Accountable Care Organizations: Part 1
A major ongoing debate in the healthcare industry is regarding the expected transition of the sector to accountable care organizations (ACOs). Two aspects of this transition yield interest and apprehension alike. One is the process of care delivery, with the need for an extensive network of providers that must closely cooperate and coordinate during the care process to realize and share any savings. The second area of interest (and apprehension) pertains to the physical infrastructure, or built space.
What range and type of facilities will provide care in the future, and, hence, be needed for physical infrastructure growth? What will happen to the traditional acute care hospital? In essence, both areas in question are interrelated. Clarity on the first area will greatly enhance decision-making in the second. One fundamental question pertains to the future of acute care hospitals. What will be their role, and how significant will they be in the new ACO model?
There is a feeling in some circles that the role of the traditional acute care hospital will shrink, as will the need for built-up space—thereby drastically reversing the unprecedented boom in new and replacement acute care facilities witnessed over the past decade. There is some logic supporting this line of argument, and it is inherent to the way ACOs are expected to work.
For the population insured by Medicare, care delivery through ACOs represents a radical change in the way services will be rendered/reimbursed and revenue will be generated. Experts from the Advisory Board Co. have developed a series of detailed documents on this topic, and the intention here is not to elaborate on the entire topic or replicate their work, rather, readers interested in the topic should visit the Advisory Board website (www.advisoryboardcompany.com) for more information.
Collaborative healthcare providers
One facet of the change is that the collaborative group of providers, under the new stipulations, will experience more savings by keeping their customers healthy as opposed to treating them for acute sickness. That translates to less hospital care, fewer visits to the emergency department, more preventive care outside of the acute care hospital setting, and promoting health as opposed to treating illness, to realize a better savings to be shared among all involved. This is the predicted future state of healthcare delivery.
Considering the percentage of the population insured by Medicare, this scenario affects a significant portion of the care delivered by a typical hospital. Moreover, if this system proves to be successful at improving health and reducing the cost of elder care, it will certainly be noticed by private insurers. So, the argument goes, acute care beds may eventually go unused as an increasing proportion of care (and health promotion and maintenance) is conducted in other settings.
Demographic forecasts, however, suggest otherwise.
The December 29, 2010, issue of The Economist magazine reports that the number of people enrolled in Medicare will increase from 47 million (2010) to 80 million in two decades (1.65 million new entrants every year, for 20 years). In addition, the new healthcare bill is predicted to add 32 million new customers to the system. The expansion of the population base served and the number of retirees entering the system will be so huge that the possibility of unused acute care beds is slim.
What about other healthcare facilities?
With the state of acute care hospitals unlikely to decline, the next question pertains to the physical manifestation of the other facilities that will deliver preventive care and promote health among the larger populace (as integral parts of the ACO).
Will such facilities continue to operate in their current locations—medical office buildings, (physically) freestanding group practices and labs, and so forth? Will they look and feel the same? If so, will that constitute the optimal strategy to promote health, and thereby reduce the necessity of care in acute care hospitals in order to maximize returns? Maybe, maybe not. Then, how should our care settings in the future strive to look and feel?
The past years have witnessed discussions on the idea of retail clinics to promote speed of care. Such health clinics, situated in shopping malls, are expected to make it easier for people to combine healthcare with shopping. It is a strategy that begins to articulate a model for health optimization.
There is a marginal degree of fit with the core emphasis in the new ACO model—preventive maintenance, and health promotion at the individual and community levels. These two areas of emphasis are not mutually exclusive, but are related in meaningful ways. Of course, regular checkups for illnesses/diseases (prevention) will avoid a hospital visit and reduce episodes of more serious conditions. However, promotion of health at the individual and community levels constitutes much more than preventive interventions. That is where the prevailing settings for healthcare delivery may fall short, primarily at the pre- and post-acute care level of health support.
Better comprehending the potential shortcoming warrants mapping concepts from a closely related domain—active living. There are two reasons why the new ACO objectives are related to concepts of active living. The first is the close link between obesity and disease. The second constitutes the subtle difference between what people typically perceive active living to be and the true definition of active living.
