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Deciphering the Alphabet Soup of Health Reform

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Shortly after the Affordable Care Act was passed nearly two years ago, I spent a lot of time talking to people about the key elements of the law, how it would not only expand health care coverage but also support changes to improve quality while keeping costs in check. When I talked about these delivery system reforms, my favorite joke was to put up a slide with a mermaid, a unicorn, and the words "accountable care organization" and point out that no one had ever seen any of these things in real life.

Today, we're starting to see accountable care organizations take shape, but to many of us, they remain as mysterious as mermaids. The whole alphabet soup of health care payment and delivery models is dizzying: PCMHs, HHs, BHOs, ACOs! OMG, what do all these things mean?! We know what they stand for (Patient-Centered Medical Homes or Primary Care Medical Homes, Health Homes, Behavioral Health Organizations, and Accountable Care Organizations,), but what do those models look like, how well will they work in practice, and how will they affect the way patients experience care?

Health care providers and payers already are placing their bets, focusing on the approaches that best fit their patient population, their organizational capacity and mission, and the potential for additional reimbursements and incentives.

For the rest of us, I'm not sure it much matters whether we understand every detail of how a health home differs from a behavioral health organization (by the way, even the experts offer varying definitions of these concepts!). What is most important is to understand the key common elements of all of these models. In essence, there are just three key concepts that embody the changes all of us hope will transform our care system into one that improves outcomes and increases efficiency:

1. Emphasis on care coordination and disease management. A recent New York Times article highlighted insurance companies' growing attention to case management and care coordination for patients who have costly chronic illnesses like diabetes. Providing effective disease management will require broadening the traditional health care provider team to include social workers, community health workers, and diabetes educators.

2. Rewards for better care, not just more care. All of the alphabet soup approaches involve some approach to payment reform that moves away from the simple fee-for-service system. Eventually, my hope is that payment reform will base rewards on patient outcomes, not just on improved care processes. Not every model is quite there, but incentivizing and rewarding improved processes of care is a step in the right direction.

3. Use of health information technology. Late last month, CMS issued preliminary rules for Stage 2 Meaningful Use of electronic health records; Ashish Jha's blog post on that topic is a very helpful primer! Electronic health records will be a key component of managing and coordinating patients' care. Collecting and sharing data to paint a picture of health care quality, price, and patient outcomes will become the standard. And, personal health records that engage patients to take a more active role in managing their health will become much more common. The surgeon general last month announced the winners of a "healthy app" challenge, just as Britain announced a big push for clinicians to promote apps to help their patients manage their care.

In some ways, the alphabet soup of new models really represents a continuum of approaches that get increasingly serious about transforming the care process, the reimbursement paradigm, and the use of information. Let's hope that many parts of New York State get far along that continuum where providers focus on preventive care while wisely using health care resources when necessary and engaging patients as partners in the health maintenance enterprise.

As a postscript, I will provide my own very brief guide to the alphabet soup; even though the high-level concepts driving them are most important, I think it's helpful to try to get to a common understanding of what these different models mean. But, I warn you: not everyone will agree with these categorizations!:

Primary Care Medical Homes: a primary care provider that has instituted a series of processes that have been shown to permit better outcomes (for example, some activities that help patients do self-management). Medicaid in New York State pays a small bonus to providers who become PCMHs.

Health Homes: a new Medicaid demonstration program that actually provides payments for care management for patients with serious chronic illnesses. To qualify, providers need to have good systems of care and good relationships with a wide range of specialists that will facilitate care management.

Behavioral Health Organizations: a "concept" still in the development phase that would encourage primary care providers, mental health providers, substance use providers, and other specialty providers to link together to care for patients with significant mental health and substance use problems.

Accountable Care Organizations: technically, this is a Medicare initiative that will offer stark financial incentives to a health care provider willing to bear some or all risk for the health care costs and needs of a defined population of Medicare recipients. A newly emerging term is "ACO-ish type arrangements" (this one doesn't even have an acronym yet!), which refers to the creative efforts of many providers to begin working with their payers to develop capitation arrangements to pay for more focused populations of patients with defined sets of health needs.

How would you clarify my categorizations of these models? Please let me know in the comments how you make your way through the alphabet soup and how you would define these concepts!