The American health care system has been criticized by patients and health care experts alike. Although it could be argued that premier health care institutions in the United States are among the finest in the world, American healthcare is challenged to provide coordinated, cost-effective care to many of its citizens. In fact, statistics compiled by the Organization for Economic Cooperation and Development measuring the cost and quality of health care in seven leading economically developed countries in the world (Western Europe, Canada and the U.S.) consistently show that the costs in the U.S. are twice as much as the next most expensive country on the list and our quality ranks last.
Many Americans had hopes that "health care reform" would address the issues of access, affordability and quality, but unfortunately, the Patient Protection and Affordable Care Act (also known as the ACA or "Obamacare") primarily governs insurance and payment rather than making improvements in how health care is actually provided.
However, there are provisions in the ACA that attempt to improve quality and reduce cost. For example, the ACA created a new annual "wellness" examination with no co-pay for Medicare beneficiaries; it includes immunizations and screenings to detect illness or prevent it before it becomes serious. The ACA also included a rule to create Accountable Care Organizations (ACOs) to achieve the "Triple Aim" for Medicare patients: improve quality, decrease cost of care and improve patient experience.
Committed to improving the health of the population in our region, Susquehanna Health has joined other regional health care organizations to create River Health Accountable Care Organization (RHACO). The participants in the RHACO have been working together for the past year to create the ACO and all the support structures needed to meet the CMS requirements. The organizations that have formed RHACO include Susquehanna Health, Susquehanna Health Medical Group, Family Practice Center Inc., Susquehanna Community Health & Dental Center, North Penn Health Services in Tioga County, PinnacleHealth and PinnacleHealth Medical Group (Harrisburg), and Annville Family Medicine in Annville. RHACO includes 195 physicians and over 41,000 patients in 14 counties.
CMS (Center for Medicare and Medicaid Services) announced in December that RHACO is one of 123 new ACOs approved by Medicare that began operation on Jan. 1.
An ACO brings together hospitals and doctors to provide services to patients (in this case, those with traditional Medicare coverage) that coordinate health care by improving efficiency and ensuring quality of services. Better coordination of care reduces duplication, eliminates waste and ensures timely access to needed services. RHACO must demonstrate cost savings but also prove high quality of services by meeting 33 defined quality measures and achieving excellent patient experience. Any cost savings would be shared equally by CMS and RHACO but only if all 33 quality measures are met.
All Medicare patients (excluding those on Medicare "Advantage" plans and those who are also receiving Medicaid) who are patients of participating primary care doctors are automatically included in the ACO. These patients will receive a letter in the near future giving them the opportunity to opt out of having their health data reported to their doctor in the ACO. Patients who "opt out" will remain in the ACO but may miss out on the benefits of ACO care coordination and quality activities because their doctor will not have access to their health information.
Medicare patients in the ACO will receive enhanced services to coordinate care between their personal primary care doctor, specialists and hospitals. Nurse navigators will help patients with chronic illnesses to manage care more effectively in their home environments and help with transitions of care to and from hospital, nursing facility, physician office and home.
I welcome you to learn more by visiting RiverHealthACO.org.
Dr. William C. McCauley is a pulmonologist with Susquehanna Health and President of Susquehanna Health Medical Group.