More Related Content Similar to Accountable Care Organizations: Overview and the Role of Information Technology (20) Accountable Care Organizations: Overview and the Role of Information Technology1. Accountable Care Organizations:
Overview and the Role of Information Technology
Colin Konschak, MBA, FHIMSS
Mary Sirois, MBA, CPHIMS
David Shiple
May 11th, 2011
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2. Objectives
1. Describe the intention and programmatic features of the Medicare
Shared Savings Program
2. Identify financial impacts associated with the accountable care
organization
3. Describe potential delivery models for the accountable care organization
4. Describe quality reporting requirements and issues
5. Identify HIT requirements for the Medicare Shared Savings Program
6. Identify alignment between Meaningful Use requirements and Shared
Savings requirements
7. Describe a potential ACO IT reference model
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3. 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
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4. 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
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5. 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
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6. 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
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7. 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
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8. ACO Roadmap: Navigating the Financial Issues for Your ACO
Source: Accountable Care Organizations: A Roadmap for Success by Bruce Flareau, MD
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9. Requirements to Participate in the MSSP
Accountable for quality, cost and care Participate for not less than a 3 year
of Medicare FFS beneficiaries period
Posses a formal legal structure Include sufficient primary care ACO
allowing for receipt/distributions of professionals to care for population
payments
Maintain at least 5,000 beneficiaries Provide information on ACO
assigned to the ACO professionals to the Secretary
Leadership/management structure Define processes to promote evidence
that includes clinical and based medicine and patient
administrative systems engagement
Report on quality and cost measures, Demonstrate patient centeredness
and coordinate care through the use criteria
of enabling technologies
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11. Delivery Models for ACOs
1 ACO 2 ACO
IPA or Primary Care Group
MSPG
Specialty
Groups
HOSPITAL
HOSPITAL
3 ACO 4 ACO 5 ACO
Physician-
Hospital Private
Organization IDN Payer
Affiliate Employed
Hospital
CIN Physicians Physician CIN
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13. “Relational Model of How
High-Performance Work Systems Work”
High Performance Work
Practices Relational Quality Outcomes
Coordination
Selection for Cross-functional
Patient-Perceived
Teamwork
Shared Goals Quality of Care
Cross-functional Conflict
Shared Knowledge
Resolution
Mutual Respect
Cross-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
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17. Measurement Areas for ACOs
Outcomes Process
Patient Experience
Utilization
Care Access
Coordination To Care
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19. 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 evidence
and technical assistance provided by Group Health's MacColl Institute for into action. Health Aff (Millwood). 2001;20:64-78.
Healthcare Innovation
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20. Quality Reporting Measures
Domain Category # of
Measures
Patient/Caregiver Experience 7
Care Coordination Better Care for Individuals 16
Patient Safety 2
Preventive Health Better Health for Populations 9
At-Risk Population/Frail Diabetes 31
Elderly 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
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21. Patient/Caregiver Experience
Better 1. Timely care, appointments and information
Care for 2. How well doctors communicate
Individuals
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
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22. 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
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23. 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
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24. 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
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25. 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
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26. 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
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27. 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).
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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.”
• 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
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31. ACO IT Reference Model
Key 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”
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32. ACO IT Reference Model
Legend: What is/ will be on the radar screen for:
Providers Payers ACO's 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
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ACO Revenue Cycle Management Risk Mgt
33. ACO Alignment w. MU
Legend: 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
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ACO Revenue Cycle Management Risk Mgt
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34. 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
EMPI
Market 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
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ACO Revenue Cycle Management Risk Mgt
35. 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
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ACO Revenue Cycle Management Risk Mgt
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36. 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
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37. DISCUSSION
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38. 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
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39. 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
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40. 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
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42. 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
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43. Transaction / Value Based
What 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
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Editor's Notes 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.