you can make sense of this incredible amount of clinical and non-clinical data, If you look at all these different types of capabilities, it becomes clear to me that healthcare information technology, whether it’s as workflow management solutions, whether a connectivity solution, whether data warehousing, analytics, decision support, these are all critical pieces of healthcare information IT – the infrastructure for an ACO.

Is there any one provision in the proposed ACO rule that you would particularly want to change?
One of my personal perspectives is on the assignment of numbers of beneficiaries to ACOs. I believe in order to achieve patient engagement, which is a critical issue in achieving the quality, cost and outcome goals, is the prospective assignment of members or beneficiaries to ACOs. I understand why CMS has gone with the retrospective model, but I think we can achieve similar goals by combining prospective assignment with perhaps a retrospective settlement of performance because their concern was that in order to look at performance you really need to look at retrospective utilization of use of a system by the beneficiaries. I believe that in a retrospective assignment it’s hard to get patients engaged in their care, and therefore it’s going to be much harder to achieve patient engagement, participation and shared decision-making.