ACO Foundational Data and Information Technology Needs

1. ACOs under the Medicare Shared Savings
Program and the Role of Health IT
Speaker Bio
Shelley Price, MS
Director, Payer and Life Sciences
HIMSS
Conflict of Interest Disclosure
Shelley Price, MS
y ,
• Have no real or apparent conflicts of interest
to report.
1

2. Learning Objectives
ACOs under the Medicare Shared Savings
Program and the Role of Health IT
g
Understand the basics of a Medicare
ACO under the proposed CMS
rulemaking
MSSP ACOs: Definitions
• What is an ACO?
– Must be a legal entity
– Have an taxpayer identification number
– Be comprised of eligible group of ACO participants
• ACO professionals in group practices
• networks of individual practices of ACO professionals
• partnerships or joint venture arrangements between hospitals and ACO
professionals
• hospitals employing ACO professionals
• other groups of providers of services and suppliers as determined by the
Secretary
– Have a mechanism for shared governance
5
MSSP ACOs: Program and Governance
• Program
– Voluntary program; extensive application required
– 3‐year contract required; begins January 1, 2012
– Strong focus on primary care; PCP must be excl to 1 ACO
St f i PCP tb l t 1 ACO
– MU requirement: 50% of PCPs by yr 2
• Governing Body
– Broad authority & responsibility for administrative,
fiduciary, & clinical operations
– Proportional representation of ACO participants
• at least 75% are “participants”, i.e. providers such as MDs, PAs, NPs
• at least 1 Medicare beneficiary 6
2

3. MSSP ACOs: Beneficiaries
• Medicare FFS population
• Retrospective assignment to an ACO
– Not an opt in; assigned at the end of the year
Not an opt‐in; assigned at the end of the year
– Based on plurality of primary care to an ACO participant
• Patient may opt‐out
– ACO provider
– PHI
• Minimum number of benes in ACO: 5,000
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MSSP ACOs: Risk – 2 Models
• 1‐sided risk model
– Yr 1‐2: sharing in savings only; Yr 3: add in shared losses
– Savings based on quality performance up to 50% savings
– Yr 3 losses max: 5%
Y 3l 5%
– Bonus up to 2.5% for rural clinics, FQHCs
• 2‐sided risk model
– Yr 1‐3: sharing in both savings & losses
– Savings based on quality performance up to 60% savings
– Yr 3 losses max: 10%
– Bonus up to 5.0% for rural clinics, FQHCs
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MSSP ACOs: By the Numbers
• Estimated Participation
– ACOs: 75‐150
– Beneficiaries: 1.5‐4.0M
e e c a es 5 0
• Costs and Savings (3 years)
– Total savings: $510M (Federal)
– Bonuses to ACOs: $800M
– Penalties from ACOs: $40M
– Average ACO startup cost incl 1st yr operating: $1.73M
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3

4. Speaker Bio
Alan Gilbert, MPA
AxSys Technology
Vice President, Business
Development
Conflict of Interest Disclosure
Alan Gilbert, MPA
,
• Have no real or apparent conflicts of interest
to report.
Learning Objectives
ACOs under the Medicare Shared
Savings Program and the Role of
Savings Program and the Role of
Health IT
ACO Foundational Data and
Information Technology Needs
4

5. Data Needs for ACO Environment
Data to be shared from:
• CMS to ACOs
• ACOs back to CMS
• Within the ACO itself
42 CFR Part 425 [CMS‐1345‐P]
RIN 0938‐AQ22 Medicare Program; Medicare Shared Savings Program:
Accountable Care Organizations
Data Needs for ACO Environment
Data to be shared from:
• CMS to ACOs
–CMS will share
• aggregate data
• Beneficiary identifiable data
42 CFR Part 425 [CMS‐1345‐P]
RIN 0938‐AQ22 Medicare Program; Medicare Shared Savings Program:
Accountable Care Organizations
Data Needs for ACO Environment
Data to be shared from:
• ACOs back to CMS
– ACOs have focus on Quality
– C S id ifi d 2 Q li h
CMS identified 2 Quality Themes, 5 Key Domains,
K i
and 65 Measures within the dimensions of
improved care and improved health that CMS
proposes will serve as the basis for assessing,
benchmarking, rewarding, and improving ACO
quality performance.
42 CFR Part 425 [CMS‐1345‐P]
RIN 0938‐AQ22 Medicare Program; Medicare Shared Savings Program:
Accountable Care Organizations
5

