Case Study Analysis Case 5: Accountable Care Organizations Ashley Lewis South University Online MHC 6999: Case Studies in Healthcare Organizations Professor Mountasser Kadrie, Ph.D. 21 January 2015 Executive Summary An Accountable Care Organization or ACO primary purpose is to provide quality care to Medicare patients (CMS.gov, 2015). Also, ACO’s help to reduce unnecessary reproduction of services and medical errors (CMS.gov, 2015). An ACO can consist of physicians, hospitals, and other healthcare organizations. From the article provided, many organizations would like to become an ACO. Unfortunately, most healthcare organizations are not equipped due to lacking of technological infrastructure and other core technology needs. …show more content…
Based on the case study, I addressed some key issues for organizations trying to become an ACO. The biggest issue faced by organizations is due to being blindsided about certain expectations. An external environmental analysis and an internal environmental analysis was obtained. Also, a pie chart was provided to display the top challenges of becoming an ACO. The external environmental analysis provided healthcare organizations who participated in ACO. The internal environmental analysis discussed the strengths and weaknesses of organizations part of an ACO. The strategy was formulated to address the issues that ACO’s lacked. Recommendations were made in reference to key issues addressed in the implementation of ACO’s. The strategy implementation will address how the strategy formulation would be carried out. Lastly, the benchmarks would provide a measurement for success for the ACO. Key Issues The primary issue with implementation of an ACO is that many insurance companies were blindsided.
There was not much detail available for the ACO implementation model. Insurance providers felt there was not much structure based on quality and effectiveness. Many insurance providers looked to build their own ACO. The framework for the ACO was variable. The ACO framework presented different results when it came to infrastructure, operations, and performance. Another ACO concern is lack of integration when evaluating different benefits among various insurance providers. The ACO framework would become more complicated. Overall, this made it more difficult for patients to understand (Goedert, …show more content…
2011). External Environmental Analysis The external environmental analysis will provide an overview of the threats and opportunities of an ACO. There are five national pilot sites who are participating in implementation of an ACO. The five national pilot sites include: Norton Healthcare-Humana; Carilion Clinic; Tucson Medical Center; HealthCare Partners Medical Group; and Monarch HealthCare. The implementation of the ACO is carried out by Engelberg Center for Healthcare Reform at Brooking Institution and Dartmouth Institute for Health Policy and clinical practice (Goedert, 2011). According to a survey conducted by Healthcare Intelligence Network, 228 healthcare organizations provided the top five challenges to starting an ACO (American College of Emergency Physicians, 2012). The top five challenges include: cost (22 percent); staff/management buy-in (20 percent); other (18 percent); reimbursement (12 percent); and evidenced based care (8 percent) (American College of Emergency Physicians, 2012). (American College of Emergency Physicians, 2012) Internal Environmental Analysis The internal environmental analysis will provide an overview of the strengths and weakness of ACO implementation.
There are companies like Norton Healthcare and Humana who has teamed up to improve healthcare. Both Norton Healthcare and Humana wanted to build their ACO internally by their own standards instead of being pushed from outside forces. Norton Healthcare and Humana were able to address breaches in payer claims. Addressing breaches in payer claims is essential to help reduce cost while improving access to healthcare. Parrish Medical Center has also implemented an ACO in hopes to expand to other stakeholders within the community. The downfall is that many healthcare organization think that implementation of an ACO is done overnight. ACO implementation can take up to five years. Also, the payer delivery system is not concrete in the beginning. Any information on patients who were seen by physicians outside of the organization are not seen. Data such as emergency department charges and payments can be easily missed (Goedert,
2011). Directional Strategy In 2009, the HITECH Act was passed to put the healthcare industry in a position to support information technology infrastructure in reference to healthcare reform. The use of information technology is important when implemented ACO’s. Both are needed to increase quality of care, arrange patient care, and reduce annual cost. When these goals are obtained, future ACO’s will be rewarded by reimbursement incentives such as saving programs (Goedert, 2011). Strategy Formulation ACO strategy formulation can be based upon many things. The strategy formulation is considered important and can be analyzed under different circumstances. The primary focus would entail finding a solution to the problem. In order to adapt to increase change, the financial infrastructure and reporting infrastructure should be improved. ACO’s must ensure budgeting and monthly reports reflect the current status of the organization. Market entry would involve the use of data aggregation. Data aggregations would ensure new ACO’s have accessibility to shared administrative and clinical data. In order to stay competitive, ACO’s must review performance management, clinical data exchanges and role base security. Patient and procedure information would stay more accurate. Also, data for cost and quality would be monitored. This will help monitor trends among other ACO’s (Goedert, 2011). Recommendations Development for ACO’s should be centered on patient care. I will present the following recommendations to help improve key issues related to implementation of an ACO. The recommendations are followed: 1. Surveys used to compare results in the future. 