Mark Twain once said, ”It ain’t what you know that gets you into trouble. It’s what you know for sure that just ain't so.” That statement pretty much sums up today’s healthcare challenges. What we’ve historically known ”for sure” about navigating the healthcare landscape no longer applies. For better or worse, health reform is here, and it’s a new day.

Now What?
The list of changes and challenges facing hospitals is as long as it is uncertain: 1,000+ pages of healthcare legislation...the advent of accountable care ...meaningful use...health information networks...quality care at a lower cost; and the smaller the hospital, the greater the challenge. The rules are the same, but must be met with a fraction of the resources. To succeed, you’ll need to get out in front of this still-evolving curve.

For most hospitals, including Marquette General Health System (MGHS) — a 366-bed tertiary referral center in Michigan’s Upper Peninsula, reform-related challenges began blipping more urgently on our radar in 2009. No one knew what reform would require, but we knew we wanted to be successful, regardless of what model finally evolved.

Clinically, we were primarily a paper-based organization, with McKesson’s Paragon® financial applications running our back office. Our physicians were unaware of care-related costs and believed there was little variation in how they and their colleagues practiced care. We were a standalone community hospital in need of a new vision — and we believed it would take the form of an accountable care organization (ACO).

Equation for Success
Our work began with the basic customer value proposition:

Value = (Quality + Service) % Cost

Going forward, this equation would drive our organizational structure, care delivery, compliance efforts and reimbursements.

Specific strategies followed. We would coalesce with others to form an ACO, creating a regional culture of value and safety predicated on close relationships. In 2010, we formed our first partnership with Bell Hospital, a 25-bed, critical access hospital in nearby Ishpeming, Mich. Now doing business as Superior Health Partners (SHP), our aim is to expand the number of partnerships while maintaining local services and control.

A second strategy was to make structural changes needed to achieve the ACO strategy. Clearly, information technology would be key to enabling our ACO to share data and best practices, and to optimize and coordinate care across partnerships.

Now We’re Ready
The response to our new technology has been uniformly positive. Clinicians and administrators alike appreciate the online access to real-time data and trend reports, as well as the ability share patient data and best practices. Our HIS has given us the tools to improve continuity of care, clearly define and improve quality, share information across the region, and improve reimbursements.

Based on this foundation, we’re optimizing care while supporting local control at the community level. By decreasing patient migration out of the area, we’re improving both the region’s health and economy. And we’re creating our envisioned regional culture of value and safety. Superior Health Partners is well on the path of our ACO journey. Rather than looking back longingly at tradition, we’re looking enthusiastically toward transformation. We don’t exactly know what tomorrow will bring, but we know we’ll be ready.

David Graser is senior vice president, chief operating officer, Marquette General Health System and chief information officer, Superior Health Partners, where he has played a leading role in creating the organization’s ACO. Prior to joining MGHS, Graser was the CIO for health systems in Louisiana and Texas, and served as a Medical Service Corp Officer with the United States Air Force. He holds a BS in Business Administration and an MBA, both from the University of Illinois, Champaign/Urbana. Graser is also a fellow in the American College of Health Care Executives.

Experts point to rising healthcare costs as a symptom of overuse, underuse and misuse of care delivery services. With the 2010 Patient Protection and Affordable Care Act (PPACA), the Centers for Medicare & Medicaid Services (CMS) set a goal of changing the model for payment for care from the fee-for-service model, which rewards providers for quantity of care, to a model that makes the care delivery organization accountable for delivering quality and value. The new model focuses on achieving the ”Triple Aim” of better health, better care, and lower costs for the overall population.

The accountable care organization (ACO) must have an infrastructure that supports information exchange among members and settings of care to achieve care integration and coordinated care delivery. Success also depends on an infrastructure that aggregates and normalizes patient-centric data, provides analytics for population health management, and offers clinical and financial decision support at the point of care.

Skin in the Game
In an ACO, everyone has ”skin in the game” — from the hospital, to the physician practice, to the extended care facility, to the payer. Medical decisions are based on medical evidence, and reimbursement is based on patient outcomes and the cost-effectiveness of treatments. Both the ACO and patient’s primary care physician are responsible for the patient’s outcomes along the continuum of care. In an ACO, members must accept and understand their own and each other member’s responsibilities for the patient’s care. Also important is clarity on when, how, and to what degree responsibility is transferred to other ACO participants during the course of care.

Having a primary care ”home” within the organization that is ”connected” to the rest of the ACO for the exchange of information is vital for the management of the patient’s care. This includes settings such as hospitals and other acute settings of care, outpatient specialists, extended care facilities, laboratories and pharmacies, as well as the patient and their families/caregivers.

A Range of Risk/Reward Models As long as the ACO achieves the Triple Aim, models may vary. PPACA supports piloting a broad range of payment models that have varying degrees of clinical and financial risk, such as:

• Pay for performance (quality, efficiency, and consumer engagement)
• Shared savings for reductions in utilization when quality thresholds are met
• Additional payment (per member, per month) for additional care activities that are not on the fee schedule
• Bundled payments for clinically defined episodes of care
• Partial capitation, including a predefined monthly payment to cover specific services for a defined group of patients
• Global budgets or payments that would provide an agreed-upon fixed budget or payment for the medical needs of a population of patients

Coupled with risk assumption is accountability for quality, outcomes, evidence-based processes, consumer access and experience. The greater the risk, the greater the potential for reward.

