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  • NPRM released March 31, 2011Accountable Care Organization (ACO) means a legal entity that is recognized and authorized under applicable State law, as identified by a TIN, and comprised of an eligible group of ACO participants that work together to manage and coordinate care for Medicare FFS beneficiaries and have established a mechanism for shared governance that provides all ACO participants with an appropriate proportionate control over the ACO’s decision making processACO participant means a Medicare-enrolled provider of services and/or a supplierACO provider/supplier means a provider of services and/or a supplier that bills for items and services it furnishes to Medicare beneficiaries under a Medicare billing number assigned to the TIN of an ACO participant in accordance with applicable Medicare rules and regulations
  • In March of ‘10 PPACA was enacted, The HCERA was then enacted which amended it. Together, they are known as the Affordable Care ActDefinition of the Shared Savings Program, “a program that promotes accountability for a patient population and coordinates items and services under Parts A and B, and encourages investment in infrastructure and redesigned care processes for high quality and efficient service delivery”
  • Links payments directly to the quality of care deliveredRewards providers for high quality, efficient careImprove QualityUse of adjusted outcome and patient experience measuresMeasures aligned cross Medicare and MedicaidAligned with MU measures and best practicesLower growth in expendituresReward providers for reducing unnecessary expendituresContinual improvement of qualityUse of ongoing cost reducing and quality improving redesigned care processes across the entire patient population
  • Reduce growth in expendituresEstimated net savings for CY’s 2012 through 2014 = $510MEstimate 75-150 ACOs in first 3 years of the program
  • Shared savings model (one-sided model)Entry point for less experienced organizations in accepting financial riskAllows for time to gain experience, while under the FFS modelProposed that these organizations will transition to the two-sided model in their final year of their initial agreementShared savings/losses model (two-sided model)For those organizations experienced with managing population health and accepting riskGreater reward for those accepting riskOnly for MSS, Commercial ACOs come in a variety of flavors
  • Previous slide we talked about expectations, the NPRM gives us clearer direction on the requirements:
  • Technology such as CDS or a paper based methodology would likely sufficeTechnology such as portals, PHR’s, or paper based education as well as just engaging them in the processSuch reporting may include “developing a population health data management capability” or “implementing practice and physician level data capabilities with Point of service reminder systems” Measuring physician clinical and service performance, and coordinate care, such as through the use of telehealth, remote patient monitoring, and other such enabling technologies.” They are looking for ACOs to coordinate care across the ENTIRE continuum. They give examples such as:Capability to use predictive modeling to anticipate likely care needsUtilization of case managers in primary care officesRemote monitoringTelehealthEstablishment and use of HIT, including EHR and HIE to enable the provision of a beneficiary’s summary of care record during transitions of care both within and outside of the ACO.
  • Transaction based vs. Value basedCommercial vs. CMS ACOShared SavingsTriple AimStructure and GovernanceLegal ConsiderationsFundamentally different than the HMOFee for Service paymentsLegislative Next StepsOngoing alignment between ACO and MUInvestments in HIT are expected and required
  • Traditionally non radiologists referred patients needing MRI to hospitals and other facilitiesThose factilities billed for the services, the referring physician did not bill anythingOver 1.5M episodes of care with 11,844 total orthodpedists and 6k neurologists- The 6% increase in spending was not only accounted for by MRI. Other services and procedures also accounted for the increase.Why? Financial? Convenience? Quality?Convenience: easier to make a referral, less paperwork, patient doesn’t have to go somewhere else. **However, much of the MRI useage did not occur on the day of the first visit but on a subsequent visit.
  • Transcript

    • 1. 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
    • 2. 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
      © 2010 DIVURGENT. All rights reserved.
      2
    • 3. 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
      © 2010 DIVURGENT. All rights reserved.
      3
    • 4. 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
      © 2010 DIVURGENT. All rights reserved.
      4
    • 5. 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
      © 2010 DIVURGENT. All rights reserved.
      5
    • 6. 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
      © 2010 DIVURGENT. All rights reserved.
      6
    • 7. 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
      © 2010 DIVURGENT. All rights reserved.
      7
    • 8. © 2010 DIVURGENT. All rights reserved.
      8
      ACO Roadmap: Navigating the Financial Issues for Your ACO
      Source: Accountable Care Organizations: A Roadmap for Success by Bruce Flareau, MD
    • 9. © 2010 DIVURGENT. All rights reserved.
      9
    • 10. Organizational Models
      © 2010 DIVURGENT. All rights reserved.
      10
    • 11. 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
      © 2010 DIVURGENT. All rights reserved.
    • 12. © 2010 DIVURGENT. All rights reserved.
      12
      Principles of Successful Integration
    • 13. “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
      © 2010 DIVURGENT. All rights reserved.
    • 14. ACO Change Management Model
      14
      © 2010 DIVURGENT. All rights reserved.
    • 15. © 2010 DIVURGENT. All rights reserved.
      15
      ACO Roadmap: Governance and Launch
    • 16. Quality Measurement
      © 2010 DIVURGENT. All rights reserved.
      16
    • 17. Measurement Areas for ACOs
      Outcomes
      Process
      Patient Experience
      Utilization
      Care
      Coordination
      Access
      To Care
      17
      © 2010 DIVURGENT. All rights reserved.
    • 18. Leverages Current Quality Measures
      18
      © 2010 DIVURGENT. All rights reserved.
    • 19. 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
      © 2010 DIVURGENT. All rights reserved.
    • 20. 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
      © 2010 DIVURGENT. All rights reserved.
    • 21. 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
      • 22. All based on NQF standards
      21
      © 2010 DIVURGENT. All rights reserved.
