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.

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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. Rainier Health Network

21. Rainier Health Network

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. 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. 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. 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. 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. 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. 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. 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. 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. 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

33. 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

34. 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

35. Supporting 21st Century Patient Care
Analytics
Care
Management
(Process of
Care)
Clinical
Source
Hx, Dx,Tx
Patient
Care
Team
Clinic
System
performance

36. 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

37. A Way to Think About This
 Simon Sinek on TED ~ YouTube
 Knowing Your “Why”

38. 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?

39. 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

40. Your Turn!