Achieving ACO Success Via Peer-to-Peer Learning

April 13, 2015 Craig Schneider, Ph.D, Senior Health Researcher,

Mathematica Policy Research

DISCLAIMER: The views and opinions expressed in this presentation are those of the author and do not necessarily represent official policy or position of HIMSS.

Conflict of Interest

Craig Schneider, Ph.D has no real or apparent conflicts of interest to report.

© HIMSS 2015

Learning Objectives

The objectives of this session are to: • Discuss the core competencies that Medicare ACOs need to achieve success • Describe the role of the learning system in helping Medicare ACOs achieve

the core competencies • Describe the data sources that are made available to ACOs and how they are

used for quality and financial performance measurement • Discuss the diversity of ACOs and the challenge of designing a learning

system that meets each of their needs • Explain how the learning system uses data collection methods to

continuously improve curriculum and implementation

Advancing ACO Success Via Peer to Peer Learning

Satisfaction—ACOs ACOs provide feedback regarding the learning system. Satisfaction metrics derived from individual webinar/event feedback forms, quarterly surveys, interviews, and focus group decisions.

Treatment/Clinical Learning system follows continuous quality improvement model—test and revise implementation methods and curriculum.

E-information/Data CMS provides claims data to ACOs to assist them in assessing quality performance, and develops baseline benchmarking reports to illustrate their financial performance. Learning system provides electronic dashboard and technical assistance to ACOs to help them understand the data.

Prevention/Patient Education Patient engagement is a core competency of accountable care, and ACOs are responsible for several preventative health quality measures.

Savings Medicare ACO programs are designed to save the Medicare program money while improving quality of care. ACOs that achieve sufficient savings share in those savings and improve their bottom line.

Outline

• Introduction to Medicare ACOs • Quality and financial measures • Structure of the learning system • Core competencies and curriculum • Pioneer dashboard • What we’ve learned • Conclusions and next steps

Introduction to Medicare ACOs

• Background • Models of Medicare ACOs • Why CMS established a learning system • Quality and financial measures

Current CMS ACO Models

• Pioneer • Shared Savings Program (SSP)

– Advance Payment (AP) – ACO Investment Model (AIM)

• End-Stage Renal Disease Seamless Care Organization (ESCO)

CMMI’s Thinking

• Why establish ACOs?

• Why establish a learning system for the ACOs?

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Launching an ACO

• Year 1/start-up priorities: – Analyze data to understand patient populations – Engage providers – Hire staff – Identify priority areas for care improvement – Understand program requirements and processes

• Year 2/implementation priorities: – Implement, scale specific care mgmt strategies – Focus on post-acute care (PAC), high-risk/high-cost

pts (HRHC) – Deeper engagement of patients, doctors, community

in improvement efforts – Address patient turnover

Source: Pham et al JAMA, 9/17/14

http://www.advisory.com/research/health-care-advisory-board/resources/2012/posters/where-the-acos-are

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Quality Measures for Pioneer, SSP

• Patient/Caregiver Experience (CG-CAHPS) – Timely care, appts., info – How well physician communicates – Patients’ rating of doctor – Access to specialists – Health promotion, education – Shared decision-making – Health status/functional status

• Care Coordination/Patient Safety – Risk standardized, all conditions readmissions – ASC admissions: COPD, asthma, heart failure – % PCPs who got EHR incentive payments – Medication reconciliation – Screening for fall risk

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Quality Measures (2)

• Preventive Health – Flu, pneumo immunization – Adult weight screening and follow-up – Tobacco use assessment, cessation intervention – Depression screening – Colorectal cancer screening, mammography – Proportion who had blood pressure screened

• At-Risk Populations – Diabetes: composite measure for HbA1c, LDL, BP, smoking, aspirin; % HBA1c

controlled – Hypertension: % pts w/ BP <140/90 – Ischemic vascular disease: Lipid profile, LDL control, take aspirin – Heart failure: Beta-blocker therapy – Coronary artery disease: Rx to lower LDL, ACE inhibitor

