Healthcare Town Hall

Accountable care organizations (ACOs) and patient-centered medical homes (PCMHs) may provide nurses with greater career options. In this Nurse Zone article, Milliman’s Patty Jones discusses some new roles opening up for nurses skilled in care coordination and data analysis.

Here is an excerpt:

“Accountable care and a lot of the initiatives coming out of health reform provide some interesting and new opportunities for nurses,” said Patty Jones, RN, [MBA], a principal at Milliman, a consulting and actuarial firm in Seattle, adding that the positions will take advantage of skills nurses already have and necessitate some to develop new talents.

…“For an accountable care organization to be successful, they are tasked with coordinating the needs of a member or a patient over a series of services and different levels of care over the course of time,” said Jones, explaining that efforts will focus on case managing smoother transitions between settings and ensuring the patient takes prescribed medications and follows through with appointments to avoid re-hospitalizations.

“This is a natural place for nursing and nurse leaders to use skills in terms of care coordination and assist the patient to reach out and get attached to other levels of care,” Jones said.

Newer emerging roles, Jones said, involve patient education and engagement. But the teaching must take place within the framework of the patient’s readiness to learn and motivation for changing to a healthier state.

“It’s a coming together of the science and psychology of nursing,” Jones said.

A third area of opportunity for nurses involves resource management at the patient and organization level, not something all nurses are skilled at or interested in.

“There are real opportunities for clinical leaders, nurses included, to be part of the financial and resource management discussion,” Jones said.

Additionally, nurses will need a population view, similar to a public health approach, to identifying and closing gaps in preventive care. However, it will require an analytic mind and comfort with data.

For more perspective on how healthcare’s changing landscape is affecting nursing professionals, click here.

Reform ACOs, Healthcare, nurses, nursing, Patty Jones

Some have anticipated a shortage of healthcare providers in the coming decades as the U.S. population ages. With that in mind, the Alliance for Health Reform has produced a toolkit focused on “nursing, the coming shortages, how [shortages] might be avoided, and how health reform is contributing to the changing role of nursing.” The following excerpt provides context:

Currently there are about 3 million licensed registered nurses in the United States. Most, about 60 percent, work in hospitals. Almost 266,000 are advanced practice registered nurses (APRNs).

It is projected that 260,000 additional nurses will be needed by 2025 to care for the increased population, the increase in insured population and the explosive care needs for chronic diseases in the population and geriatric care in older age groups.

Several factors are thought to contribute to the projected shortage in nursing. These include a decline in RN earnings relative to other career options, an aging nursing workforce, job dissatisfaction among nurses, and an aging, sicker population that will require more intense health care services.

An October 2010 report by the Institute of Medicine recommended that nurses be allowed to practice to the full extent of their education and training, yet scope of practice laws vary from state to state. Is the time right for states to update these laws to mitigate the shortage of providers especially in primary care and especially in rural areas?

Among the resources provided in the toolkit is Patty Jones’ paper entitled “The Nurse’s Role in Accountable Care,” which considers the important role registered nurses will need to fulfill if accountable care organizations (ACOs) are going to be successful under healthcare reform. Here is an excerpt from her paper:

Nurses currently work in a variety of organizations likely to be involved with [ACOs], including practitioner offices and clinics, hospitals, insurers, and community health organizations. As a result, they often are in a position to help address one of the key needs of accountable care: improving care delivery and coordination across a variety of settings and types of care.

…Most organizations will need to take stock of their current resources, fill in gaps, and re-engineer their process. Most can leverage their current resources and help ensure the success of their program by accurately assessing and augmenting the skills of their nursing staff.

Quality of Care, Reform ACOs, Healthcare Reform, nurses, nursing, Patty Jones

Yesterday, Health & Human Services announced 89 new accountable care organizations (ACOs), doubling the number of Medicare ACOs.

With this in mind we’ve pulled together all of our ACO research into a single location. Here you go:

• Accountable care organizations: The new provider model
• Controlling healthcare costs the old, new way
• The Medicare Shared Savings Program and the Pioneer Accountable Care Organizations
• Building an accountable care information system
• The nurse’s role in accountable care
• Nuts and bolts of ACO financial and operational success
• Evidence-based guidelines: Essential building blocks for accountable care
• ACO gain/loss sharing
• Patient attribution in ACOs
• ACOs and medical professional liability
• Milliman’s announcement that it has been selected for a Society of Actuaries-sponsored ACO research study

 
Also, this video offers a nice overview of the ACO concept.

