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Episode 28 – August 2021: What’s the Point of an ACO, Anyway?

August 2021

Our summer vacation episode features two previously-released stories. First, we offer a reminder of what accountable care organizations do and why they do it. Second, we explore the advantages of telescribes with PenBay’s Brad Samojla, DPM.    

BACON Episode 28 Transcript

Julie: This is BACON brief ACO news from the MaineHealth Accountable Care Organization, a compost-able monthly podcast for health care providers. I'm Julie Grosvenor.

Mike: And I'm Mike Clark. Julie, did you see compost-able?

Julie: Yes!

Mike: Alright. Julie and I are practicing physicians and liaisons with the MaineHealth ACO.

Julie: Yes. And compostable. You know, so since it's August in Maine, that means pretty much the whole state has gone up to camp or retreated to a remote island in Penobscot Bay or is basically anywhere but at work.

Mike: That's a good point. So, you know, in the spirit of this laziest month of the year, we're not producing a new episode of BACON for August. Instead, we're bringing you two popular segments from the past.

Julie: Well, I have to say, Mike, I'm delighted that we've been around so long that we can do a best-of show.

Mike: Yeah.

Julie: So for our Meaty Topic, we will remind ourselves of the why behind the ACO with our 2019 story called What's the Point of ACOs Anyway?

Mike: Yeah, that was a good one. And we'll take another listen to a popular Sizzle segment on one of our ACO's favorite ideas, using scribes to help providers meet the challenge of clinical documentation.

Julie: So pull up your comfy hammock or beach chair and take a listen.

Mike: (Meaty Topic intro)

Julie: For this month's Meaty Topic, we continue exploring the basics of the MaineHealth Accountable Care organization. We're going to talk about why the organization does what it does. We spend a lot of time on the nitty gritty of the ACO, the quality measures, contracts, utilization rates. But we don't talk much about why the ACO exists. In short, what's the point of the ACO and its work?

Mike: Great question. Well, to begin to answer that, we need to look back at the genesis of ACOs. ACOs were first proposed in a 2006 paper by Dartmouth researchers looking for a solution to two very large problems in health care. Quote, serious gaps in quality and widespread waste, end quote. Of course, this problem was not a revelation to anyone. Serious efforts to improve quality have been going on since the late 1990s. And controlling wasteful spending has been a priority since the 80s. These guys suggested that provider accountability was a possible solution. Now, they weren't even the first to focus in on that. But what was new was where they thought accountability should lie. Not with the individual provider, as in earlier efforts, but with the local network of care made up of the primary care and specialist providers and the hospitals where they worked or admitted their patients. They called this network the extended medical staff.

Julie: Why make accountability at that level?

Mike: Well, because to paraphrase their paper, this extended medical staff can ideally be organized to deliver coordinated and longitudinal care. That's the kind of care evidence suggests that can improve quality and reduce wasteful spending. An individual provider couldn't do that. So it just didn't make sense to place accountability at that level.

Julie: Ok, so what they call the extended medical staff becomes this new entity, an accountable care organization. And that's what monitors quality and spending for the whole group and reports out results in aggregate?

Mike: Yeah. Yeah, that's basically it. ACOs exist to improve quality and reduce wasteful spending, and they do it by making groups of providers accountable for performance in both of those areas and by promoting care coordination.

Julie: So poor quality and wasteful spending were an issue back in 2006. So how about now, 13 years later? All figured out, or is it still a big enough problem to justify the existence of ACOs?

Mike: Well, there is still waste. Just this fall, JAMA published a study that attributed as much as 300 billion dollars of waste each year to low-value care and failures in care delivery and care coordination. There's plenty of opportunity there for ACOs to make an impact. Imagine what we could do with even a fraction of 300 billion dollars. We'd have significant funds to improve some of the underlying drivers of poor health, like poor educational attainment and substandard housing and other environmental factors.

Julie: Yeah, and quality. Quality has been increasing since 2006, hasn't it?

Mike: Yep. There's some good news there. Many quality metrics are indeed improving. For example, the rate of avoidable admissions decreased an impressive 32 percent from 2000 to 2015. And that's according to an article by the Peterson Center on Health Care and the Kaiser Family Foundation. However, the same article notes that we in the U.S. often lag behind comparable countries. Looking at avoidable admissions related to specific chronic diseases makes us pretty clear. Our voidable admission rate for diabetes is 38 percent higher than comparable countries. For CHF, it's 55 percent higher and for asthma, wait for it, it's 143 percent higher. I think we can say that great progress has been made on quality, but more progress is certainly possible.

