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Qualuable Attains ACO Status

February 26, 2013
By Scott Robertson (shared with permission from the Business Journal)

There's a new accountable care organization in town. On January 10, Health and Human Services (HHS) Secretary Kathleen Sebelius announced that Qualuable Medical Professionals, an organization comprised of physicians groups in the Tri-Cities, was one of 106 new ACOs to be recognized by Medicare.

Qualuable (the name is an amalgam of "quality" and "valuable") is comprised of more than 500 primary Care providers and specialists who represent Highlands Physicians, Inc.; Holston Medical Group; Medical Care, LLC; Mountain Region Family Medicine and State of Franklin Healthcare Associates.

Doctors and health care providers can establish Accountable Care Organizations in order to work together to provide higher quality care to their patients. More than 250 Accountable Care Organizations have been established nationwide.

Accountable Care Organizations are not solely reimbursed on a fee for service basis. Instead, they share with Medicare any savings generated from lowering the growth in health care costs, while meeting standards for quality of care.

ACOs must meet quality standards to ensure that savings are achieved through improving care coordination and providing care that is appropriate, safe, and timely. The Centers for Medicare & Medicaid Services (CMS) has established 33 quality measures on care coordination and patient safety, appropriate use of preventive health services, improved care for at-risk populations, and patient and caregiver experience of care.

The physicians groups that make up Qualuable are also members of the OnePartner Health Information Exchange (HIE). In fact, having a common electronic health records system is a key to being able to become an ACO, according to Scott Fowler, MD, JD, president of Holston Medical Group. "When doctors work together and share the pathway a patient’s taking through their care model, they are optimizing patient care. The HIE was an opportunity among the different groups to integrate and work better together in a patient-centered model and provide better care."

As Medicare became more involved in promoting ACOs, says Fowler, it only made sense for the groups to consider applying for ACO status. "When it became obvious that there was going to be some support from the federal government for meaningful use, that we were going to be moving toward a model that might begin to incentivize and pay for some of the infrastructure associated with this, I think that’s where the first effort to have an integrated system began," says Fowler. "That started the conversation, which then built a framework around already-willing partners who already had a vision of patient care. That gave us a framework that could have become a variety of things, one of which was an ACO under the Medicare Shared Savings Program."

Ronald Blackmore, MD, president of State of Franklin Healthcare Associates, says that the groups had been talking informally for years but that there had been no real impetus to work together until Medicare started pushing the ACO model. "As local and national changes happened, we found ourselves needing to work together more,” says Blackmore. "That drove our groups together."

Moving toward the ACO system wasn’t really so much a great leap forward, says Fowler, as it was a bow to necessity. "It became very obvious when meaningful use money started to be paid and when these value-based contracts started to produce some income that fee for service - the way that we've been paid for practicing medicine for years and years - was going to become an unsustainable model which was going to be augmented with these other ways to make money. So it really wasn’t a choice that anybody made. It was an imperative that we begin this process."

Blackmore says the goals of the new ACO dovetail with those of previously established ACOs across the country. "You've heard of triple aim. We`re looking to have better outcomes as we share data and put protocols together based on what works in East Tennessee. Hopefully that will enable us to develop a product that costs less for the consumer, for the businesses. As we do this for Medicare, it will transform into something that will work for commercial businesses. If we can keep people out of hospitals and, when appropriate, do fewer tests, then that will mean lower costs. Then, hopefully, the patients will he more satisfied."

It's inevitable that medical care move to a value-based system, says Fowler, and not just because the other side is shrinking. “We also haven't trained enough new physicians in America to handle all the patients in the system, so physicians are going to have to work better together as teams to take care of this population. The old model runs out at the ability of the doctor to see the next patient who comes into the office. We need to go with a model that has enough depth and team support that we can apply the right resources in the right way.

Adds Blackmore, "The shortage of physicians is not going to get any better. It's just going to get worse. There are more Medicare patients. The population is getting older, yet there are fewer physicians to treat them. The only way we can handle that is to work smarter."