View All News

Improving Population Health by Integrating Aco’s and PCMH.s

February 1, 2018

Improving Population Health

Developing Accountable Care Organizations Through the Integration of Patient Centered Medical Homes

Joseph Jasmon, MBA

Accountable Care Organizations (ACO)

An Accountable Care Organization (ACO) is a network of Hospitals, Doctors and other Healthcare Delivery Organizations that share responsibilities for providing care to a population of patients.  Within the Affordable Care Act (ACA), ACO’s are charged with the agreement to manage a minimum of 5,000 Medicare Beneficiaries for at least 8 years.

ACO’s must perform within certain guidelines and must have collaborative leadership, aligned incentives, coordinated clinical programs and a robust technology infrastructure.

Successful ACO’s must have the following:

-Governance Structure

-The ability to measure costs, productivity, quality and outcomes

-The ability to aggregate data from individual units

-A sufficient number of patients to detect a statistically significant difference in performance from established targets

-The ability to report data to external groups

-The necessary information technology and work process design capability to improve care on a continuing basis.

Patient Centered Medical Home (PCMH)

A Patient Centered Medical Home (PCMH) is a team based health care delivery model led by a physician or group of physicians that provided comprehensive and continuous medical  care to  patients with the goal of obtaining maximized health outcomes.

Improving care through a safe, effective and patient centered model is the foremost objective of a PCMH.  The provision of medical homes may provide better access to healthcare improve the overall health of a population and increase patient satisfaction.

Successful PCMH’s must have the following:


-Continuity of care

-Comprehensiveness of care



Improving Population Health

It is clear that the emergence of Accountable Care Organizations (ACO) and Patient Centered Medical Homes (PCMH) are a direct response for the need to improve access and quality of care.  In order to achieve this new balance or improvement, in overall population health, providers must become clinically integrated.

Clinical integration of providers is a pre-requisite to the care coordination of a given population.  This care coordination is crucial to the development and improvement of models designed to improve the overall health of a population.

It is the goal of ACO’s to create a system focused on the provision of safe, effective, timely, efficient and equitable patient centered care.   In order to meet population health improvement goals it will be imperative to ensure clinical integration and care coordination.  The development of an ACO is a challenging and time consuming task that requires the creation of a complex organization.

Patient Centered Medical Homes are the building blocks of ACO’s, where specialists collaborate with primary care physicians in a collaborative effort to improve care, improve the overall health of a population and reduce costs.

Specifically, these organizations will have to increase the utilization of evidence based health services and prevention measures.  They will need to improve the overall quality of care and patient safety and provide for care coordination across the entire continuum.

The 6 fundamental goals for improving population health can be simply defined as follows:

-It must be safe

-It must be effective

-It must be patient centered

-It must be timely

-It must be efficient

-It must be equitable

Improving population health will require a series of relationships, key players and key competencies as listed below:

Key Players

-Hospital/Health Systems

-Primary Care Physicians

-Specialty Care Physicians

-Ancillary Services (lab, x-ray, etc.)

-Post Acute Care Partners


-Home Health

-Skilled Nursing

-Physical Therapy


-Wound Care

-Wellness and Prevention

-Health Coaches

-Care Coordinators

-Case Managers

-Managed Care Partners

-Information Technology



-Capital Partners

-Community Health Providers


Key Competencies

-Collaborative Leadership

-Aligned Incentives

-Integrated Clinical Programs

-Technology Infrastructure

-Robust Committee Structure

-Governing Process

-Fiduciary Responsibilities

-Accountability Measures

-Reporting Rules

-Operational Management

-Clinical Management

-Software Integration

-Data Integration

-Risk Assessment

-Work Force Assessment

-Payment Methodology

-Physician Relationships

-Hospital; Relationships

-Community Alliances

-Population Health Analysis

-Utilization Management

-Care Coordination

The Process/Solution

The process/solution to improving population health by developing ACO’s and the integration of patient centered medical homes begins with the identification of the key components, members and requirements.

The initial steps of the integration process will be to identify the needs, expectations and experience of a defined population.  In many cases this begins with the development of a PCMH or the utilization of an existing PCMH as a springboard to the development of a fully integrated ACO.

In either case we begin with the identification of key members of the ACO or PCMH.  These members will include primary care physicians, specialty care physicians, third party payers, hospitals and health systems, ancillary providers, post-acute care providers, community service providers among others.

