Accountable Care Organizations: Overview and the Role of Information Technology

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Accountable Care Organizations:Overview and the Role of Information Technology

Colin Konschak, MBA, FHIMSSMary Sirois, MBA, CPHIMSDavid ShipleMay 11th, 2011

© 2010 DIVURGENT. All rights reserved.

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Objectives1. Describe the intention and programmatic features of the Medicare Shared

Savings Program

2. Identify financial impacts associated with the accountable care organization

3. Describe potential delivery models for the accountable care organization

4. Describe quality reporting requirements and issues

5. Identify HIT requirements for the Medicare Shared Savings Program

6. Identify alignment between Meaningful Use requirements and Shared Savings requirements

7. Describe a potential ACO IT reference model


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Level Setting

• Commercial Accountable Care Organizations (ACOs)

• Medicare Shared Savings Program ACOs• Notice of Proposed Rulemaking (NPRM) • Definition of an Accountable Care Organization

– Legal entity– Comprised of an eligible group of ACO participants – Established a mechanism for shared governance


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Affordable Care Act• Patient Protection and Affordable Care Act / Health Care and

Education Reconciliation Act of 2010• Goals:

– Improve quality of Medicare services– Support innovation– Establish new payment models– Align payments with costs– Strengthen program integrity– Secure financial future of the program

• Requires the Secretary to establish the Medicare Shared Savings Program with a three part aim:– Better care for individuals– Better health for populations– Lower growth in expenditures


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Value Based Purchasing

• Links payments directly to the quality of care delivered

• Rewards providers for high quality, efficient care• Improve Quality• Lower growth in expenditures


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Shared Savings Program• Intentions

– Promote accountability for a population– Improve coordination of items and services– Encourage investment in infrastructure– Redesign care processes to improved quality and efficiency– Share savings with the ACO– Achieve at the highest level, the three-part aim– Reduce growth in expenditures

• The Program Itself– Allows for providers to work together– Establishes shared savings payments– Secretary given discretion to determine assignment of beneficiaries – Establishes principles and requirements for payments and treatment of savings– Payments will continue under FFS– Establishes the methodology to calculate savings– ACOs must not avoid at-risk patients


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Two Distinct Models

• Shared savings model– Entry point for less experienced organizations in accepting financial

risk– Allows for time to gain experience, while under the FFS model– Proposed that these organizations will transition to the two-sided

model in their final year of their initial agreement

• Shared savings / losses model– For those organizations experienced with managing population

health and accepting risk– Greater reward for those accepting risk


8© 2010 DIVURGENT. All rights reserved.

ACO Roadmap: Navigating the Financial Issues for Your ACO

Source: Accountable Care Organizations: A Roadmap for Success by Bruce Flareau, MD

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Requirements to Participate in the MSSP

Accountable for quality, cost and care of Medicare FFS beneficiaries

Participate for not less than a 3 year period

Posses a formal legal structure allowing for receipt/distributions of payments

Include sufficient primary care ACO professionals to care for population

Maintain at least 5,000 beneficiaries assigned to the ACO

Provide information on ACO professionals to the Secretary

Leadership/management structure that includes clinical and administrative systems

Define processes to promote evidence based medicine and patient engagement

Report on quality and cost measures, and coordinate care through the use of enabling technologies

Demonstrate patient centeredness criteria


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ORGANIZATIONAL MODELS


ACO

IPA or Primary Care Group

ACO1 2

ACO4ACO3

Physician-Hospital

Organization

ACO5

Private Payer

CIN

Specialty Groups

HOSPITAL

MSPG

HOSPITAL

Affiliate Physicians

EmployedPhysician

IDN

HospitalCIN

Delivery Models for ACOs

© 2010 DIVURGENT. All rights reserved. 11

© 2010 DIVURGENT. All rights reserved.12

Principles of Successful Integration

High Performance Work Practices

Selection for Cross-functional Teamwork

Cross-functional Conflict Resolution

Cross-functional Performance Measurement

Cross-functional Rewards

Cross-functional Meetings

Cross-functional Boundary Spanners

High Performance Work Practices

Selection for Cross-functional Teamwork

Cross-functional Conflict Resolution

Cross-functional Performance Measurement

Cross-functional Rewards

Cross-functional Meetings

Cross-functional Boundary Spanners

Relational Coordination

Shared Goals

Shared Knowledge

Mutual Respect

Frequent Comm.

Timely Comm.

Accurate Comm.

Problem Solving Comm.

Relational Coordination

Shared Goals

Shared Knowledge

Mutual Respect

Frequent Comm.

