ACO Development


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Applying managed care business practices to ACO management and operations

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ACO Development

  1. 1. Accountable Care Organizations Applying Managed Care Business Practices
  2. 2. <ul><li>Goals of ACO Initiative: </li></ul><ul><ul><li>Better care for individuals </li></ul></ul><ul><ul><li>Better health for populations </li></ul></ul><ul><ul><li>Lower growth in expenditures </li></ul></ul><ul><li>Organizational structure: </li></ul><ul><ul><li>A legal entity under state law and with distinct tax ID </li></ul></ul><ul><ul><li>Comprised of eligible group of participants working together to manage and coordinate care for Medicare patients (fee-for-service) </li></ul></ul><ul><ul><li>Operate under mechanism of shared governance for decision-making and control </li></ul></ul><ul><ul><li>Ability to manage a continuum of health care needs for patients through shared accountability and risk where appropriate </li></ul></ul>Summary of ACO Requirements
  3. 3. Summary of ACO Requirements Continued <ul><li>Who may form an ACO: </li></ul><ul><ul><li>ACO professionals (licensed physicians and other practitioners such as physicians assistants, nurse practitioners or clinical nurse specialists) </li></ul></ul><ul><ul><li>Network of individual practices of ACO professionals </li></ul></ul><ul><ul><li>Partnerships or joint ventures between hospitals and ACO professionals </li></ul></ul><ul><ul><li>Hospitals employing ACO professionals </li></ul></ul><ul><ul><li>Other providers or suppliers as determined by CMS that are appropriate </li></ul></ul>
  4. 4. Critical Success Factors- Applying Managed Care Practices <ul><li>Forming a provider-driven organizational structure with alignment of goals, clinical integration and outcomes-based performance </li></ul><ul><li>Financial management practices, operational efficiencies and health information technology capabilities </li></ul><ul><li>Broad scope of services offered by ACO provider delivery system- serving diverse patient needs </li></ul><ul><li>Partnership contract structure among participating providers- forming a business alignment </li></ul><ul><li>Responsibility for medical management (risk) and disease management programs- the right service in the right setting </li></ul><ul><li>Coordination and collaboration of patient care plans and outreach programs </li></ul>
  5. 5. Barriers to ACO Development <ul><li>Access to capital to: </li></ul><ul><ul><li>Build care coordination capabilities </li></ul></ul><ul><ul><li>Invest in organization infrastructure </li></ul></ul><ul><ul><li>Invest in robust information technology </li></ul></ul><ul><li>Aversion to financial losses </li></ul><ul><li>Building the ACO leadership team </li></ul><ul><li>Confidence in target benchmarks </li></ul><ul><li>What happens beyond year 3 (Medicare Shared Savings Program? </li></ul>
  6. 6. Challenges for an ACO <ul><li>Unknown patient population (aligned membership) and underlying costs </li></ul><ul><li>No assigned membership- freedom to self-refer (Medicare fee-for-service) </li></ul><ul><li>No formal process for directing patients through health care system or resource consumption </li></ul><ul><li>Requires lots of coaching by primary care practitioner (medical home and care coordinator role) </li></ul><ul><li>Must manage risk through care coordination, education and collaboration with partner providers for cost efficiency </li></ul><ul><li>Quality metrics requires disease-specific and individual case management </li></ul>
  7. 7. Organizational structure and alignment <ul><li>Formal structure for governance and control processes for decision-making </li></ul><ul><li>Clinical integration across practice settings (i.e. shared protocols, treatment pathways) </li></ul><ul><li>Adoption of uniform business practices and sharing of clinical information </li></ul><ul><li>Quality and peer review process </li></ul><ul><li>Shared responsibilities for care outcomes </li></ul><ul><li>Compensation linked to performance </li></ul><ul><li>Compliance and performance monitoring </li></ul>
  8. 8. Organizational structure and alignment suggested structure Board of Directors Quality Review Committee Compensation Committee Finance & Operations Oversight Compliance Committee Utilization Management Committee Provider and member/customer constituent representation Clinical representation Quality metrics and peer review process Provider stakeholder Representation Shared savings allocation Provider and member representation Program monitoring Provider and administrative Representation ACO budget vs actual Clinical representation Policy development and outcomes review Patient/Customer Advisory Council
  9. 9. Financial Management, Operational Efficiencies and Health Information Technology <ul><li>Willingness to accept risk of an unknown patient population </li></ul><ul><li>Creating ACO budget based on actuarially determined targets for utilization and costs </li></ul><ul><li>Adoption of risk management practices (UM, referrals, out-of “network” leakage) </li></ul><ul><li>Increased primary care practice scope (reduce specialist referrals) </li></ul><ul><li>Utilize mid-level practitioners (physicians assistants, nurse practitioners) </li></ul><ul><li>Utilize hospitalist for inpatient admissions </li></ul>