The first area of relationship is simple, and is well documented. The association between obesity and diseases is common knowledge. According to the Centers for Disease Control and Prevention, diet/inactivity is the second major cause of death in the United States. Physical inactivity is closely linked with obesity, stroke, and high blood pressure, cardiovascular diseases, diabetes, and colon cancer. Obesity, one of the most serious public health problems in the United States, has witnessed an exponential rise over the past decades in all states except Colorado. Thus, both physical activity and diet constitute solutions to both health promotion and illness prevention.
More specifically, it is important to note that preventing illness by intervening with individuals (or a population) once they are obese is a separate issue from preventing obesity in the first place. Both are decisively associated with the most fundamental interest of ACOs. What better way is there to prevent hospitalization and ED visits? Physical activity is the primary tenet of the active living movement. The question, then, is how can active living be promoted?
It would be appropriate to state that most people picture gym exercise when conceiving the notion of active living. While it certainly qualifies as physical activity, active living is more than gym exercise. It encompasses the entire range of physical settings that people use in their day-to-day life, and all types of activities. The underlying essence is to motivate the use of a more physically
active option while conducting usual day-to-day activities.
This concept is currently more prevalent at the urban level, with such ideas as whether people can be motivated to use mass transit to travel to work or walk from the parking to their building instead of taking a shuttle. Such concepts have also attracted attention in school design, with child obesity levels competing with the adult obesity problem in the country.
The active living framework is amenable for mapping to the healthcare discussion in two ways. The first domain of interest is the fact that active living is about people’s day-to-day activities. In this model, people are not necessarily brought into gym and sports facilities to engage in physical activities. Rather, the core attempt is to integrate physically active options in people’s routine activities that they would have conducted in any case, whether inside their home, in their place of work, or out in the community. This distinction is important, since when mapped to the ACO discussion, it distinguishes between two alternatives.
The first is about individuals making conscious efforts and planning to visit certain destinations to receive care for illness prevention. The second is about the care destinations strategically positioning themselves in physical settings that are an integral part of the individual’s or community’s day-to-day life.
The difference is between people seeking medical attention when they lose health to prevent acute illness, and motivating people to seek advice and interventions to remain healthy and avoid loss of health. The latter case would serve the goals of ACOs better, as it is focused on motivating people to remain healthy when they are healthy as opposed to seeking medical attention when they begin to lose health. It will render health promotion and illness prevention an integral (and perhaps pleasurable) aspect of peoples’ daily lives.
Retail and civic healthcare locations
This framework has significant implications. It suggests that provider locations of the continuum of care in (physically) stand-alone buildings, inside medical office buildings, or isolated locations may not optimally serve the ACO objectives. Providers of continuum of care that do not need proximity to an acute care hospital may better serve their population by relocating to areas that people visit as part of their daily living.
The option of locating in retail outlets or in shopping malls has already been discussed above. However, it needs to be more than just shopping malls and must expand to other civic and public facilities, such as libraries, community centers, theatres, business districts, and other areas people visit as part of their daily existence.
Further, considering the strong association between active living and health/disease prevention, it may make greater practical sense to design these public destinations in ways that promote physically active options. There is evidence in literature that the design of the physical environment impacts the degree of physical activity, which is readily available to support decision-making in this model.
The fundamental point is that this model will mark a radical change in the range of additional building types (and hence businesses) that will begin to interact actively with ACOs. Healthcare was always a complex and diverse setting. That diversity will expand significantly. The range of expertise needed to design ACO infrastructure will also increase to include building types that were, until now, considered distinct from healthcare. Our civic, commercial, and assembly facilities, among others, may begin to feel different from the way they feel today.
Is this strategy farfetched? It depends on the scale at which it is envisioned. Irrespective of the scale of implementation, there are two fundamental strategies that appear to be key to the success of ACOs—bringing health to the populace and capitalizing on the potentials inherent to active living principles in the design of the physical setting of care.
That, in turn, will witness a radical transformation of the physical environment of healthcare settings, as well as our public buildings. More buildings will be multipurpose, warranting a rethinking of the way we design our public realm—both public- and private-owned. It is a strategy that will optimize the synergies between therapeutic environments, active living, and sustainability. HCD
Dr. Debajyoti Pati, PHD, FIIA, LEED AP, is vice president, director of research at HKS Inc. He can be reached at firstname.lastname@example.org.