Timely Comm.

Accurate Comm.

Problem Solving Comm.

Quality Outcomes

Patient-Perceived

Quality of Care

Quality Outcomes

Patient-Perceived

Quality of Care

Efficiency Outcomes

Patient Length of Stay

Efficiency Outcomes

Patient Length of Stay

Note: Model from the work of Dr. Jody Gittell on Relational Coordination in Healthcare Organizations. http://www.jodyhoffergittell.info/content/rc2c.html

“Relational Model of How High-Performance Work Systems Work”


ACO Change Management Model



ACO Roadmap: Governance and Launch

QUALITY MEASUREMENT


Measurement Areas for ACOs

Outcomes Process

CareCoordination

AccessTo Care

Utilization

Patient Experience


Leverages Current Quality Measures


Reflects Chronic Care Model

Wagner EH. Chronic disease management: what will it take to improve care for chronic illness? Eff Clin Pract. 1998;1:2-4. (The Chronic Care Model image first appeared in its current format in this article)Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer J, Bonomi A. Improving chronic illness care: translating evidence into action. Health Aff (Millwood). 2001;20:64-78.

Copyright 1996-2011 The MacColl Institute. The Improving Chronic Illness Care program is supported by The Robert Wood Johnson Foundation, with direction and technical assistance provided by Group Health's MacColl Institute for Healthcare Innovation


http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?orig_db=PubMed&db=PubMed&cmd=Search&defaultField=Title+Word&term=Chronic+disease+management+what+will+it+

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?orig_db=PubMed&db=PubMed&cmd=Search&defaultField=Title+Word&term=Chronic+disease+management+what+will+it+

Quality Reporting MeasuresDomain Category # of

MeasuresPatient/Caregiver Experience 7

Care Coordination 16

Patient Safety 2

Preventive Health 9

At-Risk Population/Frail Elderly Health

Diabetes 31

Heart Failure

Coronary Artery Disease

Hypertension

Chronic Obstructive Pulmonary Disease

Frail Elderly

42 CFR Part 425 [CMS-1345-P]RIN 0938-AQ22 Medicare Program; Medicare Shared Savings Program:

Accountable Care Organizations

Better Care for Individuals

Better Health for Populations


Patient/Caregiver Experience

Patient/Caregiver Experience

Better Care for

Individuals

1. Timely care, appointments and information2. How well doctors communicate3. Helpful, courteous, respectful office staff4. Patient’s rating of doctor5. Shared decision making6. Health status/functional status

• All measures collected via patient survey• All based on NQF standards


Care Coordination

Care Coordination/ Transitions

Better Care for

Individuals

1. 30-day acute care readmission rates2. 30-day post discharge physician visit3. Medication reconciliation 60 days following

hospital discharge4. Quality of preparation for care transition5. Ambulatory Sensitive Conditions

1. Diabetes short-term complications2. Uncontrolled diabetes3. COPD4. CHF5. Dehydration6. Bacterial pneumonia7. Urinary tract infection

6. Stage 1 Meaningful Use1. % ALL physicians2. % PCP3. % PCPs using clinical decision support4. % PCPs using eRx5. Patient registry use

• Data submission via claims, GPRO, patient survey

• Measures based on CMS, NQF and HITECH


Patient Safety

Patient Safety

Better Care for

Individuals

1. Health Care Acquired Conditions:1. Foreign object retained after surgery2. Air embolism3. Blood incompatibility4. Stage II and IV pressure ulcers5. Falls and trauma6. Catheter-associated UTI7. Manifestations of poor glycemic control8. Central line associated blood stream infection9. Surgical site infection10. AHRQ Patient Safety indicators

1. Accidental puncture or laceration2. Iatrogenic pneumothorax3. Post op DVT or PE4. Post op wound dihiscence5. Decubitus ulcer6. Selected infections due to medical care7. Post op hip fracture8. Post op sepsis

2. CLABSI bundle

• Data submission via claims or CDC National Healthcare Safety Network

• Measures based on CMS and NQF standards


Preventive Health

Preventive Health

Better Health for

Populations

1. Influenza immunization2. Pneumococcal vaccination3. Mammography screening within 24

months4. Colorectal screening5. Cholesterol management for patients with

cardiovascular conditions6. Adult weight screening and follow-up7. Blood pressure measurement in patient

with hypertension8. Tobacco use assessment and tobacco

cessation intervention9. Depression screening

• Data submission via GPRO data collection tool Measures based on PQRS, HITECH and NQF measures


