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Accountable Care Organizations: Overview and the Role of Information Technology
 

Accountable Care Organizations: Overview and the Role of Information Technology

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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.

Accountable Care Organizations: Overview and the Role of Information Technology Accountable Care Organizations: Overview and the Role of Information Technology Presentation Transcript

  • Accountable Care Organizations:Overview and the Role of Information TechnologyColin Konschak, MBA, FHIMSSMary Sirois, MBA, CPHIMSDavid ShipleMay 11th, 2011 1 © 2010 DIVURGENT. All rights reserved.
  • Objectives1. Describe the intention and programmatic features of the Medicare Shared Savings Program2. Identify financial impacts associated with the accountable care organization3. Describe potential delivery models for the accountable care organization4. Describe quality reporting requirements and issues5. Identify HIT requirements for the Medicare Shared Savings Program6. Identify alignment between Meaningful Use requirements and Shared Savings requirements7. Describe a potential ACO IT reference model 2 © 2010 DIVURGENT. All rights reserved.
  • 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 © 2010 DIVURGENT. All rights reserved.
  • 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 © 2010 DIVURGENT. All rights reserved.
  • 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 © 2010 DIVURGENT. All rights reserved.
  • 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 © 2010 DIVURGENT. All rights reserved.
  • 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 © 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 8 © 2010 DIVURGENT. All rights reserved.
  • Requirements to Participate in the MSSPAccountable for quality, cost and care Participate for not less than a 3 yearof Medicare FFS beneficiaries periodPosses a formal legal structure Include sufficient primary care ACOallowing for receipt/distributions of professionals to care for populationpaymentsMaintain at least 5,000 beneficiaries Provide information on ACOassigned to the ACO professionals to the SecretaryLeadership/management structure Define processes to promote evidencethat includes clinical and based medicine and patientadministrative systems engagementReport on quality and cost measures, Demonstrate patient centerednessand coordinate care through the use criteriaof enabling technologies 9 © 2010 DIVURGENT. All rights reserved.
  • ORGANIZATIONAL MODELS 10 © 2010 DIVURGENT. All rights reserved.
  • Delivery Models for ACOs 1 ACO 2 ACO IPA or Primary Care Group MSPG Specialty Groups HOSPITAL HOSPITAL3 ACO 4 ACO 5 ACO Physician- Hospital Private Organization IDN Payer Affiliate Employed Hospital CIN Physicians Physician CIN 11 © 2010 DIVURGENT. All rights reserved.
  • Principles of Successful Integration 12 © 2010 DIVURGENT. All rights reserved.
  • “Relational Model of How High-Performance Work Systems Work”High Performance Work Practices Relational Quality Outcomes CoordinationSelection for Cross-functional Patient-Perceived Teamwork Shared Goals Quality of Care Cross-functional Conflict Shared Knowledge Resolution Mutual RespectCross-functional Performance Measurement Cross-functional Rewards Frequent Comm. Timely Comm. Efficiency Outcomes Cross-functional Meetings Cross-functional Boundary Accurate Comm. Patient Length of Stay Spanners Problem Solving Comm. 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.
  • ACO Change Management Model 14 © 2010 DIVURGENT. All rights reserved.
  • ACO Roadmap: Governance and Launch 15 © 2010 DIVURGENT. All rights reserved.
  • QUALITY MEASUREMENT 16 © 2010 DIVURGENT. All rights reserved.
  • Measurement Areas for ACOs Outcomes Process Patient Experience Utilization Care Access Coordination To Care 17 © 2010 DIVURGENT. All rights reserved.
  • Leverages Current Quality Measures 18 © 2010 DIVURGENT. All rights reserved.
  • 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-Copyright 1996-2011 The MacColl Institute. The Improving Chronic Illness 4. (The Chronic Care Model image first appeared in its current format in this article)Care program is supported by The Robert Wood Johnson Foundation, with direction Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer J, Bonomi A. Improving chronic illness care: translating evidenceand technical assistance provided by Group Healths MacColl Institute for into action. Health Aff (Millwood). 2001;20:64-78.Healthcare Innovation 19 © 2010 DIVURGENT. All rights reserved.