Electronic Health Records ACOs, Bill O'Brien, George Berry, Helen Blumen, Kate Fitch, Patty Jones, Rich Moyer, Richard Kipp, Rob Parke, Susan Pantely, Victoria Boyarski

An editorial in The Atlantic recently argued strongly in favor of the expansion of the role of nurses in primary care:

Should the ACA pass muster with the Supreme Court next month, an additional 30 to 33 million previously uninsured Americans will be covered — and even if ACA is not implemented in full, and in the end merely expands Medicaid, it will add 17 million to the insured ranks by 2020.

One of the best ways to alleviate this shortage is to expand the scope of practice for advanced practice registered nurses (APRNs), well-trained registered nurses with specialized qualifications who can make diagnoses, order tests and referrals, and write prescriptions. APRNs could provide a variety of services that primary care physicians now provide.

This issue remains contentious, but one of the most interesting points the author made concerned a frequent topic of this blog—the growth of accountable care organizations (ACOs):

Employers and patients are beginning to clamor for progress in this area and the turf wars may lose steam as we move away from fee-for-service and toward accountable care organizations, in which a team of providers takes responsibility for the well-being of a population in return for global rather than provider-specific payments.

A 2011 article on Gannett’s Nurse.com on the role of nurses in federally sanctioned ACOs referenced Milliman’s own Patty Jones on the topic:

According to Patty Jones, RN, MBA, a healthcare management consultant with the Seattle office of Milliman, an actuarial consulting firm, nurses are the logical choice to help patients navigate barriers to care and to educate them about how to best care for themselves. They already serve as health coaches for patients with multiple chronic illnesses, and they perform discharge and transition planning for those who are hospitalized. Jones predicted these roles will expand in an ACO.

You can read Patty’s paper on the topic of nurses in accountable care here.

Reform ACOs, nurses, nursing, Patty Jones

With accountable care organizations (ACOs) soon to serve more than a million Medicare patients, it is clear that this model of care delivery is receiving an unprecedented test of its viability, and, if it works as intended, may reshape how healthcare is paid for on a larger scale. Cigna alone plans to have more than a million people enrolled in ACOs by 2014, and says it believes that ACOs are going to be important regardless of the Supreme Court’s ruling on the Patient Protection and Affordable Care Act (PPACA).

With so much focus on the topic, it’s worth taking a look back at some of the research and analysis on ACOs published by Milliman on the topic over the past couple of years.

First, for a good summary of ACOs—what they are and how they work—start with this overview video featuring a number of Milliman experts.

For many observers, the key question about ACOs is whether they represent a financially viable model compared to fee-for-service. Effective financial management will be key to success. Milliman has produced a number of relevant papers:

• “Nuts and Bolts of ACO Financial and Operational Success: Calculating and Managing to Actuarial Utilization Targets” provides significant operational detail on dealing with utilization in an ACO context.
• “ACO Gain/Loss Sharing” proposes a framework for allocating savings within an ACO that emphasizes rewards for an ACO’s component entities based on their relative contributions to the organization’s total shared savings and quality performance. Such a framework is required when applying as a Medicare ACO, but the Centers for Medicare and Medicaid Services (CMS) has not provided a detailed procedure for creating one. This paper tries to help fill that gap.
• “A First Look at ACO’s Risky Business: Quality Is Not Enough” discusses downside risk faced by Medicare ACOs; while somewhat dated at this point it still contains some useful concepts.
• “Pioneer ACOs: Quantifying Risks and Identifying Opportunities” focuses on how Pioneer ACOs can control costs and identify savings opportunities given the additional risks they face.

 
With all the attention on Medicare ACOs, it’s easy to forget that they exist in the private market, as well. For more on such entities, look at “ACOs Beyond Medicare,” which describes the potential advantages for providers who partner with a private insurer rather than with CMS. A 2011 Managed Healthcare Executive roundtable featuring Milliman consultant Rob Parke also discussed ACOs in the private market.

