Crossing Borders: Opportunities for Wellness and Medicine to Collaborate Under the ACA

Now is the time for wellness professionals and organizations to offer their services to the medical community. The emphasis on patient outcomes and preventive health under the Affordable Care Act (ACA) presents a number of opportunities for professionals and organizations that excel at patient communication, care coordination and disease management to partner and collaborate with physicians, hospitals and insurers. For example, a common theme in ACA initiatives such as Accountable Care Organizations (ACOs), Primary Care Medical Homes (PCMH) and the Quality Improvement Strategy (QIS) is to coordinate patient care among a team of health professionals to ultimately improve patient outcomes.

Poor care coordination is associated with duplicate procedures, conflicting treatment recommendations, unnecessary hospitalizations and nursing home placements, and adverse drug reactions. Care coordination transfers information between one participant in a patient’s care to another and establishes accountability for each aspect of a patient’s overall care.

Medicare’s ACO program, the Medicare Shared Savings Program (MSSP), requires as part of its patient-centeredness criteria the coordination of care throughout an episode of care and the submission of individualized care programs that promote improved outcomes for patients. The ACA defines a function of a PCMH is to coordinate and integrate care. The ACA’s QIS, which is set to start in Fall 2016, requires health insurance exchange plans to have a strategy that provides incentives for improving health outcomes through case management, care coordination, chronic disease management and use of medical homes. These ACA initiatives work in concert with one another; PCMH’s are often part of an ACO, and soon Exchange plans will need to incentivize providers to adopt ACO and PCMH care coordination initiatives.

Hospitals and physicians will not be able to meet these care coordination/disease management requirements on their own. The initiatives demand collaboration among a diverse set of professionals and organizations. Organizations and professionals such as community health workers, health educators and health promotion specialists, home health professionals, complementary and alternative medicine providers, psychologists and social workers all offer unique and valuable skill sets that fill in the care continuum, which must be seamless in order to improve patient and population health outcomes.

The ACA care coordination initiatives are gaining popularity in the provider community. The federal Department of Health and Human Services (DHHS) seeks to have 50%-90% of Medicare fee for service payments in value-based payment programs, such as ACOs, medical homes and bundled payments by 2018. Organizations and professionals that offer care coordination and disease management services must begin positioning themselves as experts in an aspect of the care coordination models. To do that, they must collect data showing the value of the services they provide and then they must use that data to build relationships with physician groups and acute care facilities. The goal for these professionals and organizations is to enter into contractual arrangements with ACOs, PCMHs and insurers to serve as member of a health team accountable for improving the health of a population. Professionals and organizations that jump on the care coordination train early will have an advantage.