ACO’s and Health IT:
True Delivery System Reform
or
Another Round of Unintended
Consequences?
Comments & Reflections for Y...
Accountable Care Organizations
Elliott Fisher (2010):
 A provider-led organization willing to be
accountable for the full...
The Law
 SEC. 1899. (a) ESTABLISHMENT.— (1) IN GENERAL.—
Not later than January 1, 2012, the Secretary shall establish a
...
Patient Protection and Affordable Care
Act
CMS Perspective:
 Organizations must agree to be accountable for
the overall c...
How providers organize themselves as accountable
entities is expected to vary based on existing
practice structures in a r...
The Challenge
• CMS and NCQA focus on structural
features of an ACO
• These structures will not cause delivery
system perf...
The Work of Building an
ACO
and minimizing unintended consequences
Time Allocation
•50% developing a shared patient
- cent...
Expectations of the ACO
Structure
 Complete and timely information on services
and patients (EHR /registries)
 Ability t...
Expectations - continued
 Ability to measure, report and improve quality
 Ability to assess and manage financial risk
 ...
Expectations - continued
 Ability to analyze data in the aggregate
 Ability to manage other providers’ service use
 Abi...
Prevalent Assumptions
 Care integration efforts at the market level will
be shaped by payment “reform”
 An integrated de...
Comment
 ACO is a conceptually rational response to
current finance and delivery system chaos
 A movement that is gettin...
Reality:
Primary Care Coordination Complexity
FFS Medicare, 2005
The typical primary care physician has
229 other physicia...
Keys
 Managed care principles are required to shape
patient centric, community-wide care
coordination [corollary: an ACO ...
Why We Started Thinking This Way
Puget Sound Health Alliance Reporting (1)
All Commercial and FFS Medicaid
PSHA (2) NPN NP...
Moving from Concept to Implementation
Ground Level ACO Requirements:
 A “care coordination and management” culture
 At t...
The ACO “Savings” Mantra
[Technical View]
 Avoided hospitalizations and reduced ED use
 Reduced lengths of stay (care ma...
The ACO Opportunity
[Adaptive View]
 Develop clinically meaningful delivery
system support tools based on a culture of
ac...
Example of Where We’re Going
 …what’s in the way and what will be
required to break out of our constrained
view of what’s...
Rainier Health Network
Rainier Health Network
Patient Risk Stratification:
RAINIER HEALTH NETWORK
Risk Score # Beneficiaries % Beneficiaries Total Spend
0.29 18,514 99....
Connect the Dots
 5% = 932 people with risk scores ~ 3.0 and 31%
of the total spend; 10% = 47% : savings op
 Patient ID ...
Getting to Go:
Deep Ruts in the i-Highway
Rainier Health Network
 Franciscan Medical Group:
 400 provider multispecialty...
More Ruts: Care Management
 Nursing care management (routine case
management, complex case management, care
coordination,...
Still More Ruts: Analytics
 Data collection from disparate sources
 Hundreds of vendors now claiming expertise
in the an...
Why Focus on Care Management?
 Key Principles:
 Well-coordinated care is a universal expectation
 Physicians share a co...
Care Coordination: What does it
take?
• Coordination among caregivers
– Identity as a community
– Commitment to serve to e...
From Our Limited ACO Experience:
A Disruptive Innovation and its Effects
Web-based referral/care coordination service
• On...
Improving Accountability
Serving each other:
 All outbound referrals sent through common service
– Appropriate clinical i...
Jan Feb Mar Apr May Jun
Total ED Discharges 840 951 1064 1058 1069 1042
Repeat visits in 30-60 days 98 113 126 111 110 104...
What We Are Learning from this
Experience
We are beginning to:
 provide a better patient experience
 reducing redundanci...
Also Learning…
 The distance between the care-giver’s
world view and the business world view
(IT, administration) is huge...
Supporting 21st Century Patient Care
Analytics
Care
Management
(Process of
Care)
Clinical
Source
Hx, Dx,Tx
Patient
Care
Te...
A Care Team View
How might we achieve the Triple Aim if each care
giver were operating from an iPad with one button,
one t...
A Way to Think About This
 Simon Sinek on TED ~ YouTube
 Knowing Your “Why”
Avoiding an Unintended
Consequence
Triple Aim #1: reduce the cost of care
 Are we going to reduce the unit cost of provid...
In the IT Business of Medical Care the
Tail Often Tends to Wag the Dog
 By training, medicine is very hierarchical
 And ...
Your Turn!
iHT² Health IT Summit Seattle - Rick MacCornack, Chief Systems Integration Officer, Northwest Physicians Network, CEO, Rai...
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iHT² Health IT Summit Seattle - Rick MacCornack, Chief Systems Integration Officer, Northwest Physicians Network, CEO, Rainier Health Network - Closing Presentation "ACOs and Health IT: True Delivery System Reform or Another Round of Unintended Consequen

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Rick MacCornack, PhD
Chief Systems Integration Officer
Northwest Physicians Network
CEO
Rainier Health Network

Closing Presentation "ACOs and Health IT: True Delivery System Reform or Another Round of Unintended Consequences?"