Analytics — The Enabler
Because the quality and efficiency of care will affect the amount and distribution of payments, healthcare analytics will be used to provide transparency on care performance and cost for individual physicians and business entities in the ACO organization. Analytics also provides the engine for patient care improvement and population health management.

Health IT will connect ACO members, providing them and the patient with greater visibility into the care delivery system via electronic health records (EHRs), Personal Health Records (PHRs) and Health Information Exchanges (HIEs). More importantly, ”intelligent” connectivity provides actionable information for providers, patients, and other stakeholders. Health IT can support the health of the ACO by empowering the patient to easily handle their financial obligations, leading to increases in self-pay collections and reductions in provider bad debt and A/R days.

Expectations are that the development of ACOs to serve Medicare patients will influence adoption of this model by the private sector, which will contract with the same ACOs. There are basic requirements a provider organization must meet to contract with CMS as a Medicare ACO (see the article below for specifics).

For more information on accountable care concepts: Providing Accountability — Accountable Care Concepts for Providers.

At Peninsula Regional, the patient experience is our big focus. We want to make sure that patients who arrive at our hospital sick and in need of care, leave in better health without new problems.

I was brought in as a physician and nurse educator to develop processes that make our hospital an even safer place. To achieve this, I think it's important to look at the business model of a hospital. When your processes are safe, you have fewer errors, less redundancy, and more efficiency. We're starting to understand in this industry how all of those key concerns are linked. If a hospital is efficient, it has fewer errors. If a hospital has quality outcomes you know it is safe and has effective processes. To me, it starts with the business model. A hospital that's in better business health has built-in care quality.

Our informatics system has been developed with care quality in mind. The new technology we're bringing to the field has made things much more transparent and helped us improve our processes, but there are some challenges and obstacles. Physicians and nurses have seldom had folks looking over their shoulders. They're used to practicing autonomously. All the different healthcare IT tools enable us to communicate more efficiently but we need to make sure the technology steps over that autonomous culture and gives us a more team-oriented approach to taking care of patients.

Compassion goes with healthcare. If you're not compassionate, and you're in healthcare, you're in the wrong business. But we also have a responsibility to fund healthcare for the future. We can do that by making sure we're being as cost effective as possible right now.

Good Samaritan is the largest hospital in our region, and the only hospital in Knox County. Our vision is to become the regional center of excellence for this part of rural Southwest Indiana. We've got an aging population, and very high Medicare and Medicaid Rates. If you listen to the news today, you know that reimbursement is going to continue to be strained for some time. So we will balance our focus on reimbursement with our responsibility and a mission to provide the best care possible for the people of our communities.

If you don't have a margin, you can't achieve your mission. We understand this, so we're accustomed to providing appropriate care procedures in very cost-effective ways. But we want to get even better at that. Two years ago, we began a self-assessment journey to look at how we can improve our organization in terms of processes. We did this by engaging in the Baldrige National Quality Program for Hospitals. This is helping us deliver better health care outcomes and higher quality service by focusing on organizational performance. We know that if we become better at doing what we do, we can provide higher quality care for our patients at less cost.

If you follow other organizations that have gone through the detailed steps of examining what interferes with or supports good processes, you see how the quality of care and patient satisfaction goes up at the same time that revenues also increase. That happens because those organizations are finding new and better ways of doing things.

I've been at Good Samaritan for over 20 years, and I know we have the opportunity now to grow and learn how to do healthcare better because we have better tools than we've ever had before. We're looking at everything, from what physicians and nurses can do to what patients can do. On the provider side, for example, the way we treat heart attacks in Vincennes, Indiana should be no different than San Diego, California. I'm not talking about relying on cookie cutter medicine but on using best practices in the most effective and efficient ways. On the patient side, we need to get people more involved in their own health. But helping people to be responsible for their own health requires us to educate them and give them the information they need in a timely manner and put the right tools in their hands.

We take our mission very seriously at Good Sam because we know that our patients are also our friends. They're the people we buy groceries from, or sit with at church, or root for the home team with at a Friday night football game.

When I was a practicing physician, I could only affect one patient at a time. Now, because we track and measure outcomes, we can affect the entire population of patients in our hospital system.

It's that link between quality and best practices that makes me passionate about working with Electronic Health Records. As CMIO, I keep our informatics department very closely tied to our quality department. We're learning to apply the decision support tools we have in the EHR system to achieve outcomes that our quality department knows are critical for better patient health.

Using electronic portals, we can make information available wherever the provider or the patient happens to be. Imagine a patient at a cardiology clinic. The cardiologist can now access the primary care record and the hospital record and get a much broader and deeper view of what's going on. What are the problems the patient is facing? What medications has he or she taken while in the hospital? What other care episodes have there been? That information now travels with the patient. In turn, the patient can review those records and get a clearer understanding of his or her condition, and then access additional information to learn how to become even healthier.

Healthcare quality is getting better as we get better at sharing information more thoroughly across the system. Over the next several years, we'll work to make the continuum of care even more seamless. We want the ability to have all the necessary information about a patient at our fingertips.