It is important to identify and define the key goals of the organization.  In all cases regarding ACO’s and PCMH’s, the following goals must be first and foremost in their development process;

-Patient care must be safe

-Patient Care must be effective

-Patient Care must be improved

-Care must be patient Centered

-Patient Care must be timely, efficient and equitable

-We must strive to improve health

-We must strive to reduce costs

-We must be clinically integrated

Models and Payment Methods

Within the development of an ACO, there are two options currently being implemented.  These are the Medicare ACO and the Commercial ACO.  Currently there are no efforts being pursued to create a Medicaid ACO.  Included in the development.    In these models physicians are paid in a variety of ways; fee-for-service, reduced fee-for-service plus bonus, per member per month plus bonus and pay for performance methods.  Medicare ACO’s  can be paid in one of three ways - an up front fixed payment, an upfront variable payment or a monthly payment.  In any case the structure and payment methodologies must be taken into consideration at the beginning of the development process.

Quality of Care

Organizations designed to improve population health must focus their efforts on improving quality of care and must prove their effectiveness through measurements and improvements.

Specifically, CMS will be looking at the following:

-The patient/caregiver experience

-Care coordination/patient safety

-Preventive health

-At risk populations—Diabetes, hypertension, ischemic vascular disease, heart failure, coronary artery disease

ACO’s and PCMH’s should focus their quality efforts in the areas of; outcomes, care coordination, patient experience, utilization, process and access to care.  In addition, in order for ACO’s to receive shared savings program payments from Medicare, they will be required to measure and perform on  the following:

-Timely care, appointments and information

-Provider communication

-Patient’s rating of their providers

-Access to specialists

-Health promotion and education

-Shared decision making

-Health status/functional status

Finally as the ACO progresses through the program and matures, CMS will require reporting and performance on an additional 33 quality measures.

Primary Care Medical Home Standards

The utilization of a PCMH as a means to improve population health can and should serve as an initial step towards the development of an ACO in a given defined population.

The standards set forth for the PCMH are as follows:

-Enhance Access—During office hours, after hours, electronically, creating continuity of care, performing medical home responsibilities

-Identify and Manage the Patient Population—Patient information gathering, clinical data identification, comprehensive health assessment, utilization of the data for population management

-Plan and Manage Care—Implement evidence based guidelines, identify high risk patients, managed care, manage medications, electronic prescribing.

-Provide Self Care and Community Support—Self care process, referrals to community, community resources

-Track and Coordinate Care—test tracking and follow up, referral tracking and follow up, coordinate with facilities, facility transition

-Measure and Improve—performance measures, patient/family feedback, continuous quality improvement, reporting, external reporting

Alignment of the PCMH and the ACO

The integration and/or alignment of the PCMH and the ACO is easily presented through the linkages shown below:

ACO Risks and Challenges

The development of population health improvement organizations  come with a series of challenges and risks.  It is important to understand that the focus of this effort must continue to circle around the patient.    This becomes even more prevalent when integrating ACO’s and PCMH’s.

These efforts will include governance, physician relations, clinical and quality outcomes, budget and finance, payer relationships, administrative operations, strategic planning and legal compliance.  This initiative will not be successful without the fundamental support of a strong technology infrastructure and information services.


Improving population health cannot be completed on a broad scale without developing a clinically integrated network .  Regardless of the method chosen—ACO or PCMH or the integration of the two—organizations must be mindful of the details and the process required to be successful and compliant.

An integrated solution that brings together best practice solutions to your organization will be your best chance for success.  If you are starting today you will need to move quickly. The vetting process alone will take several months to a year to determine which vendors have created a best practice solution, review demos and make your selections.

As described in this document, the complexities and details are significant.  We provide an integrated innovative solution for population health management, ACO or PCMH development and management.  We have spent the time reviewing demos and vetting products and services.  We bring the most comprehensive solution available to you and your organization.

Below we have defined the process in 10 steps:

-Create a Clinically Integrated Network

-Identify Your Population

-Assess Your Population—Risks, Health Status, etc.

-Integrate New and Existing Data

-Create Health Improvement Plans

-Create Measurement Tools

-Implement Plans

-Measure and Monitor

-Improve Patient Health

-Report Results

Our initial assessment and review of your organization, its current status and needs will allow us to identify and implement an appropriate solution  to improve the health of your targeted population.

Read More

Other News