TOPEKA — Today, there’s little to stop someone on Medicare from seeing two doctors about the same ailment.

There’s often a good chance the two doctors won’t know about one another and each is likely to run the same tests.

Medicare, not uncommonly, will pay for the visits to both doctors and for both sets of tests.

That’s inefficient, expensive and may do little or nothing to make the patient healthier.

In an effort to combat the lack of coordination that is widely recognized as a major shortcoming of the current health system, the new federal health reform law includes provisions intended to encourage wider use of Accountable Care Organizations or ACOs.

An ACO assumes responsibility for coordinating a broad continuum of care designed to improve or maintain the health of a large number of patients.

Generally, an ACO would be paid a flat rate for each person in its care as opposed to billing for each procedure or treatment.

Because the care is closely coordinated and stresses prevention and chronic-disease management, it is expected to reduce emergency-room visits and return hospitalizations, which eventually would reduce costs.

Rules yet to come

Earlier this month, the federal Centers for Medicare and Medicaid Services issued a formal “request for comments” on how an ACO might function, how it could measure quality and how it could be financed. Comments are due Dec. 3.

“The rules and regulations defining what an ACO is aren’t out yet, so there’s a lot we don’t know,” said Tom Bell, chief executive of the Kansas Hospital Association. “But, still, this is what everybody in health care is talking about now. It’s the hot topic.”

CMS plans to have several ACO pilot projects up and running by Jan. 1, 2012. Initially, their focus will be limited to Medicare patients.

An ACO is expected to coordinate care in ways that improve patient health while lowering long-term health care costs.

“The concept, generally, is to go to a system that pays for population care rather than what we have now, which is a system that pays for pieces of care per patient,” said Marvin Fairbank, director of contracted care services at Stormont-Vail HealthCare, Inc., in Topeka.

“We’re exploring what it’s going to take for us to do an ACO,” Fairbank said. “Now, I can’t tell you what it’s going to look like, but at this point I think it’s pretty clear that having a good electronic medical record system in place is going to be absolutely pivotal and the docs are going to have to be involved. This is going to be a systems thing. It’s not going to be just the hospital or just the docs. There’s going to have to be collaboration on a lot of different levels.”

Closing the gaps

Fairbank and others said they expect ACOs to emphasize annual health assessments, access to preventive care, medical homes, electronic medical records, and extensive follow-up with patients after a doctor’s office visit or a hospital stay.

ACOs, they said, should begin to close the gaps in a health care system that’s long been based on caring for people after they’ve become sick rather than keeping them well.

“There are gaps in the system we have now. There’s not a health care provider who’ll tell you there isn’t,” said Janell Moerer, vice president of business operations at Via Christi Health in Wichita.

In November, Via Christi and Coventry Health Care announced plans for launching Advantra Total Care, a Medicare advantage plan that, over time, may come to be seen as an ACO.

“It’s definitely an ACO-like model,” Moerer said.

Enrollment for Advantra Total Care will begin in January, she said.

Via Christi and Coventry formed a partnership late last year after Coventry bought Preferred Health Systems Insurance, a for-profit subsidiary of Via Christi.

Advantra Total Care enrollees, Moerer said, will undergo a “wellness screening” that will be used to create a plan for their “getting and staying healthy.”

Navigators

Enrollees will be assigned a primary-care physician whose office will develop their electronic medical records, which will be accessible to other health care providers in the system, including surgeons, pharmacists, and rehabilitation specialists.

The plan also will have “navigators” whose job will be to make sure enrollees get the care they need when they need it.

Particular attention will be paid to those with chronic conditions - diabetes or heart disease, for example.

“The goal is to help people stay out of the hospital or the emergency department,” Moerer said.

The navigators, she said, will be physician’s assistants or advanced registered nurse practitioners.

”We are trying to have clinical people closer to the front lines, to be more proactive,” Moerer said.

When an enrollee is discharged from a hospital, the navigator, Moerer said, will have a pharmacist check the medications the patient will use at home.

“What tends to happen is when people are in the hospital they get their medication changed,” Moerer said. “But when they get home, they still have their old medication in the medicine cabinet and they keep taking it, which a lot of times results in an adverse reaction. We don’t want that to happen.”

In many ways, Moerer said, Advantra Total Care will function like a Managed Care Organization (MCO) or Health Maintenance Organization (HMO).

“In the past, the argument could be made that HMOs were designed to restrict care,” she said. “This program is designed to reduce duplication and to proactively promote health and wellness.”

It remains to be seen whether the program will meet the CMS criteria for being considered an ACO.

“We’ve been working on this since January or February, and it’s really not being driven by health reform because none of us really know what the impact of health reform is going to be,” Moerer said. “This is about knowing that the current models are not sustainable.”

Clinical integration model

Other groups also are assembling ACO-like plans.

“We are exploring what’s called a clinical integration model,” said Karen Cox, chief operating officer at ProviDRs Care Network, a preferred provider organization run by the Medical Society of Sedgwick County.

The model, she said, calls for “extracting” claims data from medical providers.

This data, in turn, would be “returned” in ways designed to make sure that all the physicians who see a patient have all the same information.

Having the information, Cox said, would significantly reduce duplication while allowing physicians to hone in on patients with chronic diseases.

“It’s at that point that we would like to be able to create a pay-for-performance system that would take those (chronic disease) reports, spell out the evidence-based guidelines and then pay the doctor for carrying out each of the steps within those guidelines,” she said.

“That way, the patient is getting more care, the doctor is getting paid more, and in the long run costs will be reduced because the patient will be healthier.”

The state’s largest health insurer, Blue Cross Blue Shield of Kansas, is weighing its options with respect to ACOs.

“We’re still in the research and data and information gathering stages,” said Mary Beth Chambers, a spokeswoman for the company. “A lot of various ACO models are being discussed, but how they might work in Kansas and whether they would meet the (CMS) definition of an ACO, it’s just too early to know. We’re still in the planning phase.”