Accountable Care Organizations: The Role of IT

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

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

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

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

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

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

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.

“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.

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.

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.

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 ,[object Object]

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 ,[object Object]

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 ,[object Object]

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 ,[object Object],24 © 2010 DIVURGENT. All rights reserved.

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 ,[object Object]

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.”

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” ,[object Object]

© 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

ACO IT Reference Model Patient ,[object Object]

Besides clinical data sharing, HIEs support handoff’s such as referrals and care transitions

Accountable Care Organizations: The Role of IT

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