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Structure of the Learning System (LS)

• LS Model • Curriculum topics • Dashboard for Pioneer ACOs

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Learning System Model

Self Evaluation

Participant Feedback

Input from CMS

Input from SMEs Analysis of Dashboard, L&M Reports, and Other Sources

• Webinars •Innovation Pods •Tech. Assistance

• IPLCs • F2F

• Case Studies • Guidelines

Modalities Identify & Prioritize Learning Needs

Online

In-Person

Written

Develop Curriculum

ESCO Pioneer SSP/AP/AIM

Core Competencies

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Curriculum Topics • Care coordination

– Primary care – Improve transitions – Avoid readmissions – Reduce disparities – Behavioral health

• Provider engagement – Payment incentives – Data feedback – Contracting – Support transformation

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Curriculum Topics (2) • Health information technology

– HIT infrastructure for accountable care – Clinical decision support – Data analytics

• Managing population health – Risk stratification – Evidence-based medicine – Working with community on population health

• Quality improvement – Understand measures – Respond to quality data – Patient safety – PDSA cycles

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Curriculum Topics (3)

• Patient-centered care – Patient engagement – Information follows the patient, – Chronic care mgmt. – Improve bene experience of care

• Leadership – Measure costs of care – Manage risk – Partner with payers – Role of Board and executive leadership – Practice transformation – Clinical/financial integration

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Project Dashboard Mathematica created web-based, interactive

dashboard for Pioneer ACOs that: • Provides opportunities to assess trends • Enables ACOs to see their own data compared to

ACO average; CMS to have program-wide view • Compares performance on key cost metrics • Compares performance on 33 GPRO/PQRS

quality measures For Pioneers currently; ESCOs to be added next year

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Project Dashboard – Cost Comparison

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Project Dashboard – Cost Comparison (2)

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Project Dashboard – Quality Measures

Mathematica is creating an electronic dashboard that will: • Provide opportunities to assess trends • Compare performance on key cost metrics:

– Total costs, costs by line of service; also reported as percentages

– Cost data to be aggregated at ACO level; blinded data for peers

– Drill-downs of cost metrics • Compare performance on 33 GPRO/PQRS quality

measures • For Pioneers; ESCOs to be added next year • ACOs to see their own data compared to benchmarks;

CMS to have program-wide view

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Project Dashboard – Demographic Data

What the LSACO Project Team Has Learned

• Data needs of ACOs • Other core competencies

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What We’ve Learned About the Data Needs of ACOs • HIT

– Interoperabiitly; manage data from multiple EHRs • Analytics

– As close as possible to real-time data – Allow a fair amount of time to establish data analytics

• Provider engagement – Disseminate data and report cards to docs – Physician training in utilizing data

• Patient engagement – How address benes who opt out of data sharing – Condition-specific plans for pts to take home

• Risk stratification – Predictive analytics

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What We’ve Learned About the Data Needs of ACOs (2)

• Identify high-risk/high-cost (“frequent fliers,” “HUG”) • Quality improvement

– Capture data for quality measurement – Quality metric analysis

• Care coordination – Coordinated care management system – Get info from hospital when bene discharged

• Behavioral health – Integrate BH services with physical care

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What We’ve Learned About …

• Care coordination – Multi-disciplinary teams develop care plan for HRHC – Share list of HRHC pts w/ PCPs – house calls, care mgmt – Hospitals, care mgrs in hospitals & SNFs help transitions – Partner w/ ambulance co. to assess fall risk, visit homes – Notice system when patients go to SNF – Ensure food security for patients – work with community to put in a

grocery to improve access to food – Monitor pt support services/agencies to learn about pt home conditions – Partner w/ pharmacy to provide med rec and pt education – Embed care coordinators into practices

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What We’ve Learned About … (2) • Post-acute care

– Share data w/ SNFs – Identify SNFs that are high-quality and low-cost – Partner w/ high-quality HHAs