2. A new process to evaluate the needs of ACO’s in their current population. 3. A system in place to measure the coordination of care. 4. Improvement with communication in reference to clinical knowledge and medicine to patients, physicians, and organizations. 5. A new process to measure clinical performance and effectiveness of ACO (White, Kallem & Bronnert, 2011). Strategy Implementation Strategy implementation starts within the ACO. Patient registries are useful when monitoring patient population (White, Kallem & Bronnert, 2011). Improved case management can help reduce cost for patient population (White, Kallem & Bronnert, 2011). Disease management programs would be essential when monitoring follow-up treatment (White, Kallem & Bronnert, 2011). The Centers of Medicare and Medicaid Service (CMS) has provided ACO’s with 65 quality performance measurements for the first quarter (White, Kallem & Bronnert, 2011). Also, to calculate quality performance measurements, CMS can use claims data and a group practice report model provided by CMS (White, Kallem & Bronnert, 2011). When it comes to sharing data, ACO’s and their affiliates are covered under HIPAA (White, Kallem & Bronnert, 2011). CMS requires ACO’s to participate in a data use agreements. The data use agreement requires ACO to not share Medicare information to anyone outside the ACO (White, Kallem & Bronnert, 2011). If the ACO doesn’t agree, the ACO will no longer exist (White, Kallem & Bronnert, 2011). The use of a clinical integrated network would increase competition (Anderson & Hogan, 2013). The use of employed and independent physicians would increase the success of an ACO (Anderson & Hogan, 2013). Benchmarks The measurement of success should be based upon cost efficiency and quality performance. The Centers of Medicare and Medicaid (CMS) has participated in a transitions demonstration (Zigmond, 2011). The transitions demonstration observes the position of a physician in healthcare (Zigmond, 2011). The transition demonstration monitors monthly data and growth expenditures against the national average (Zigmond, 2011). The focus is to improve the ACO model and entire healthcare system (Zigmond, 2011). Also, Medicare offers several ACO program alternatives. These alternatives include: Medicare Shared Savings Program; Advanced Payment ACO Model; and Pioneer ACO Model (CMS.gov, 2015). Medicare Shared Saving Programs helps participants become a part of an ACO (CMS.gov, 2015). The Advanced Payment ACO Model provided incentive for those who already participate in ACO (CMS.gov, 2015). The Pioneer ACO Model are for healthcare providers who participate in coordinated care (CMS.gov, 2015). References Anderson, D. G., & Hogan, N. C. (2013). Emerging 'super ACOs' unique needs. Healthcare Financial Management, 67(10), 88-92, 94. Retrieved from http://search.proquest.com/docview/1449531723?accountid=87314 American College of Emergency Physicians. (2012, November). Retrieved from Accountable Care Organizations (ACOs): http://www.acep.org/ACO/ CMS.gov. (2015, January 6). Retrieved from Accountable Care Organizations (ACO): http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ACO/index.html?redirect=/ACO/ Goedert, J. (2011, April 1). Getting ready for accountable care organizations. Health Data Management. Retrieved from http://www.healthdatamanagement.com/issues/19_4/getting-ready-for-accountable-care-organizations-42230-1.html?zkPrintable=true White, S., Kallem, C., Viola, A., & Bronnert, J. (2011). An ACO primer. Journal of AHIMA, 82(6), 48-51. Retrieved from http://search.proquest.com/docview/869069313?accountid=87314 Zigmond, J. (2011). Benchmarks met in ACO tryout. Modern Healthcare, 41(33), 12. Retrieved from http://search.proquest.com/docview/884186093?accountid=87314
Balance sheet lists assets, liabilities and owner’s equity. The assets listed on the balance sheet are acquired either by debt (liabilities) or equity. “Companies that use more debt than equity to finance assets have a high leverage ratio and an aggressive capital structure. A company that pays for assets with more equity than debt has a low leverage ratio and a conservative capital structure. That said, a high leverage ratio and/or an aggressive capital structure can also lead
CAH needs to add value to be able get more patients that will increase the profits for CAH. One way for CAH to add value would be to focus on disease management. Take diabetes, the patient would see a primary care doctor, got to an optometrist and get their labs done together and the providers would communicate with each other to make sure the patient is getting the care they need. The primary care doctor could make sure that the patients are reminded of when their next appointments are. Using web-based health also would help to add value ("Capturing the Value from Value-Added Services"). The Veterans Affairs Administration uses a web-based health notification system to allow patients to know what their lab results are and to refill prescriptions from their home that would then be mailed to
