As prez4web061611

Accountable Care Organizations:Overview and the Role of Information Technology
Colin Konschak, MBA, FHIMSS
Mary Sirois, MBA, CPHIMS
David Shiple
© 2010 DIVURGENT. All rights reserved.
1

Objectives
Describe the intention and programmatic features of the Medicare Shared Savings Program
Identify financial impacts associated with the accountable care organization
Describe potential delivery models for the accountable care organization
Describe quality reporting requirements and issues
Identify HIT requirements for the Medicare Shared Savings Program
Identify alignment between Meaningful Use requirements and Shared Savings requirements
Describe a potential ACO IT reference model
2

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
3

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
4

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
5

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
6

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
7

8
ACO Roadmap: Navigating the Financial Issues for Your ACO
Source: Accountable Care Organizations: A Roadmap for Success by Bruce Flareau, MD

9

Organizational Models
10

ACO
1
2
ACO
IPA or Primary Care Group
MSPG
Specialty
Groups
HOSPITAL
HOSPITAL
ACO
ACO
ACO
4
3
5
Private Payer
Physician-Hospital Organization
IDN
Hospital
Affiliate Physicians
Employed
Physician
CIN
CIN
Delivery Models for ACOs
11

12
Principles of Successful Integration

“Relational Model of How High-Performance Work Systems Work”
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
Quality Outcomes
Patient-Perceived
Quality of Care
Relational Coordination
Shared Goals
Shared Knowledge
Mutual Respect
Frequent Comm.
Timely Comm.
Accurate Comm.
Problem Solving Comm.
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
13

ACO Change Management Model
14

15
ACO Roadmap: Governance and Launch

Quality Measurement
16

Measurement Areas for ACOs
Outcomes
Process
Patient Experience
Utilization
Care
Coordination
Access
To Care
17

Leverages Current Quality Measures
18

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
19

Quality Reporting Measures
Better Care for Individuals
Better Health for Populations
42 CFR Part 425 [CMS-1345-P]
RIN 0938-AQ22 Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations
20

Patient/Caregiver Experience
Timely care, appointments and information
How well doctors communicate
Helpful, courteous, respectful office staff
Patient’s rating of doctor
Shared decision making
Health status/functional status
All measures collected via patient survey
All based on NQF standards
21

Care Coordination
30-day acute care readmission rates
30-day post discharge physician visit
Medication reconciliation 60 days following hospital discharge
Quality of preparation for care transition
Ambulatory Sensitive Conditions
Diabetes short-term complications
Uncontrolled diabetes
COPD
CHF
Dehydration
Bacterial pneumonia
Urinary tract infection
Stage 1 Meaningful Use
% ALL physicians
% PCP
% PCPs using clinical decision support
% PCPs using eRx
Patient registry use
Data submission via claims, GPRO, patient survey
Measures based on CMS, NQF and HITECH
22

Patient Safety
Health Care Acquired Conditions:
Foreign object retained after surgery
Air embolism
Blood incompatibility
Stage II and IV pressure ulcers
Falls and trauma
Catheter-associated UTI
Manifestations of poor glycemic control
Central line associated blood stream infection
Surgical site infection
AHRQ Patient Safety indicators
Accidental puncture or laceration
Iatrogenic pneumothorax
Post op DVT or PE
Post op wound dihiscence
Decubitus ulcer
Selected infections due to medical care
Post op hip fracture
Post op sepsis
CLABSI bundle
Data submission via claims or CDC National Healthcare Safety Network
Measures based on CMS and NQF standards
23

Preventive Health
Influenza immunization
Pneumococcal vaccination
Mammography screening within 24 months
Colorectal screening
Cholesterol management for patients with cardiovascular conditions
Adult weight screening and follow-up
Blood pressure measurement in patient with hypertension
Tobacco use assessment and tobacco cessation intervention
Depression screening
Data submission via GPRO data collection tool Measures based on PQRS, HITECH and NQF measures
24

At-Risk Populations
Diabetes – 10 measures
Heart Failure – 7 measures
Coronary Artery Disease – 6 measures
Hypertension – 2 measures
COPD – 3 measures
Frail Elderly – 3 measures
Data submission via GPRO data collection tool and claims(1)
Measures based on CMS, PQRS, HITECH and NQF measures
25

Technologies Involved in Quality Management
26

27
Results of Physician Group Practice Demonstration (Through 12/2010)

ACO Roadmap: Quality
28

Information Technology Implications
29

May “require the use of specific decision support tools...”
In the application, an ACO must provide documentation describing plans to:
Promote evidence based medicine
Promote beneficiary engagement
Report internally on quality and cost metrics
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
30
Medicare ACO IT Requirements
Requires 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.”

31
ACO IT Reference Model
Key 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”

Legend: What is/ will be on the radar screen for:
Patient
Payers
ACO's
Providers
Survey Tools
PHR
Self-Service
Secure Communications
Coordinated Care Plans
Health Plan
Hospital
Specialist
Primary Care
Community Support Providers
Claims
EHR
EHR
EHR
EHR
Member Registry
EMPI
Security Infrastructure
Health Information Exchange
Disease Mgt
Enterprise Data Warehouse
Care Mgt
Disease Registries
Enrollment
Data Analytics
32
Risk Mgt
ACO Revenue Cycle Management

33
ACO Alignment w. MU
Legend: Alignment to Meaningful Use
Patient
Not Applicable
Stage 2
Stage 1
Survey Tools
PHR
Self-Service
Health Plan
Hospital
Specialist
Primary Care
Claims
EHR
EHR
EHR
EHR
Member Registry
EMPI
Disease Mgt
Care Mgt
Disease Registries
Enrollment
Data Analytics
Risk Mgt

Patient
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
Survey Tools
PHR
Self-Service
Health Plan
Hospital
Specialist
Primary Care
Claims
EHR
EHR
EHR
EHR
Member Registry
EMPI
Disease Mgt
Care Mgt
Disease Registries
Enrollment
Data Analytics
Risk Mgt

35
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
Patient
Survey Tools
PHR
Self-Service
Health Plan
Hospital
Specialist
Primary Care
Claims
EHR
EHR
EHR
EHR
Member Registry
EMPI
Disease Mgt
Care Mgt
Disease Registries
Enrollment
Data Analytics
Risk Mgt

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
36

Discussion
37

38
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

39
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

40
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

41
ACO Roadmap: Establishing the ACO Technology Framework

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
42
Recommended Next Steps

Transaction / Value Based
What happens when Physicians acquire MRI equipment in-office?
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?
Source: Health Affairs, December 2010 29:12, pgs2252-2259
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