• Provider engagement – Work w/ specialists on EBM, contracts for shared savings – Disease mgmt initiative to develop best clinical pathways – Use EMR data to show how pts benefit from providers’ efforts – Practice-based ACOs – exchange info re: pt referrals w/

hospital – Provide pt and population dashboards to MDs

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What We’ve Learned About … (3) • Health IT

– Single EMR system and interoperability across settings – Obtain ADT info from hospitals – Encounter system to track pt admits; care mgrs. reach out to pts

• Patient engagement – Appts 365 days/year; partner w/ clinics offering evening hours – Pt portal and social media to build pt community – Classes to help seniors learn to use computers – Employ pt advocates; use social workers for counseling – Partner w/ AARP to hold educational seminars about ACOs – Annual wellness visit – build trust, get data (helps prov. engage

too) – Exit brochures/cards w/ PCP, insurance info (don’t know they’re in

ACO) – Enrichment Center – “senior center-like” atmosphere in doc’s office

What We’ve Learned About … (4)

• Leadership/organization – Use existing infrastructure to reduce start-up costs

• End-of-life care – NPs visit home to discuss palliative options (not office visit) – Work with family members to role play various scenarios – MOLST, “five wishes tool,” www.epec.net (Education in Pal/EOL)

• Risk stratification – Develop health risk assessment tool

• Primary care – Work w/ PCPs to reduce urgent care visits – identify “HUG” pts

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2 Questions Asked at an IPLC Meeting

1. What is one thing that you would recommend that ACOs do in the first year? • Go into 2nd year with resources think you need (whether/not achieved

savings in 1st year) • Invest in predictive analytics software • Gain and maintain physician trust by being 100% transparent with them 2. What is exciting you the most about this work? • Strong emphasis on quality and improving quality in a measurable way • Disseminating data to the providers in a way that impacts care delivery • Participating in historically significant innovation in health care delivery • Helping patients in the community • Chance to be proactive rather than reactive with patients • The opportunity to reward and recognize primary care.

ACOs’ Evaluations of the Learning System

• 20 webinars for SSP, 11/’13 – 12/’14 – average attendance of 222 people

– Presentations Excellent/Very Good: 82% – Q&A Excellent/Very Good: 78% – Got ideas to use in my ACO: 89% – Can apply what I learned in my job: 84%

ACOs’ Evaluations of the Learning System

• 8 IPLCs held to date – average 25 participants from

13 ACOs – Strongly agree/agree that attending improved my

ability to lead change: 83% (100% in Ann Arbor) – Learned 1 or more new ideas: 94%

• Pioneer face-to-face meeting 2014

– 74% rated the meetings as Excellent or Very Good, 26% as Good

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Challenges for ACOs to Meet

• Patient and beneficiary engagement • Patient attribution – who are my patients, churn • Aligning incentives (much of care still FFS) • Integrating multiple EHRs, interoperability • Limited funding for transformation, eyeing return on

investment • Behavioral health • Coordinating patient care within the ACO • Data sharing • Lack of timely and complete data • Collaboration in a competitive marketplace

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Challenges for ACOs to Meet (2)

• Build provider network in rural areas • Organizational transformation • Leveraging private contracts, Medicaid • Participating in evolving models/programs (Pioneer,

SSP) • Integrating newly acquired organizations • Optimizing use of care managers/navigators/guides in

care team

Advancing ACO Success Via Peer to Peer Learning

Satisfaction—ACOs 89% of webinar attendees and 83% of IPLC participants found ideas that they could bring back to their ACO.

Treatment/Clinical We piloted the In-Person Learning Collaborative before expanding it throughout the country.

E-information/Data Dashboard contains cost, quality, and demographic data for analysis.

Prevention/Patient Education ACOs assessed on 7 patient/caregiver experience measures and 9 prevention measures.

Savings Last year achieved $417 million in Medicare savings and $460 million in ACO Shared Savings.

Questions?

Craig Schneider, Ph.D Senior Health Researcher Mathematica Policy Research (617) 715-6955 cschneider@mathematica-mpr.com