  • Quality Reporting MeasuresDomain Category # of MeasuresPatient/Caregiver Experience 7Care Coordination Better Care for Individuals 16Patient Safety 2Preventive Health Better Health for Populations 9At-Risk Population/Frail Diabetes 31Elderly Health 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 20 © 2010 DIVURGENT. All rights reserved.
  • Patient/Caregiver Experience Better 1. Timely care, appointments and information Care for 2. How well doctors communicateIndividuals Patient/Caregiver 3. Helpful, courteous, respectful office staff Experience 4. Patient’s rating of doctor 5. Shared decision making 6. Health status/functional status• All measures collected via patient survey• All based on NQF standards 21 © 2010 DIVURGENT. All rights reserved.
  • Care Coordination 1. 30-day acute care readmission rates Better 2. 30-day post discharge physician visit Care for 3. Medication reconciliation 60 days following Individuals Care hospital discharge Coordination/ 4. Quality of preparation for care transition Transitions 5. Ambulatory Sensitive Conditions 1. Diabetes short-term complications 2. Uncontrolled diabetes 3. COPD 4. CHF 5. Dehydration 6. Bacterial pneumonia• Data submission via claims, 7. Urinary tract infection GPRO, patient survey 6. Stage 1 Meaningful Use• Measures based on CMS, 1. % ALL physicians NQF and HITECH 2. % PCP 3. % PCPs using clinical decision support 4. % PCPs using eRx 5. Patient registry use 22 © 2010 DIVURGENT. All rights reserved.
  • Patient Safety 1. Health Care Acquired Conditions: Better 1. Foreign object retained after surgery Care for 2. Air embolism Individuals 3. Blood incompatibility Patient Safety 4. Stage II and IV pressure ulcers 5. Falls and trauma 6. Catheter-associated UTI 7. Manifestations of poor glycemic control 8. Central line associated blood stream infection 9. Surgical site infection 10. AHRQ Patient Safety indicators 1. Accidental puncture or laceration 2. Iatrogenic pneumothorax• Data submission via claims or 3. Post op DVT or PE CDC National Healthcare 4. Post op wound dihiscence Safety Network 5. Decubitus ulcer• Measures based on CMS and 6. Selected infections due to medical care NQF standards 7. Post op hip fracture 8. Post op sepsis 2. CLABSI bundle 23 © 2010 DIVURGENT. All rights reserved.
  • Preventive Health 1. Influenza immunization Better 2. Pneumococcal vaccination Health for Populations 3. Mammography screening within 24 Preventive Health months 4. Colorectal screening 5. Cholesterol management for patients with cardiovascular conditions 6. Adult weight screening and follow-up 7. Blood pressure measurement in patient with hypertension 8. Tobacco use assessment and tobacco• Data submission via GPRO data collection tool Measures cessation intervention based on PQRS, HITECH and 9. Depression screening NQF measures 24 © 2010 DIVURGENT. All rights reserved.
  • At-Risk Populations 1. Diabetes – 10 measures Better Health for Populations 2. Heart Failure – 7 measures At-Risk 3. Coronary Artery Disease – 6 Population measures 4. Hypertension – 2 measures 5. COPD – 3 measures 6. Frail Elderly – 3 measures• Data submission via GPRO data collection tool and claims(1)• Measures based on CMS, PQRS, HITECH and NQF measures 25 © 2010 DIVURGENT. All rights reserved.
  • Technologies Involved in Quality Management Reminders and Outreach Team Coordination/Care Transition Coordination Patient Health Record Case Management Evidence-based Care Planning Shared Decision Support Tools Predictive Modeling 26 © 2010 DIVURGENT. All rights reserved.
  • Results of Physician Group Practice Demonstration (Through 12/2010)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). 27 © 2010 DIVURGENT. All rights reserved.
  • ACO Roadmap: Quality 28 © 2010 DIVURGENT. All rights reserved.
  • INFORMATION TECHNOLOGY IMPLICATIONS 29 © 2010 DIVURGENT. All rights reserved.