A fundamental component of the Affordable Care Act is support for the creation of so-called Accountable Care Organizations. Health care information technology will play a critical role in the reform process, perhaps in ways which are not yet well understood. Using the framework and early experience of a local CMS appointed ACO, this session is intended to ask questions and provide examples for how IT efforts might contribute to healthy, disruptive change in improving medical care delivery.

Learning Objectives:

∙ Consider the unintended consequences of the current IT trajectory in supporting medical care delivery in relation to the mandates of the
Affordable Care Act. Consider some opportunities for future IT contributions and what will need to occur for these opportunities to be tapped.
∙ Reflect on the historical contributions of IT in health and how there will necessarily be a shift in IT development in the future in support of
medical care delivery reform.

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  • Important! Provider led, manage care, measure and improve, new payments.
  • #2 – implies a closed panel? what all is included: drugs, mental health, DME, LTC, dental, vision, etc.#4 – teamwork likely has malpractice premium implications as non-MDs do more things
  • #2 – or not – Fisher says no financial risk, just do with bonuses#2 – must know the costs and the drivers of cost in all settings know where to focus the interventions for greatest return on investment#3 – identified by CMS lead as the key feature of success in the Medicare PGP demo#4 – extensive use of nurse care managers in PGP Medicare demo
  • iHT² Health IT Summit Seattle - Rick MacCornack, Chief Systems Integration Officer, Northwest Physicians Network, CEO, Rainier Health Network - Closing Presentation "ACOs and Health IT: True Delivery System Reform or Another Round of Unintended Consequen