Membership Services (MSD) at Kaiser Permanente used to be a modest department of sixty staff. However, over the past few years the department has doubled in size, creating minor departmental reorganization. In addition the increase of departmental staffing, several challenges became apparent. The changes included primary job function, as well as the introduction of new network system software which slowed down the processes of other departments. These departments included Claims (who pay the bills for service providers outside of the Kaiser Permanente network), and Patient Business Services (who send invoices to members for services received within Kaiser Permanente). Due to the unforeseen challenges created by the system upgrade, it was decided that MSD would process the calls for both of the affected departments. Unfortunately, this created a catastrophic event of MSD receiving numerous phone calls from upset members—who had received bills a year after the service had been provided. The average Monday call volume had risen from 1,800 to 2,600 calls per day. The average handling time for each phone call had risen as well—from an acceptable standard of 5.6 minutes to an unfavorable 7.2 minutes. The department continued to be kept inundated with these types of calls for the two years that these changes have been effect.
Cimasi, R. J. (2013). Accountable care organizations: Value metrics and capital formation. (pp. 90-92). CRC Press. Retrieved from http://books.google.com/books?id=EDMTlDWYvmUC&dq=specific service payment bundled&source=gbs_navlinks_s
The way in which healthcare organizations need to implement a new strategy into their A/R departments comes from the realization that time of registration is the best time to ask the patient for payment (Souza& McCarty, 2007). Front end staff in the healthcare industry has not been responsible for collecting payment from the patient before services are rendered; that responsibility has been that of the A/R staff. There have been other healthcare organizations that have found solutions to problems within their A/R departments. Sutter Health was successful in identifying problems in their A/R department, finding solutions for those problems in their A/R department and implementing their solution program into their company. Sutter Health has set themselves up for continued success in their A/R department.
To guarantee that its members receive appropriate, high level quality care in a cost-effective manner, each managed care organization (MCO) tailors its networks according to the characteristics of the providers, consumers, and competitors in a specific market. Other considerations for creating the network are the managed care organization's own goals for quality, accessibility, cost savings, and member satisfaction. Strategic planning for networks is a continuing process. In addition to an initial evaluation of its markets and goals, the managed care organization must periodically reevaluate its target markets and objectives. After reviewing the markets, then the organization must modify its network strategies accordingly to remain competitive in the rapidly changing healthcare industry. Coventry Health Care, Inc and its affiliated companies recognize the importance of developing and managing an adequate network of qualified providers to serve the need of customers and enrolled members (Coventry Health Care Intranet, Creasy and Spath, http://cvtynet/ ). "A central goal of managed care is containing the costs of delivering care, but the wide variety of organizations typically lumped together under the umbrella of managed care pursue this goal using combination of numerous strategies that vary from market to market and from organization to organization" (Baker , 2000, p.2).
Health Care workers are constantly faced with legal and ethical issues every day during the course of their work. It is important that the health care workers have a clear understanding of these legal and ethical issues that they will face (1). In the case study analysed key legal and ethical issues arise during the initial decision-making of the incident, when the second ambulance crew arrived, throughout the treatment and during the transfer of patient to the hospital. The ethical issues in this case can be described as what the paramedic believes is the right thing to do for the patient and the legal issues control what the law describes that the paramedic should do in this situation (2, 3). It is therefore important that paramedics also
Healthcare in the U.S. has recently been affected by implementation of the Affordable Care Act (ACA) of 2010. The intent is to create a healthca...
The current focus on new healthcare models is a reaction to long-standing concerns around quality, cost, and efficiency. Accountable Care Organizations model focus on integrated healthcare to promote accountability and improve outcomes for the health of a defined population. The goal of integrated healthcare is to ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors (CMS, 2014). The following paper will analyze an ACO’s ability to change healthcare in the United States.