6. Quality Themes , 5 Key Domains and 65 Measures
Quality Themes
• Better Care for Individuals
• Better Health for Populations
Key Domains
Key Domains
• Patient/Caregiver Experience
• Care Coordination
• Patient Safety
• Preventive Health
• At‐Risk Population/Frail Elderly Health
42 CFR Part 425 [CMS‐1345‐P]
RIN 0938‐AQ22 Medicare Program; Medicare Shared Savings Program:
Accountable Care Organizations
65 Measures
Quality Reporting and Performance
• 65 measures
– Patient/Caregiver Experience (7)
– Care Coordination (16)
– Patient Safety (2)
Patient Safety (2)
– Preventive Health (9)
– At‐Risk Population/Frail Elderly (31)
• Required to Submit on all measures
– Yr 1: report only
– Yr 2‐3: measured on performance 42 CFR Part 425 [CMS‐1345‐P]
RIN 0938‐AQ22 Medicare Program; Medicare Shared Savings Program:
Accountable Care Organizations
65 Measures Quality Reporting and Performance
Page 1 of the 65 Measures
42 CFR Part 425 [CMS‐1345‐P]
RIN 0938‐AQ22 Medicare Program; Medicare Shared Savings Program:
Accountable Care Organizations
6

7. Data Needs for ACO Environment
Data to be shared from:
• Within the ACO itself
– Longitudinal/Community Health Record
– EMPI
– Health Information Exchange (HIE)
lh f h ( )
– Hierarchical Data Security
– Collaborative Clinical Decision Support
– Provider‐to‐Provider Communication Tools
– Integrated Workflow Management
– Active Care Management
HIMSS ACO Workgroup – Chapter 4 – ACO Management Tools FAQ
Where will this data come from
to satisfy these requirements?
Speaker Bio
Kobi Margolin
Clinigence
CEO
• Cofounder and GM US Operations,
Algotec (sold to Kodak, 2004)
• VP Business Development, Accelarad
(2005‐2008)
• Founder, KM Consulting Group (2008)
• Founder and CEO, Clinigence (2010)
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8. Conflict of Interest
Disclosure
Kobi Margolin
• Have no real or apparent conflicts of
interest
Learning Objectives
ACOs under the Medicare Shared
Savings Program and the Role of
Savings Program and the Role of
Health IT
• Analytics for ACOs –
Data and Technology Needs
Why Analytics?
Can this be the
road to
accountable care?!
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9. The Value of Analytics
Data
Actionable
Information
Knowledge
Clinical Analytics
Data
Actionable
Information
Knowledge
Clinical Analytics
Data
• Claims
Actionable
• EMR Information
• Timely
Knowledge • Relevant
• Process (guidelines, • Complete
interventions)
• Accurate
• Outcome
(benchmarks)
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10. Which Technologies?
Data
• Acquisition
Actionable
• Aggregation Information
Analytics • Visualization
Knowledge
• Management
What Data?
Value/Type Claims EMR HIE/
Cross‐EMR
Cost   
Care continuum
C i  ‐ 
Patient outcomes ‐  
Actionable ‐  
Acquisition & Aggregation
Semantic
interoperability
Remote
Remote
Health monitoring;
information personal
EMRs; exchange health
Clinical records
Electronic Data
claims; Repository
disease
registries
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11. Creating Knowledge
Research Insight
Knowledge Action
Information
Data
Knowledge Management
Semantic;
Semantic;
ontology‐
Collaboration; based
social
networking
Content
Management;
Clinical decision
support
Care Improvement
• Staff
performance
• Process Staff
effectiveness
effectiveness
• Innovation & Process
learning of best
practices Innovation
& Learning
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12. Analytics Technologies
Data
Process
Predictive mining
intelligence
modeling
Process ‐
outcome Population
analysis Population h lth
health
outcomes management
Process
compliance Provider (health; cost)
mapping performance analysis
analysis
Provider‐ Business
centric intelligence
quality
reporting
Visualization Technologies
• Benchmarking
Visualization Technologies
• Benchmarking
• Trending
– Retrospective
– Real‐time tracking
l i ki
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13. Visualization Technologies
• Benchmarking
• Trending
– Retrospective
– Real‐time tracking
l i ki
• Population mapping
• Interactive data mining
• Real‐time feedback loops
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