Becoming Part of the Team: ACOs and Integration Strategies

"The true value of ACOs will be determined not only by cost savings but by assessing improvements in quality while being cost effective." — AccountableCareFacts.org

Health care policy is being played on a new field that seeks to improve efficiency and outcomes over current payment models. This is not the time to wait and see if and how it will affect you. Instead, understand that it will and make sure you're prepared by facilitating relationships with other health care providers.

Accountable care organizations (ACOs) are playing out in larger organizations such as hospitals, which provide a more seamless transition due to existing infrastructure. What is important is that these ACOs are proving to be both cost-effective and patient-centered. Currently, ACOs are focused on Medicare, but all insurance payers are taking notice, with some conducting their own case studies.

You should take notice as well, because once the formula is sound and the results are firm, it will begin to filter down with the expectation that it will eventually reach independent practices. Those who thrive will illustrate a collaborative team approach, and meet ACO goals and objectives.

In fact, seeing the potential benefits, some health care practitioners, including chiropractors, are voluntarily forming ACOs which are supported by private payers. One such example is ACO Chicago, where a website comment by board member John Veneto, MD, alludes to their goals: "And it will ... give independent physicians a chance to survive and compete in the challenging health care market."

The game rules of achieving this objective are straightforward and include conforming to evidence-based care, which most chiropractors do; and engaging with other health care providers, which many chiropractors don't do or don't know how to do. (We'll get to this shortly.)

An ACO Perspective on Chronic Low Back Pain

Let's look at chronic lower back pain from an ACO perspective. It's already clear that it takes a multifactorial approach to outplay a multifactorial condition – in other words, a team approach in which each player has a unique skill to help improve outcomes, and reduce costs and care redundancy, through collaboration. One player alone cannot win every game for the team, and this is especially true for chronic low back pain.

For the chiropractic community, ACOs appear to offer many DCs what they have always wanted and what the research supports: a first stop for managing back pain and a continued seat at the table for cases that do not respond. In fact, lower back pain guidelines support an algorithm for chiropractic participation in both the acute and chronic patient (Chou, 2007).

Our opportunity to thrive in health care is to remain unique. We have the skills needed to assess, diagnose and plan a patient-focused game strategy that is effective, safe and costs less. Yet we aren't competitive. Most chiropractors do not have major rehab equipment, do not provide injections, do not prescribe medication and don't perform surgery. But we do work well alongside all of these, helping to prevent an escalation in care.

Importantly, playing in the game means we, as a profession, are helping to shape health care and secure our place at the table. Like any player, statistics are being collected and those statistics reflect value. If our statistics are anything like our research, our value will be quickly recognized. We have multiple opportunities to demonstrate:

• Multiple uses for our services: acute, chronic, postsurgical, etc.
• Comprehensive approach: e.g., ergonomic, postural, education, exercises, manipulation, nutrition, weight loss
• Specialties in chiropractic: e.g., sports, pediatrics, neurology, rehab, etc.
• Noninvasive
• Not competitive
• Patient satisfaction (another sticking point with ACOs)

A Few Experts Weight In

If I haven't persuaded you yet, perhaps these experts will:

"Not only is it important at this time to be engaging with other healthcare providers such that care coordination is improved and the data being collected on CQMs can effectively identify high risk patient populations, but it is time for the chiropractic industry to proactively serve in guiding and leading this healthcare movement toward a culture of health and well-being.

"These rapidly changing times are calling upon all chiropractic physicians to step up to not only integrate quality improvement into their practices, but to work collaboratively with other providers to establish evidence-based outcomes to create a healthier population tomorrow than we have today. It is not time to become an ostrich and bury our heads in the sands hoping this will all blow over, but rather become actively involved.

"It is the chiropractic profession's time to shine. Our profession has always been about the triple aim: improved patient experience, improved population health, and lower costs. The door is wide open for the doctor of chiropractic who is willing to improve, practice evidence-informed care, and get with the changing times. Chiropractic care will become a part of the new care continuum and health care team – the question is, will you and your practice be among them?" — Scott Munsterman, DC, FICC; CEO, Best Practices Academy

"With the recent implementation of the new healthcare requirements for your practice, there are two areas that have become even more important than ever: detailed documentation and integrative care and management. I cannot overstate their importance in general practice, but especially in the personal injury arena. In particular, integrative care protects you and your practice from unwanted med legal consequences by mitigating risk and liability. It also secondarily raises the quality of care for your patients. If you value the benefits of a good night's sleep, I would highly recommend incorporating integrative care and management into all of your algorithms." — S. Scott Tauber, DC, DABCO, CPC; COO, American Institute of Personal Injury Physicians

How to Break Down Barriers to Integration

The problem is, most chiropractors don't know how to approach medical physicians or are not familiar with how to break down barriers. And once there, they are not sure how to communicate a need for their services – even though they know it exists. Here are some proven tips to help:

Get Time: The most available and successful route is your patients. Nothing speaks higher of your services than illustrated efficacy in a patient the doctor knows. Make it procedure to gain consent from your patients to communicate with their physicians and any other health care providers they have seen about their care. Upon discharge of a non-medical legal case, write a simple one-page report that speaks to the disability or functional limitations experienced by the patient, an examination summary, basic care summary and number of treatments. How did your care impact the disability and functional limitations? Many medical-chiropractic relationships have started this way.

One tip to help improve medical outreach outcomes is to leverage patient reports by hand walking them in to the physician. Reports act as an aide to get past gatekeepers who are protective of physician time, and allow you to actually meet the doctor and introduce yourself. Use this quick introduction to summarize the patient's outcome and ask for time when it is more convenient to continue the education.

Convey Your Message: Have a meaningful conversation; don't be a commercial! Start with a patient type that's most likely an issue for the MD. Chronic lower back pain which has not responded to traditional care is an excellent starting point. It's an area about which medical physicians feel frustrated and chiropractors tend to excel. Focus on pain and disability issues to create a sense of need and urgency.

Use Research as a Foundation: Research helps to support your conversation. If you know you are going to be introducing chronic lower back pain to a primary care physician, find research that compares traditional chiropractic care (i.e., manipulation) to traditional medical care (i.e., NSAIDs). This helps illustrate a patient type through research, as well as the efficacy of your care compared to traditional options.

Ask for the Business: Many chiropractors are afraid to confront the issue - was your conversation meaningful enough that the physician will try referring a few patients? If you don't find out, you'll be guessing and disappointed with lackluster results. I find a statement as straightforward as, "Was there anything we didn't discuss that would prevent you from referring a patient for a trial of chiropractic care?" an easy and comfortable way to ask for their business.

Time to Get in the Game

Our profession is at risk. We have not successfully and fully integrated with the medical community, but our competitors have. To not have done so, while also facing health care reform, means we are potentially losing ground and market share. It makes building medical relationships now, a sense of urgency both for your own practice and for our profession.

Currently, most patients seek out chiropractic care at least in part because traditional care has failed them or failed to offer an approach they want. If all of managed care adapts to ACO outcomes and models, those patients may not have a choice – or they may find similar solutions with our competitors who understand the rules on the ACO field. It's time to get in the game!