    • 23. 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
      • 24. Measures based on CMS, NQF and HITECH
      22
      © 2010 DIVURGENT. All rights reserved.
    • 25. 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
      • 26. Measures based on CMS and NQF standards
      23
      © 2010 DIVURGENT. All rights reserved.
    • 27. 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
      © 2010 DIVURGENT. All rights reserved.
    • 28. 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)
      • 29. Measures based on CMS, PQRS, HITECH and NQF measures
      25
      © 2010 DIVURGENT. All rights reserved.
    • 30. Technologies Involved in Quality Management
      26
      © 2010 DIVURGENT. All rights reserved.
    • 31. © 2010 DIVURGENT. All rights reserved.
      27
      Results of Physician Group Practice Demonstration (Through 12/2010)
    • 32. ACO Roadmap: Quality
      28
      © 2010 DIVURGENT. All rights reserved.
    • 33. Information Technology Implications
      © 2010 DIVURGENT. All rights reserved.
      29
    • 34. 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
      © 2010 DIVURGENT. All rights reserved.
      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.”
    • 35. © 2010 DIVURGENT. All rights reserved.
      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
      • 36. Much of the technology called for is not readily available in the marketplace
      • 37. Expect many HIT products used by payers to be modified for use by providers
      • 38. As the incentives build to keep patients healthy and out of provider facilities, home health & telehealth technology innovation will accelerate
      • 39. Privacy and security infrastructure will take on heightened importance and complexity
      • 40. Key ACO IT building blocks – such as HIEs – will quickly expand into new functionality areas
      • 41. 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
      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
      © 2010 DIVURGENT. All rights reserved.
      Risk Mgt
      ACO Revenue Cycle Management
    • 42. © 2010 DIVURGENT. All rights reserved.
      33
      ACO Alignment w. MU
      Legend: Alignment to Meaningful Use
      Patient
      Not Applicable
      Stage 2
      Stage 1
      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
      © 2010 DIVURGENT. All rights reserved.
      Risk Mgt
      ACO Revenue Cycle Management
    • 43. ACO IT Reference Model
      Patient
      • HIE’s are the key IT enabler for care coordination, giving all providers a view of a patient’s longitudinal record
      • 44. Besides clinical data sharing, HIEs support handoff’s such as referrals and care transitions
      • 45. Most HIEs contain a data repository, which can be used to feed a data warehouse
      • 46. HIE challenges include governance, privacy/ security concerns, and financial sustainability
      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
      © 2010 DIVURGENT. All rights reserved.
      Risk Mgt
      ACO Revenue Cycle Management
    • 47. 35
      ACO IT Reference Model
      • 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
      • 48. Most enterprise vendors have not excelled at longitudinal data aggregation, so other strategies are being adopted
      • 49. Buying the start of a data warehouse with products such as Amalga, Recombinant, and Healthcare Data Works
      • 50. Buying the data model from vendors such as IBM, Oracle, or Teradata as starting point
      • 51. Building the data warehouse “ground up” as a custom development effort
      • 52. Relying on analytics specialists to combine and analyze data from various applications (with tools such as SAS) to meet the ACO business needs
      • 53. 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
      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
      © 2010 DIVURGENT. All rights reserved.
      Risk Mgt
      ACO Revenue Cycle Management
    • 54. 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
      © 2010 DIVURGENT. All rights reserved.
      36
    • 55. Discussion
      © 2010 DIVURGENT. All rights reserved.
      37
    • 56. © 2010 DIVURGENT. All rights reserved.
      38
      ACO IT Observations
      • As the incentive shifts from volume to controlling costs, many technologies with slow adoption could now accelerate in adoption:
      • 57. Personal Health Records
      • 58. Remote Monitoring
      • 59. Telehealth
      • 60. Early Detection Devices
      • 61. Fitness Trackers
      • 62. Many others
      • 63. HIEs are likely to see a surge in interest (even beyond MU drivers), and expand into many functionality areas:
      • 64. PHRs
      • 65. Analytics
      • 66. Care Coordination Workflow
    • © 2010 DIVURGENT. All rights reserved.
      39
      ACO IT Observations
      • Robust, longitudinal data warehouses will be needed, but are not readily available in the market
      • 67. Many ACO’s will build custom data warehouses
      • 68. While complete data warehouses are emerging in the market, data models are available today
      • 69. Experienced data analysts will be essential: normalizing, abstracting, and interpreting data will increasingly be highly valued skill set
      • 70. Expect many ACO’s to use a combination of manual processes and BI/ Analytics tools to combine data sources and perform analysis needed
    • © 2010 DIVURGENT. All rights reserved.
      40
      ACO IT Observations
      • Many required IT solutions do not exist today, or will have to be repurposed,e.g.:
      • 71. Financial systems that have capability to report on ACO participant performance and manage savings/ loss distributions
      • 72. Care management (CM) and disease management (DM) systems currently used by payers (with claim data), may be repurposed for provider use
      • 73. A new clinical specialty is likely do to arise – the Care Coordinator - with authority and expertise make referral and care decisions
      • 74. Provider-based CM and DM systems using EHR data will be essential for this function
    • © 2010 DIVURGENT. All rights reserved.
      41
      ACO Roadmap: Establishing the ACO Technology Framework
    • 75. 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
      © 2010 DIVURGENT. All rights reserved.
      42
      Recommended Next Steps
    • 76. 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
      © 2010 DIVURGENT. All rights reserved.
      43
    • 77. Contact us for more information atinfo@DIVURGENT.com
      www.DIVURGENT.com
      © 2010 DIVURGENT. All rights reserved.
      44
      Contact Us

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