  • Medicare ACO IT RequirementsRequires an ACO to “define processes to promote evidence-based medicine andpatient engagement, report on quality and cost measures, and coordinate care,such as through the use of telehealth, remote patient monitoring, and other suchenabling technologies.”• 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 30 © 2010 DIVURGENT. All rights reserved.
  • 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” © 2010 DIVURGENT. All rights reserved. 31
  • ACO IT Reference ModelLegend: What is/ will be on the radar screen for: Providers Payers ACOs Patient Self-Service PHR Survey Tools Secure Communications Coordinated Care Plans Community Security Infrastructure Primary Care Specialist Support Hospital Health Plan Member Registry Providers EMPI EHR EHR EHR EHR Claims Health Information Exchange Enterprise Data Warehouse Disease Mgt Disease Registries Care Mgt Data Analytics Enrollment © 2010 DIVURGENT. All rights reserved. 32 ACO Revenue Cycle Management Risk Mgt
  • ACO Alignment w. MULegend: Alignment to Meaningful Use Stage 1 Stage 2 Not Applicable Patient Self-Service PHR Survey Tools Secure Communications Coordinated Care Plans Community Security Infrastructure Primary Care Specialist Support Hospital Health Plan Member Registry Providers EMPI EHR EHR EHR EHR Claims Health Information Exchange Enterprise Data Warehouse Disease Mgt Disease Registries Care Mgt Data Analytics Enrollment © 2010 DIVURGENT. All rights reserved. ACO Revenue Cycle Management Risk Mgt 33 © 2010 DIVURGENT. All rights reserved.
  • ACO IT Reference Model• HIE’s are the key IT enabler for care Patient coordination, giving all providers a view of a patient’s longitudinal record• Besides clinical data sharing, HIEs support Self-Service PHR Survey Tools handoff’s such as referrals and care transitions• Most HIEs contain a data repository, Secure Communications which can be used to feed a data warehouse Coordinated Care Plans• HIE challenges include governance, privacy/ security concerns, and financial Community Security Infrastructure sustainability Primary Care Specialist Support Hospital Health Plan Member Registry Providers EMPIMarket Leaders Data types EHR EHR EHR EHR Claims• Medicity • Order/ result transactions• Axolotl • Clinical documentation Health Information Exchange• RelayHealth • Continuity of Care Document• Orion (CCD)• dbMotion • Radiology images Enterprise Data Warehouse Disease Mgt• HealthUnity • Referrals• ICA Disease Registries Care Mgt Data Analytics Enrollment © 2010 DIVURGENT. All rights reserved. ACO Revenue Cycle Management Risk Mgt
  • 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 Patient• 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 Self-Service PHR Survey Tools Healthcare Data Works • Buying the data model from vendors such as IBM, Oracle, or Teradata as starting point Secure Communications • 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 Plans Coordinated Care• Robust, longitudinal data repositories could have profound effects – for the first time, health systems will have more longitudinal data than payers, Community giving providers more negotiating Security Infrastructure leverage Primary Care Specialist Support Hospital Health Plan Member Registry Providers EMPI EHR EHR EHR EHR Claims Health Information Exchange Enterprise Data Warehouse Disease Mgt Disease Registries Care Mgt Data Analytics Enrollment © 2010 DIVURGENT. All rights reserved. ACO Revenue Cycle Management Risk Mgt 35
  • 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 © 2010 DIVURGENT. All rights reserved.
  • DISCUSSION 37 © 2010 DIVURGENT. All rights reserved.
  • 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 © 2010 DIVURGENT. All rights reserved. 38
  • 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 © 2010 DIVURGENT. All rights reserved. 39
  • 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 © 2010 DIVURGENT. All rights reserved. 40
  • ACO Roadmap: Establishing the ACO Technology Framework 41 © 2010 DIVURGENT. All rights reserved.
  • Recommended Next Steps• 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 © 2010 DIVURGENT. All rights reserved.
  • Transaction / Value BasedWhat 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, pgs 2252-2259 43 © 2010 DIVURGENT. All rights reserved.