    1. 1. ACO’s and Health IT: True Delivery System Reform or Another Round of Unintended Consequences? Comments & Reflections for Your Right Hemisphere Rick MacCornack, PhD CSIO, Northwest Physicians Network CEO, Rainier Health Network rmaccornack@npnwa.net
    2. 2. Accountable Care Organizations Elliott Fisher (2010):  A provider-led organization willing to be accountable for the full continuum of care for its patients  Shared responsibility for care coordination and care management across all services  Leadership and management structure in place to include administrative and clinical systems  An ability to report specific performance measures  An ability to receive and distribute performance incentives
    3. 3. The Law  SEC. 1899. (a) ESTABLISHMENT.— (1) IN GENERAL.— Not later than January 1, 2012, the Secretary shall establish a shared savings program (in this section referred to as the ‘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. Under such program—  (A) groups of providers of services and suppliers meeting criteria specified by the Secretary may work together to manage and coordinate care for Medicare fee-for-service beneficiaries through an accountable care organization (referred to in this section as an ‘ACO’);  (B) ACOs that meet quality performance standards established by the Secretary are eligible to receive payments for shared savings under subsection (d)(2).
    4. 4. Patient Protection and Affordable Care Act CMS Perspective:  Organizations must agree to be accountable for the overall care of their Medicare beneficiaries  Have adequate participation of primary care physicians  Define processes to promote evidence-based medicine  Report on quality and costs  Coordinate care
    5. 5. How providers organize themselves as accountable entities is expected to vary based on existing practice structures in a region, population needs or local environmental factors. Within the ACO structure itself (i.e. subject to the direct authority of the ACO’s governance) ACOs are likely to vary widely with respect to the components of care delivery directly included. Some may include a full range of services including a variety of sub- specialists, hospitals, home care agencies, insurance products, etc. Others will be more narrowly constructed but maintain active relationships and formal contracts with providers across the spectrum of care necessary to meet the needs of their patients. NCQA Explanation
    6. 6. The Challenge • CMS and NCQA focus on structural features of an ACO • These structures will not cause delivery system performance improvement • Fork in the road: will IT support tradition in medicine or disrupt outmoded traditions, thus creating the means for care delivery reform? • Huge opportunities in the reform space
    7. 7. The Work of Building an ACO and minimizing unintended consequences Time Allocation •50% developing a shared patient - centered care culture •30% leadership development •20% information technology
    8. 8. Expectations of the ACO Structure  Complete and timely information on services and patients (EHR /registries)  Ability to coordinate care across the full continuum of services, anywhere (EHR/+???)  Patient education & self-management (Personal record, App tools) Adapted from Harold D. Miller, “How to Create ACOs”, 2010
    9. 9. Expectations - continued  Ability to measure, report and improve quality  Ability to assess and manage financial risk  Ability to coordinate care for patients Adapted from Harold D. Miller, 2010
    10. 10. Expectations - continued  Ability to analyze data in the aggregate  Ability to manage other providers’ service use  Ability to monitor other providers’ quality Adapted from Harold D. Miller “Pathways for Physician Success”, 2010
    11. 11. Prevalent Assumptions  Care integration efforts at the market level will be shaped by payment “reform”  An integrated delivery system (ACO) will rationalize the care process; improve safety; reduce duplication; achieve better clinical results  Health information technology will enable an integrated delivery system to function efficiently and effectively
    12. 12. Comment  ACO is a conceptually rational response to current finance and delivery system chaos  A movement that is getting mainstreamed (warning sign) through many vertically organized delivery systems  To date, IT’s role has largely focused on codifying a dysfunctional medical care delivery model  Not a bad thing: it’s illuminating problems  …but the real work lies ahead  Actively managing the process of patient care gets a polite nod in discussions so far. Prediction: ACO success will live or die on this issue
    13. 13. Reality: Primary Care Coordination Complexity FFS Medicare, 2005 The typical primary care physician has 229 other physicians working in 117 practices with which care must be coordinated, equivalent to an additional 99 physicians and 53 practices for every 100 Medicare beneficiaries managed by the primary care physician. H. Pham, et. al. Ann Intern Med. 2009;150:236-242.
    14. 14. Keys  Managed care principles are required to shape patient centric, community-wide care coordination [corollary: an ACO is not a contracting silo!]  The culture in which this process can flourish has to be developed – it does not now exist  Caregiver leadership is required to align forces to achieve desired clinical results from team based care  IT support for Dx and Tx today will require the addition of managing the process of care in the future
    15. 15. Why We Started Thinking This Way Puget Sound Health Alliance Reporting (1) All Commercial and FFS Medicaid PSHA (2) NPN NPN Managed Care HbA1c tested <12 mo 79% 80% 85%* LDL-C screened 73% 74% 81%* Appropriate asthma med 69% 90% 100%* Diabetic retinal exam <12 mo 61% 57% 57% Anti depressant f/u 12 wks 68% 69% N/A Anti depressant f/u 6 mo 48% 50% 47% (1) All clinics/systems in King, Pierce, Snohomish, Thurston, Mason (2) Based on data aggregation from 14 payers; excludes Medicare, 2011 Basis of an ACO
    16. 16. Moving from Concept to Implementation Ground Level ACO Requirements:  A “care coordination and management” culture  At the level of nurse-directed patient care coordination and management  Patient data sharing  Build from a shared minimal data set approach  Clinically meaningful, real time patient level care coordination across the entire medical community  Well articulated, shared responsibilities for all patient care across the ACO  Highly developed care team responsibilities parsed between process and outcome accountabilities
    17. 17. The ACO “Savings” Mantra [Technical View]  Avoided hospitalizations and reduced ED use  Reduced lengths of stay (care management)  Avoided infections (improved patient safety)  Reduced testing (eliminate duplication)  Reduced readmissions (much better transitions)  Medication management and use of generics  Case management of high-risk patients 17
