The question our country must answer is: is healthcare too big to fix?

I have had the pleasure of meeting with various community clubs, organizations and groups recently regarding the coming era of healthcare reform. More specifically, I am hoping to educate the community on Accountable Care Organizations ("ACO") and key terms that everyone should recognize. In particular, in this new healthcare environment everyone should become familiar with terms such as: value based purchasing (VBP); Accountable Care Organizations ("ACO"); bundled payments; non-payment for preventable readmissions; non-payment for infections and hospital acquired conditions and transparency.

Over the next 12 months, these terms will become more familiar because they are a significant part of what the Centers for Medicare and Medicaid Services ("CMS") will pay and, ultimately, what all payors will likely pay.

The debate about healthcare reform ended on March 3, 2010 when the Patient Protection and Affordable Care Act ("PPACA") was signed into law. This 10-year journey will address every aspect of healthcare, including issues of coverage, Medicare payment cuts, pay for performance (or VBP), delivery system reform, transparency of healthcare quality and prices, and further efforts to address fraud and abuse.

As background ...

The escalating cost of medical care has been identified as the limiting constraint on providing health coverage for all Americans. The Congressional Budget Office (CBO) and the Office of Management and Budget (OMB) have noted the cost of healthcare is a critical issue for America's economic future. This has led to significant commitments from the industry to contain cost increases as part of healthcare reform discussions. At the same time, improving outcomes also has been an important objective. Higher value healthcare that combines better outcomes with efficiency accomplishes these dual objectives.

ACOs have been promoted as one way to improve healthcare value. While definitions vary, an ACO is seen as a group of providers coming together to accept accountability for providing high-value care to a defined population. ACOs are viewed as an alternative way for healthcare providers to contract with CMS and, by extension, other payers.

Regardless of the healthcare reform debate, there is consensus that new delivery and reimbursement models are necessary, and that providers should lead and test these changes. To do so, new measures and processes will be required to help providers accept accountability for improving outcomes and the cost-effectivene3ss of delivered care. ACOs will need to measure and improve results for populations as they move across the delivery system. New payer relationships; population-specific IT and data; deeper relationships between health system and medical staff; care coordination; and new approaches to primary, specialty and hospital care will be critical success factors. This will require a broader scope of care for a much larger population than health systems have focused on in the past.

How do ACOs reduce expenditures? Through systematic efforts to improve quality and reduce costs across the organization:

• Using appropriate workforce (increased use of NPs)
• Improved care coordination
• Reduced waste (i.e. duplicate testing)
• Internal process improvement
• Informed patient choices
• Chronic disease management
• Point of care reminders and best practices
• Actionable, timely data
• Choices about capacity

The work of Quality Quest to improve care within the healthcare delivery system and achieve better patient outcomes aligns with the objectives of ACOs. Medical practices that work with Quest to implement specific team recommendations will be better able to succeed in this new environment. Some areas of focus for the organization include: electronic health records adoption, health information exchange, high tech imaging use and radiation safety, generic prescribing, colonoscopy quality and appropriateness, preventive care, and maternity care.