Question

Knowledge Management in Accountable Care Organizations

Gordon D. Brown

The Setting A large psychiatric specialty group practice in a metropolitan area provides a range of psychiatric services. The practice has grown rapidly and has thrived since its formation in the 1980s, as a result of the development of managed care plans, including the state Medicaid program that follows a carve-out model for behavioral health services. The psychiatrists carry out extensive translational research and use evidence-based protocols in their practice. They also develop these science-based protocols and embed them into their individual practices.

Several psychiatrists are concerned about the impact of the new federal mandate to develop accountable care organizations (ACOs). The mandate identifies 65 performance measures that the standard ACO must meet under the Shared Savings Program. These measures span five qual- ity domains: patient experience of care, care coordination, patient safety, preventive health, and at-risk population/frail elderly health. The only behavioral health measure mandated is in the preventive health domain, a measure for depression screening.

Some leaders of the group feel that mental and behavioral health, as a specialty area, and the clinical volume would not significantly change. They do not think they should develop an ACO strategy and have resolved to take a wait-and-see approach. Another set of leaders, including the CEO, believes that ACOs do present some threats but at the same time provide an opportunity for the group to transform itself into an information-driven practice.

Evidence-based Strategy

The practice forms a multidisciplinary team to explore an ACO strategy. The team comprises two psychiatrists, one psychiatric nurse, the practice CEO, and one healthcare management intern. The team agrees that it will entertain all ideas and proposals as well as research the literature to bring in the best explicit information and experiential knowledge available. The relevant literature topics include ACO basics, knowledge management, and managed care organizations’ limited acceptance and success since the 1980s.

The management intern, Marjorie, is interested in the medical- offset effect and its potential as a strategic asset. She presents to the team 30 years’ worth of research on the concept, including closed clinical trials. Studies on medical offset measure the impact of providing effective behavioral health services on the utilization of medical care, including physician consults and visits to the emergency department. Marjorie is impressed by the extensive studies that include a wide range of populations and conditions, including Medicaid patients and chronic care diagnoses. The findings consistently demonstrate a savings of 10 to 20 percent from reductions in medical care utilization. The psychiatrists met these studies with skepticism, however. Although they think the science behind the research is valid, they reason that the practice has a specialty in mental health and not prevention or behavioral health, so the studies are not relevant to what they do.

In a brainstorming session, the team explores alternative scenarios on how the practice might add value to the ACOs that are developing within its area. The first scenario is to embed specialty psychiatric knowledge into the ACO’s decision support system. The second scenario is to develop formal affiliations with as many ACOs as possible to capture their referrals for specialty care. The third scenario is to extend the practice’s decision support protocols to address prevention, early detection, and aggressive management of behavioral health issues. This last idea is suggested by the psychiatric nurse, who points out to the team that the nursing staff and social workers have considerable (but untapped) expertise in behavioral health. The psychiatrists worry that developing behavioral health decision support protocols would result in a loss of status for the psychiatrists and thus would be strongly opposed. They are also concerned that the strategy would result in loss of prestige and reputation for the practice as a whole.

After considerable discussion and debate, the team agrees to respect the existing culture but to pursue the collective (corporate) interest of the practice rather than one group (psychiatrists). They begin to develop a proposal for the third strategy.

What change will be made on who accesses knowledge generated by the practice and how would it be used?

Address each of the five quality domains specified by the ACO mandate, and justify their inclusion or exclusion. What are the implications of each on the structure of the clinical process and on the information system that supports the process?

What form of organizational structure would be formed with the ACO? What are the implications of collaborating with more than one ACO? Should the psychiatric group serve as the focal organization for developing an ACO?

What value is brought to the ACOs, and how would it be assessed? How would the practice be paid for its value-added services?

Answer 1

One of most important things that I learnt from this case study is that we may not make strict guidelines & may not weigh every medical issue n same scale i.e. we may not strictly abide by 65 principles that should be abided by ACOs for all medical departments.

We have to have a little bit of flexibility in catering & serving each department & each category of health issue keeping in mind sole objective of strengthen processes, proving better facilities & healthcare to patients & their relatives, speedy recovery & best of the treatments available at affordable costs.

Also, any change related to medical health is clinical & very important as it affects many areas that are critical hence extensive research should be done before committing any change & output should be foreseen as accurately as possible.

Category wise rules & regulations should be made & weighing scale should be different for different category & intensity of disease & its treatment.