Julie: So today the "why" of accountable care organizations remains the same as it did in 2006. We still need to improve quality and we still need to curb wasteful spending.

Mike: Yep. Yep. And, you know, we could look at an even bigger "why." That is, why improve quality and reduce spending, In a lot of industries, if you think about it, what you damage with poor quality and lots of waste is just the bottom line. But for us, in the profession of health care, the consequences are more profound. Higher quality and less waste can lead to more than just savings. It can contribute to improvements in the care of patients and even in our patients’ lives. I think ultimately that's what all of us involved in the ACO are striving for.

Julie: Well, I can certainly agree with that. Thank you, Mike. For links to the research we mentioned, go to MaineHealthACO.org/BACON and look for the bonus content listed under this episode, episode number eight. Do you have ideas for a future Meaty Topic. or comments about this one? Please email us at BACON@mmc.org. That's BACON@mmc.org. We want to hear from you.

Julie: (The Sizzle intro)

Julie: Welcome to the Sizzle, our monthly provider success story. Many of us have dreamed about having someone to do our clinical documentation for us, right, Mike?

Mike: Yep, absolutely.

Julie: So for Dr. Brad Samojla, that dream came true. He's been piloting a telescribing model at his podiatry practice in Belfast with support from the Waldo County General Hospital administration. Our producer, Paul Santomenna, talked to Brad about his experience.

Paul: So the scribe sort of appears digitally, virtually, in your exam room. Can you describe the setup that you have?

Brad: I have an iPad that, in my particular case, is on a cart that I roll from room to room. He is in the room with me as part of the treatment team. And I can talk to him during the exam. He can see the exam. The patients can talk to him. He can talk to the patients. So it's a true interactive process.

Paul: Ok, so just to clarify, so he's there live on an iPad through a video connection. But actually in Florida.

Brad: Correct.

Paul: Able to interact with everybody.

Brad: Right.

Paul: OK, and what part of the documentation process does he engage in the most?

Brad: As much as humanly possible. He works with me throughout the entire note, through the physical exam, counseling. The only real thing that he can't do is place orders, but otherwise he can do everything, anything written. He can write letters, he can pull up lab results for me. So if I have a patient that I need to know what their latest labs are, I'll just ask him and he'll let me know - he'll read them off to me.

Paul: Ok, so what was the situation before you had a telescribe? What was your day like? How efficient were you?

Brad: Very inefficient and very slow. I had to significantly limit the number of patients that I saw. And I would put in hours daily just to finish my notes. My day was just bogged down. Going home, I always had this sense of doom for the next day. What is the next day going to bring and how inefficient am I going to be?

Paul: And what has changed since the telescribe appeared in your life?

Brad: I've essentially doubled my patient load. I go home at the end of the day with all of my charts completed by the time my last patient is scheduled to be done. The vast majority of my notes are done within a minute or two, well, within five minutes or so after the patient has been seen. All orders are done, letters are written, they're out, the chart is complete, tucked away in bed until the next visit. Overall, my job satisfaction has literally changed overnight. I'm happy when I go home. I'm happy when I come to work. My patients in general have responded very well. The full process is not as overbearing as it was in the past. It's still overbearing in some instances, but it's much, much, much less of a challenge.

Paul: Anything you would tell fellow physicians about having a scribe?

Brad:
Again, I was fortunate to have somebody who really helped me slip into this fairly seamlessly. That's not always the case. I know other physicians and other systems who've had a scribe and have gotten very frustrated. They expect immediate results. And there's a learning curve, not only for you, but for the scribe. And one of the most important things that my scribe and I do is we have debriefings after some patients. What can we do better? Is there like a dot phrase that we can, or smart phrase, that we can write? Does everything need to be verbatim? Things like that.

Paul: And any last comments or thoughts?

Brad:
It's a great service. I absolutely love it. And I actually very much appreciate the opportunity to test it and hopefully get others to have the opportunity, because I know I'm not the only one who struggles with daily charting.

Mike: Thanks for listening to BACON this month. You can find all our episodes on your podcast app and at our web page, mainehealthaco.org/BACON. And if you have questions, comments or suggestions, we'd love to hear from you. Please email us at bacon@mainehealth.org. That's BACON@mainehealth.org.

Julie: BACON is produced by the MaineHealth Accountable Care Organization with help from MaineHealth Educational Services. Thanks for joining us and we'll see you next month with some brand new content.

Mike: See you then. Bye bye.