At-Risk Populations

At-Risk Population

Better Health for

Populations

1. Diabetes – 10 measures2. Heart Failure – 7 measures3. Coronary Artery Disease – 6

measures4. Hypertension – 2 measures5. COPD – 3 measures6. Frail Elderly – 3 measures

• Data submission via GPRO data collection tool and claims(1)

• Measures based on CMS, PQRS, HITECH and NQF measures


Reminders and Outreach

Team Coordination/Care Transition Coordination

Patient Health Record

Case Management

Evidence-based Care Planning

Shared Decision Support Tools

Predictive Modeling

Technologies Involved in Quality Management


Performance Year Type of Results Description

1 Clinical quality All 10 physician groups improved clinical management of diabetes patients achieving benchmarks for at least 7 of 10 diabetes clinical quality measures.

1 Shared savings Two physician groups shared $7.3M in savings (out of $9.5M total for Medicare).

2 Clinical quality All 10 physician groups achieved benchmarks at least 25 of 27 quality measures for patients with diabetes, coronary artery disease and congestive heart failure. Five groups achieved benchmark on all 27 quality measures.

2 Shared savings Four physician groups shared $13.8M in savings (out of $17.4M total for Medicare).

3 Clinical quality All 10 physician groups continued to improve quality of care and achieved benchmarks on at least 28 of 32 quality measures for patients with diabetes, coronary artery disease, congestive heart failure, hypertension, and cancer screening. Two groups achieved benchmark performance on all 32 measures.

3 Shared savings Five physician groups shared $25.3M in savings (out of $32.3M total for Medicare).

4 Clinical quality All 10 physician groups continued to improve quality of care and achieved benchmarks on at least 29 of 32 quality measures for patients with diabetes, coronary artery disease, congestive heart failure, hypertension, and cancer screening. Three groups achieved benchmark performance on all 32 measures.

4 Shared savings Five physician groups shared $31.7M in savings (out of $38.7M total for Medicare Trust Fund).


Results of Physician Group Practice Demonstration (Through 12/2010)

ACO Roadmap: Quality


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INFORMATION TECHNOLOGY IMPLICATIONS


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• May “require the use of specific decision support tools...”

• In the application, an ACO must provide documentation describing plans to:

1. Promote evidence based medicine

2. Promote beneficiary engagement

3. Report internally on quality and cost metrics

4. Coordinate care

• Beneficiaries should have access to their own medical records

• Act mentions processes for the electronic exchange of information

• Process for evaluating health needs of the population

• “Should have a process in place (or clear path) to electronically exchange summary of care information when patients transition to another provider or setting of care, both within and outside the ACO, consistent with MU requirements.”

• Individualized care plans shared throughout the continuum


Medicare ACO IT RequirementsRequires an ACO to “define processes to promote evidence-based medicine and patient engagement, report on quality and cost measures, and coordinate care, such as through the use of telehealth, remote patient monitoring, and other such enabling technologies.”


ACO IT Reference ModelKey Themes:

• While much of the required IT investment for ACOs overlaps with Meaningful Use, most of it does not, and will require a new IT strategic planning approach

• Much of the technology called for is not readily available in the marketplace

• Expect many HIT products used by payers to be modified for use by providers

• As the incentives build to keep patients healthy and out of provider facilities, home health & telehealth technology innovation will accelerate

• Privacy and security infrastructure will take on heightened importance and complexity

• Key ACO IT building blocks – such as HIEs – will quickly expand into new functionality areas

• While CMS may be calling for end-to-end HIT capabilities at ACO start-up, many private ACO’s can start with HIT “baby-steps”

ACO IT Reference Model

Primary Care Specialist Hospital Health Plan

EHR EHR EHR Claims

Self-Service

Patient

PHR Survey Tools

Secure Communications

Health Information Exchange

Disease Mgt

Care Mgt

Enterprise Data Warehouse

Disease Registries

Secu

rity

Infr

astr

uctu

re

Enrollment

Coordinated Care Plans

EMPI

Mem

ber R

egist

ry

Community Support

Providers

EHR

Data Analytics

Legend: What is/ will be on the radar screen for:

Providers ACO'sPayers

© 2010 DIVURGENT. All rights reserved. 32ACO Revenue Cycle Management Risk Mgt


ACO Alignment w. MU


EHR EHR EHR Claims

Self-Service

Patient

PHR Survey Tools



Disease Mgt

Care Mgt


Disease Registries

Secu

rity

Infr

astr

uctu

re

Enrollment


EMPI

Mem

ber R

egist

ry

Community Support

Providers

EHR

Data Analytics© 2010 DIVURGENT. All rights reserved.