These types of external influences keep the healthcare organization afloat and maintained for patient care. The staff such as assistants, nurses, physicians, specialists, clinicians, and managers, states their opinions for improvement and make proper judgement for patient care. Lastly, patients are a prime influence and critic of healthcare of negative aspects or positive aspects of doctor care and treatment. Conflicts of staff shortages, incorrect coding/ billing, incompetent staff, and lack of knowledge of ethics are always an issue to improve. As long ethical procedures are in effect at all times with OSHA, ACA, HIPAA, JCAHO, etc., then the healthcare facility is in good order. The Affordable Care Act is a law for all staff and managers to stay informed and know how the changes apply to patients. For future healthcare administrators and staff, it’s critical to recognize the external influences in healthcare administration and maintain ethical technology standards, code standards, hiring standards, staff capability, and law
Health Maintenance Organizations, or HMO’s, are a very important part of the American health care system. Also referred to as managed care programs, HMO's are combinations of doctors and insurance companies that are formed into one organization. This organization provides treatment to its members at fixed costs and decides on what treatment, if any, will be given based on the patient's or doctor's current health plan. Sometimes, no treatment is given at all. HMO's main concerns are to control costs and supposedly provide the best possible treatment to their patients. But it seems to the naked eye that instead their main goal is to get more people enrolled so that they can maintain or raise current premiums paid by consumers using their service. For HMO's, profit comes first- not patients' lives.
Managed Care Organizations (MCO’s) formed in the 1970’s. There are two organizations that fall under the MCO umbrella commonly known as HMO’s and PPO’s. With HMO’s, the primary care physician acts as a chief liaison, thus organizing services and treatment for the patient. With the organizational structure of HMO plans, patients must see the PCP to access specialized services they may need; however, PPO plans allow additional flexibility for the patient by allowing the patient to choose providers within the network relieving the primary care physician of acting as a gateway keeper.
One being the Health Maintenance Organizations (HMO), which was first proposed in the 1960s by Dr. Paul Elwood in the "Health Maintenance Strategy”. The HMO concept was created to decrease increasing health care costs and was set in law as the Health Maintenance Organization Act of 1973, after promotion from the Nixon Administration. HMO would, in exchange for a fee, allow members access to employed physicians and facilities. In return, the HMO received market access and could earn federal development funds. An HMO is a integrated delivery system that combines both the delivery and financial aspects of health care for consumers. Under the HMO, each patient is appointed to a primary care physician (PCP), who is essentially accountable for the long-term care of the members that she/he has been assigned and any specialists that a patient needs to see should be referred by their PCP. Some examples of HMOs are Kaiser Permanente and Humana. HMOs are licensed at the state level, under a license that is known as a certificate of authority. A pro of an HMO is that treatment for a patient can begin prior to their insurance being authorized; A member may benefit from this because there would be little to no treatment delays. A con of an HMO is that in order to save cost, most HMOs provide narrow provider networks; A member may not benefit if in an emergency because their “in-network” emergency room might be far or there are “quick-care” in their
On the continuum from status quo thinking to “thinking heaven”, my unit is 8 out of 10 (where 1 is status quo thinking and 10 is “thinking heaven”). I give my work environment these high marks based on Rubenfeld and Scheffer (2015) definition of “learning organizations” (p. 75). They explain that within this model “organizational cultures encourage critical thinking and acknowledge the inevitability of change” through characteristics of “trustworthiness, autonomy, responsibility and reflection” (Rubenfeld & Scheffer, 2015, p. 75). Through the implementation of the Accountable Care Unit (ACU), our nurses have been able to demonstrate the specific characteristics of a “learning organization” and we have learned the importance of using open
For those providers who have modified their practices to avoid penalties, reimbursement has been received based on newly presented guidelines under the ACA. The transition of reimbursing claims based on a “paid-for-value” matrix compared to the previous “paid-for-service” mindset has forced practitioners to modify their practices to reduce the amount of testing and other procedures that may not be considered medically necessary (Blumenthal, Abrams & Nuzum, 2015). To combat the confusion associated with this new mindset, the ACA has formally encouraged collaboration amongst providers through accountable care organizations which are designed to coordinate the various aspects of healthcare practices among multiple