Knowledge

Management
Organizations

in

Accountable

Care

Author: Gordon D. Brown

(Source: Health Informatics by Brown, Patrick, and Pasupathy, Health Administration
Press, 2012)

The Setting
A large psychiatric specialty group practice in a metropolitan are provides a
range of psychiatric services. The practice has grown rapidly and has thrived
since its formation in the 1980s, as a result of the development of managed
care plans, including the state Medicaid program that follows a carve-out model
for behavioral health services. The psychiatrists carryout extensive translational
research and use evidence based protocols in their practice. They also develop
these science-based protocols and embed them into their individual practices.
Several psychiatrists are concerned about the impact of the new federal
mandate to develop accountable care organizations (ACOs). The mandate
identifies 65 performance measures that the standard ACO must meet under
the Shared Savings Program. These measures span five quality domains: patient
experience of care, care coordination, patient safety, preventive health, and at
risk population / frail elderly health. The only behavioral health measure
mandated is in the preventive health domain, a measure for depression
screening.
Some leaders of the group feel that mental and behavioral health, as a specialty
area, and the clinical volume would not significantly change. They do not think
they should develop an ACO strategy and have resolved to take a wait-and-see
approach. Another set of leaders, including the CEO, believes that ACOs do
present some threats but at the same time provide an opportunity for the group
to transform itself into an information-driven practice.
Evidence-based Strategy
The practice forms a multidisciplinary team to explore an ACO strategy. The
team comprises two psychiatrists, one psychiatric nurse, the practice CEO, and
one healthcare management intern. The team argues that it will entertain all
ideas and proposals as well as research the literature to bring in the best
explicit information and experimental knowledge available. The relevant
literature topics include ACO basics, knowledge management and managed
care organizations limited acceptance and success since the 1980s.

The management intern, Marjorie, is interested in the medical offset effect and
its potential as a strategic asset. She presents to the team 30 years worth of
research on the concept, including closed clinical trials. Studies on medical
offset measure the impact of providing effective behavioral health services on
the utilization of medical care, including physician consults and visits to the
emergency department. Marjorie is impressed by the extensive studies that
include a wide range of populations and conditions, including Medicaid patients
and chronic care diagnoses. The findings consistently demonstrate a savings of
10 to 20 percent form reductions in medical care utilization. The psychiatrists
met these studies with skepticism, however. Although they think the science
behind the research is valid, they reason that the practice has a specialty in
mental health and not prevention or behavioral health, so the studies are not
relevant to what they do.
In a brainstorming session, the team explores alternative scenarios on how the
practice might add value to the ACOs that are developing within its area. The
first scenario is to embed specialty psychiatric knowledge into the ACOs
decision support system. The second scenario is to develop formal affiliations
with as many ACOs as possible to capture their referrals for specialty care. The
third scenario is to extend the practices decision support protocols to address
prevention, early detection, and aggressive management of behavioral health
issues. This last idea is suggested by the psychiatric nurse, who points out to
the team that the nursing staff and social workers have considerable (but
untapped) expertise in behavioral health. The psychiatrists worry that
developing behavioral health decision support protocols should results in a loss
of status for the psychiatrists and thus would be strongly opposed. They are
also concerned that the strategy would results in loss of prestige and reputation
for the practice as a whole.
After considerable discussion and debate, the team agrees to respect the
existing culture but to pursue the collective (corporate) interest of the practice
rather than one group (psychiatrists). They begin to develop a proposal for the
third strategy.

Case Study Questions

1. Create a strategy to leverage the knowledge base of the practice against
the value of knowledge within the developing ACOs. Consider the
following guidelines and questions for this exercise:

What change will be made on who accesses knowledge generated

by the practice and how would it be used?

Address each of the five quality domains specified by the ACO

mandate, and justify their inclusion or exclusion. What are the
implications of each of each on the structure of the clinical process
and on the information system that supports the process?
What new properties of the decision support system must be
included within the proposed strategy? How might tacit knowledge
within the practice be leveraged by primary care physicians, other
specialists, and patients?
What form of organizational structure would be formed with the
ACO? What are the implications of collaborating with more than one
ACO? Should the psychiatric group serve as the focal organization
for developing an ACO?
What value is brought to the ACOs, and how would it be assessed?
How would the practice be paid for its value-added services?

2. Comment on the environment of the practice and its readiness for

strategic change. Who might you want to add to the team that is
exploring an ACO strategy?