A number of other papers have also been published discussing various aspects of ACOs such as:

• The use of care management guidelines in managing ACOs
• Patient attribution
• The role of nurses in accountable care

Reform Bruce Pyenson, Cathy Murphy-Barron, David Mirkin, Helen Blumen, Howard Kahn, Kate Fitch, Patty Jones, Rob Parke, Susan Pantely, Tiffanie Lenderman, Victoria Boyarski; ACOs

Nurse.com gives the revised accountable care organization (ACO) regulations a positive grade:

It seems the public outcry [over the draft regulations released last spring] was heeded, and many groups, including the American Nurses Association and the American College of Nurse Practitioners, are encouraged by the changes. Some nurse leaders and educators predict nurses will be the key to success for these new programs, which emphasize care coordination, wellness, teamwork and health education — all areas of nursing expertise.

What’s next for nurses and ACOs?

Although ACO guidelines do not specifically spell out nursing roles, most policy experts see nurses’ most obvious positions as care managers, educators, hospital transition coordinators, leaders of quality assurance and — for advanced practice nurses — primary care providers.

“There is lots of opportunity for nurses because of what nurses bring to the table,” said Cheryl Schraeder, RN, PhD, FAAN, director of policy and practice initiatives at the Institute for Health Care Innovation, University of Illinois at Chicago College of Nursing.

According to Patty Jones, RN, MBA, a healthcare management consultant with the Seattle office of Milliman, an actuarial consulting firm, nurses are the logical choice to help patients navigate barriers to care and to educate them about how to best care for themselves. They already serve as health coaches for patients with multiple chronic illnesses, and they perform discharge and transition planning for those who are hospitalized. Jones predicted these roles will expand in an ACO.

What kinds of roles will nurses assume?

Judith Lloyd Storfjell, RN, PhD, FAAN, said the University of Illinois at Chicago is getting requests for nurse care managers who use clinical evidence to help coordinate care for patients, including connecting them with resources, communicating with providers and giving wellness information and education on disease processes. Storfjell is professor, associate dean and executive director at the Institute for Health Care Innovation, UIC College of Nursing. A number of nursing schools are adding programs and certifications for care management.

In addition to expanding their education and training, nurses who are interested in being part of an ACO system, or of any outcomes-oriented model, need to work both within their professional organizations and among their colleagues to make their value known, say nurse leaders and policy experts.

“The central focus of an ACO will be on care coordination in a manner that includes both quality and resource use,” Jones said. “There are an awful lot of opportunities that nurses are well suited for. Now is the time to figure out where you really have the interest, passion, or excel at something in addition to clinical skills, and develop that more.” 

 For more on nurses and ACOs, click here.

Reform ACOs, nurses, nursing, Patty Jones

The state of Indiana has posted a number of issue briefs written by Milliman consultants. The issue briefs concern Indiana’s state exchange and health reform in general. The full library is available here. Of particular interest:

• Comparison of Insurer/Plan Selection Approaches
• Offering Exchange Benefit Plans Outside the Exchange
• Health Plan Quality Monitoring
• ACA Impact on Premium Rates in the Individual and Small Group Markets
• Individual and Small Group Premium Changes Under the ACA
• 2019 Health Insurance Enrollment Projection for Indiana
• Merging the Individual and Small Group Markets

Reform Andrew Naugle, Jill Herbold, Patty Jones, Paul Houchens, Raymond Pryor, Rob Damler, state exchanges

The accountable care organization (ACO) model is sparking the imagination of leaders across the U.S. health system. Most are forging their own path, because guidelines and regulations are still murky. But for organizations interested in exploring the model, what is clear is that most already have professional resources in place that could be pivotal in implementing this promising approach to patient-centered care: registered nurses. A new reform briefing paper explores the role of nurses in ACOs.

Cost, Quality of Care ACOs, nurses, nursing, Patty Jones

The Patient Protection and Affordable Care Act (PPACA) requires health insurance carriers to meet medical loss ratio (MLR) requirements on a state-by-state basis starting in 2011 (we have blogged about this before). This leaves insurers with a fairly short time frame in which to learn the intricacies of MLR calculations. Because specifications and interpretations are also likely to evolve over time, health plans will need to keep abreast of any regulatory changes and should consider performing annual operational audits that document their compliance efforts.

Read more in a recent healthcare reform briefing paper by John Phelan and Patty Jones.

Reform John Phelan, Minimum loss ratios, Patty Jones