    18. 18. The ACO Opportunity [Adaptive View]  Develop clinically meaningful delivery system support tools based on a culture of actively coordinated and managed care  Use technology to support the culture, not the other way around.
    19. 19. Example of Where We’re Going  …what’s in the way and what will be required to break out of our constrained view of what’s “required”.
    20. 20. Rainier Health Network
    21. 21. Rainier Health Network
    22. 22. Patient Risk Stratification: RAINIER HEALTH NETWORK Risk Score # Beneficiaries % Beneficiaries Total Spend 0.29 18,514 99.4% $167,045,172 0.45 17,583 94.4% $164,824,824 0.48 17,553 94.2% $164,733,438 0.54 13,666 73.4% $154,984,948 0.73 9,239 49.6% $140,461,371 1.13 4,656 25.0% $115,038,197 2.04 1,863 10.0% $79,258,335 2.96 932 5.0% $52,467,046 4.88 187 1.0% $16,819,033 18,630 100.0% $167,263,920 Source: June 2012- May 2013 CMS Claims Data 5% of the patients = 31% of the total cost
    23. 23. Connect the Dots  5% = 932 people with risk scores ~ 3.0 and 31% of the total spend; 10% = 47% : savings op  Patient ID linked to attributed primary provider  Contact provider; verify patient information  Screen patient for case management appropriateness  Call qualifying patients’ homes  Enroll and manage patients  Maintain real time communication with patient and providers; provide appropriate documentation for practice
    24. 24. Getting to Go: Deep Ruts in the i-Highway Rainier Health Network  Franciscan Medical Group:  400 provider multispecialty group  All are now on Epic  Northwest Physicians Network  241 participating providers in RHN  35 EMR platforms  Half probably won’t exist in 3 years
    25. 25. More Ruts: Care Management  Nursing care management (routine case management, complex case management, care coordination, patient navigation) is served by highly specialized case management systems  Few are integrated with EHR or analytics platforms  Integration provides the care team with patient care coordinating information useful in managing care real time; a basis for PDSA process improvement
    26. 26. Still More Ruts: Analytics  Data collection from disparate sources  Hundreds of vendors now claiming expertise in the analytics space  Data collection from multiple PMS and EHR platforms is a requirement  Few vendors have deep experience  Payer’s need to participate by sharing claims data
    27. 27. Why Focus on Care Management?  Key Principles:  Well-coordinated care is a universal expectation  Physicians share a common patient base  Provides a framework for creation of tangible accountability  Key Implications:  Reduction in duplication, failed communication, delayed responses, risks to safety, avoiding less than appropriate service location  Improved clinical process and short term outcome  Improved patient experience
    28. 28. Care Coordination: What does it take? • Coordination among caregivers – Identity as a community – Commitment to serve to each other – Commitment to share information • Across all settings – Standard communication approaches – “Technologically agnostic” platforms – Measurement across a community, defined by the community
    29. 29. From Our Limited ACO Experience: A Disruptive Innovation and its Effects Web-based referral/care coordination service • Online referral submission • Online or fax delivery • A data view that augments EMR’s structural patient view • A secure communication platform that ties care management process with care team need to know Insurance processing by service team – Reduce administrative redundancy – Promote clinical conversations within the context of the referral – Raise the integrity of the referral process
    30. 30. Improving Accountability Serving each other:  All outbound referrals sent through common service – Appropriate clinical information accompanies each referral [complete and correct the first time] – Acknowledge referral online within 2 hours – Reported scheduling status within 48 hours – Return consultation and diagnostic reports within 3 days of visit – Actively pursue “dropped balls”
    31. 31. Jan Feb Mar Apr May Jun Total ED Discharges 840 951 1064 1058 1069 1042 Repeat visits in 30-60 days 98 113 126 111 110 104 %Repeat visits in 30-60 days 11.67% 11.88% 11.84% 10.49% 10.29% 9.98% Community-wide ED Use Reporting
    32. 32. What We Are Learning from this Experience We are beginning to:  provide a better patient experience  reducing redundancies  eliminating “dropped balls”  enhancing professional satisfaction …just by committing to serving each other…and having a technology service supporting the behavioral intent
    33. 33. Also Learning…  The distance between the care-giver’s world view and the business world view (IT, administration) is huge:  Resistance to change is often employment security anxiety  “My world is rock steady if I have 25 patients to see tomorrow” [go away]  A “cultural” view of technological innovation is critical  Technology is not a leadership tool
    34. 34. Supporting 21st Century Patient Care Analytics Care Management (Process of Care) Clinical Source Hx, Dx,Tx Patient Care Team Clinic System performance
    35. 35. A Care Team View How might we achieve the Triple Aim if each care giver were operating from an iPad with one button, one touch functions to view:  All patient data (EMRs, labs, imaging, hospital, ED, etc)  Views into real-time care management process  Audio and visual communication with patients  Tele-health connectivity  On-demand practice level aggregation of patient management measures for real-time practice management  Care team messaging for orders, instructions, follow- backs
    36. 36. A Way to Think About This  Simon Sinek on TED ~ YouTube  Knowing Your “Why”
    37. 37. Avoiding an Unintended Consequence Triple Aim #1: reduce the cost of care  Are we going to reduce the unit cost of providing medical care  …while increasing the cost of building and managing data systems to support the care process? [that’s where we’re headed now]  Or are we going to encourage disruptive technologies that (1) change the way health care is delivered (support team-based care); (2) change expectations of patients; and (3) drive payment reform into alignment with 1&2?
    38. 38. In the IT Business of Medical Care the Tail Often Tends to Wag the Dog  By training, medicine is very hierarchical  And we want to create interactive care teams? (medicine vs. healthcare)  Hierarchy is critical -- in some instances  In many instances of the care process, hierarchy is potentially dangerous  IT has a role in shaping team-based care for situationally effective behaviors
    39. 39. Your Turn!

    ×