  10. 10. Financial Management, Operational Efficiencies and Health Information Technology Continued <ul><li>Investment in information technology to: </li></ul><ul><ul><li>Integrate clinical and financial information </li></ul></ul><ul><ul><li>Manage diverse patient populations </li></ul></ul><ul><ul><li>Understand trends and impacts </li></ul></ul><ul><li>Adoption of patient-centeredness and team-based approaches to delivering care: </li></ul><ul><ul><li>Sharing care-plan information across practice settings </li></ul></ul><ul><ul><li>Collaborating with other practitioners, hospitals and allied health providers </li></ul></ul><ul><li>Promote health of patients through education and outreach </li></ul>
  11. 11. ACO Provider Delivery System <ul><li>Besides the core primary care practice </li></ul><ul><li>settings functioning as the Medical </li></ul><ul><li>Home, the following delivery system </li></ul><ul><li>components need to be available and </li></ul><ul><li>accessible to manage patient service needs </li></ul><ul><li>(not all-inclusive): </li></ul><ul><li>Wide range of key specialty practices for patient population </li></ul><ul><li>Community hospital in convenient locations </li></ul><ul><li>Tertiary/academic hospital with high level care capabilities </li></ul><ul><li>Home health and other ancillaries (DME, respiratory, PT/OT/Speech, Pharmacy) </li></ul><ul><li>Ambulatory surgery and other free-standing settings (i.e. endoscopies) </li></ul><ul><li>Post acute care rehab and skilled nursing services </li></ul>
  12. 12. Partner Contract Structure- Business Alignment <ul><li>Provider contracts (terms of participation) need to be negotiated and in place for all ACO participants </li></ul><ul><li>Protection for all stakeholders (business partners, patients, and payer sources) </li></ul><ul><li>Agreement on medical management protocols, quality assurance, billing and other business practices </li></ul><ul><li>Ensures HIPAA compliance, confidentiality and other government/payer regulations </li></ul><ul><li>Up-front payment terms and shared savings allocation spelled out </li></ul><ul><li>Process for conflict resolution </li></ul>
  13. 13. Risk Management = Medical Management and Disease Management <ul><li>Overall goal: provide best care at affordable cost in most appropriate setting </li></ul><ul><li>Adopt health plan-like utilization management practices: </li></ul><ul><ul><li>Pre-authorization </li></ul></ul><ul><ul><li>Concurrent review with Interqual ® criteria </li></ul></ul><ul><ul><li>Discharge planning and follow up </li></ul></ul><ul><li>Seek lower cost care settings </li></ul><ul><li>Utilize network of providers under contract at predetermined prices and conformance </li></ul><ul><li>Adopt health plan-like disease management programs for high risk and chronic care population: </li></ul><ul><ul><li>CAD </li></ul></ul><ul><ul><li>Diabetes </li></ul></ul><ul><ul><li>Hypertension </li></ul></ul><ul><li>COPD/emphysema </li></ul><ul><li>CHF </li></ul><ul><li>ESRD </li></ul>
  14. 14. Coordination of Care and Patient Outreach Programs <ul><li>Establish clinical staff of care counselors </li></ul><ul><li>Conduct welcome calls and introductions for identified patient population </li></ul><ul><li>Conduct risk assessment surveys from prospective data and patient base </li></ul><ul><li>Enroll targeted patients in disease management and education programs </li></ul><ul><li>Follow up with post-discharge patients (inpatient and select outpatient procedures) </li></ul><ul><li>Conduct periodic assessment and adherence calls for high risk/chronic care patients </li></ul>
  15. 15. Coordination of Care and Patient Outreach Programs Continued <ul><li>Provide medication management reviews </li></ul><ul><li>Track hospital admissions and re-admits </li></ul><ul><li>Monitor adverse events and complications </li></ul><ul><li>Improve access and availability for </li></ul><ul><li>appointments: </li></ul><ul><ul><li>Convenient scheduling </li></ul></ul><ul><ul><li>Extended office hours </li></ul></ul><ul><li>E-mail communication and newsletters </li></ul>
  16. 16. IT Resource Needs <ul><li>Architecture of practitioner’s EMR system </li></ul><ul><li>Capability to interconnect with other ACO participants (e.g. specialists, hospitals, labs etc.)- providing care plan summaries </li></ul><ul><li>Medical informatics (data mining) capability and technical help: </li></ul><ul><ul><li>For identifying and flagging high risk/at-risk patients from prospective data for targeted interventions </li></ul></ul><ul><ul><li>Conducting cost (expenditure) trend analysis </li></ul></ul><ul><li>Tracking referrals across ACO practices and outside the delivery system </li></ul><ul><li>Capability for secure internet patient contact and counseling </li></ul>
  17. 17. Self-assessment for ACO Shared Savings or Risk Programs <ul><li>Conduct patient experience surveys </li></ul><ul><li>Develop and evaluate quality and cost performance standards across ACO delivery system (based on benchmark cost management goals and clinical outcomes) </li></ul><ul><li>Share data with participating providers </li></ul><ul><li>Identify areas for improvement </li></ul><ul><li>Adopt internal pay-for-performance guidelines </li></ul><ul><li>Establish reporting mechanisms for other ACO providers/suppliers </li></ul>
  18. 18. Contact Us: For Detailed Consulting on ACO Development and Management <ul><li>Eagle Run Managed Care, LLC </li></ul><ul><ul><li> </li></ul></ul><ul><ul><li>937-350-5457 </li></ul></ul><ul><li>25 years managed care experience </li></ul>ACO development and management is more detailed than the foregoing slides may indicate. Providers interested in pursuing this initiative should consult with their legal counsel and tax advisors