ACO Revenue Cycle Management

Legend: Alignment to Meaningful Use

Stage 1 Not ApplicableStage 2

Risk Mgt



EHR EHR EHR Claims

Self-Service

Patient

PHR Survey Tools



Disease Mgt

Care Mgt


Disease Registries

Secu

rity

Infr

astr

uctu

re

Enrollment


EMPI

Mem

ber R

egist

ry

Community Support

Providers

EHR



• HIE’s are the key IT enabler for care coordination, giving all providers a view of a patient’s longitudinal record

• Besides clinical data sharing, HIEs support handoff’s such as referrals and care transitions

• Most HIEs contain a data repository, which can be used to feed a data warehouse

• HIE challenges include governance, privacy/ security concerns, and financial sustainability

Market Leaders Data types

• Medicity • Axolotl• RelayHealth• Orion• dbMotion• HealthUnity• ICA

• Order/ result transactions• Clinical documentation• Continuity of Care Document

(CCD)• Radiology images• Referrals

Risk Mgt

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EHR EHR EHR Claims

Self-Service

Patient

PHR Survey Tools



Disease Mgt

Care Mgt


Disease Registries

Secu

rity

Infr

astr

uctu

re

Risk Mgt


EMPI

Mem

ber R

egist

ry

Community Support

Providers

EHR



• Longitudinal data warehouses are not readily available in the marketplace, but are needed to support quality reporting, care management, care coordination, and other ACO requirements

• Most enterprise vendors have not excelled at longitudinal data aggregation, so other strategies are being adopted

• Buying the start of a data warehouse with products such as Amalga, Recombinant, and Healthcare Data Works

• Buying the data model from vendors such as IBM, Oracle, or Teradata as starting point

• Building the data warehouse “ground up” as a custom development effort• Relying on analytics specialists to combine and analyze data from various

applications (with tools such as SAS) to meet the ACO business needs• Robust, longitudinal data repositories could have profound effects – for the first

time, health systems will have more longitudinal data than payers, giving providers more negotiating leverage

Enrollment

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In Summary• Transaction based vs. Value based• Commercial vs. CMS ACO• Triple Aim• Legislative Next Steps• Ongoing alignment between ACO and MU• Expect experimentation, innovation and disruption


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DISCUSSION



ACO IT Observations• As the incentive shifts from volume to controlling costs, many

technologies with slow adoption could now accelerate in adoption:

– Personal Health Records– Remote Monitoring– Telehealth– Early Detection Devices– Fitness Trackers– Many others

• HIEs are likely to see a surge in interest (even beyond MU drivers), and expand into many functionality areas:

– PHRs

– Analytics

– Care Coordination Workflow


ACO IT Observations• Robust, longitudinal data warehouses will be needed, but are

not readily available in the market

– Many ACO’s will build custom data warehouses

– While complete data warehouses are emerging in the market, data models are available today

– Experienced data analysts will be essential: normalizing, abstracting, and interpreting data will increasingly be highly valued skill set

– Expect many ACO’s to use a combination of manual processes and BI/ Analytics tools to combine data sources and perform analysis needed


ACO IT Observations• Many required IT solutions do not exist today, or will have to

be repurposed,e.g.:

– Financial systems that have capability to report on ACO participant performance and manage savings/ loss distributions

– Care management (CM) and disease management (DM) systems currently used by payers (with claim data), may be repurposed for provider use

• A new clinical specialty is likely do to arise – the Care Coordinator - with authority and expertise make referral and care decisions

– Provider-based CM and DM systems using EHR data will be essential for this function


ACO Roadmap: Establishing the ACO Technology Framework

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• Conduct readiness assessment– Governance– IT Infrastructure– Physician Alignment– Risk Tolerance / Management– Ability to manage population health

• Engage health plans and major employers in risk sharing discussions

• Engage physician community• Accelerate cost reduction and clinical integration initiatives• Develop value-based purchasing IT strategy• Conduct financial impact analysis• Explore innovative delivery models


Recommended Next Steps

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Transaction / Value Based

• Study examined changes in imaging use and in overall spending

• Methodology– Examined Medicare claims data– Orthopedic surgeons and neurologists

• Results– Ability to bill for MRI led to substantial increases in MRI utilization– Also, total Medicare spending for these patients increased by as

much as 6% after 90 days from initial visit

• Why might this be?

What happens when Physicians acquire MRI equipment in-office?

Source: Health Affairs, December 2010 29:12, pgs 2252-2259


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Accountable Care Organizations: Overview and the Role of Information Technology