Ever since the draft ACO regulations were released by CMS a few weeks ago, I’ve been getting lots of questions about how technical teams and CIOs should be engaged with the business side to figure out their implementation strategies (I love these questions, by the way, so keep them coming). To help clarify some important technical and implementation issues, I’ve invited Dr. Mark Segal, vice president of government and industry affairs at GE Healthcare IT, to share his thoughts on the topic. Mark’s views in this post are not necessarily those of GE Healthcare.
Health care organizations of all types are developing accountable care organization (ACO) strategies, and in some cases, actual ACOs, looking to participate in emerging Medicare and private sector interest in accountable care. ACOs will take many forms, with different approaches to achieving needed spending control and quality outcomes. For example, the Medicare Shared Savings Program Accountable Care Organization (ACO) proposed rule, highly detailed and prescriptive in many respects, envisions considerable variability in the types of organizations designated as shared savings ACOs, including ACOs that do not have a hospital as a formal component.
Within this variability, however, there are key tasks that must be accomplished by any ACO. Recognizing and organizing around these tasks, many of which require IT support, will help nascent ACOs navigate regulatory and market uncertainty and the constant churn of buzz words. As Shahid Shah has noted, “ACOs are not a technology problem; they are a business model problem . . .”
First and foremost, the ACO must assume accountability for a population of patients. This accountability will include specific focus areas (often mandated by the payer), such as care coordination, patient engagement, and evidence-based medicine. ACO success will also require attaining and exceeding threshold metrics for quality measures to be designated by Medicare or other payers. Finally, the ultimate test is to reduce spending on the target population by a material amount relative to a benchmark level, while also meeting the required quality metrics.
The requirement for accountability comes to life when linked to a population of patients. Ironically, and by design, an ACO combines a focus on population management with built-in challenges to managing and even identifying the population.
For example, unlike a more traditional HMO or managed care organization, ACO beneficiaries are not locked-in to receive their care from the ACO’s providers. Such patient choice is a distinguishing characteristic of an ACO, but does present challenges. In some cases, moreover, as with the Shared Savings proposed rule, the population for which the ACO is held to account will not be designated until after the measurement period has concluded. As a result, while the ACO will need a population focus to be successful, it may need to manage a “population” whose members are not fixed but rather only linked by a common payer (e.g., Medicare). Indeed, CMS wants ACOs to apply accountable care to all Medicare beneficiaries, not only those “assigned” to the organization.
Managing a population, especially one that receives some care outside of the ACO, will require HIT tools to manage scheduling and referrals, enhance patient experience and ties to ACO providers, and ensure exchange of clinical data between ACO and non-ACO clinicians. ACOs will also need population based reporting and analytics.
Second, an ACO will need to focus on quality measurement and management, including internal and external reporting, typically using quality measures that are largely dictated by the payer. In many cases, these measures derive from evidence-based medicine and will correlate to clinical decision support tools that enable a virtuous cycle of measurement, evaluation, adjustment of practices, and measurement. The proposed rule does not require electronic health record (EHR)-based quality reporting, such as that used for meaningful use. CMS does, however, signal its plans for ACO convergence over time with EHR-based external quality reporting. Moreover, ACOs will need capabilities for near real-time internal quality measurement to effectively manage and correct quality issues, with EHR-based reporting, and associated data collection work-flows an important enabler of such reporting.
Third, ACOs will need the ability to exchange data within the ACO and across providers, for example, hospitals, medical practices, and post-acute care providers. This requirement involves standards-based internal interoperability and internal and external use of standards based health information exchange (HIE), as both a noun (an HIE organization/infrastructure) and a verb (to exchange). Moreover, ACO-based data exchange need not await formation of a large community-based HIE organization but rather, can involve HIE that is focused initially on ACO members and prime referral partners. Beyond data exchange, ACOs will need to integrate clinical, financial and administrative data, apply robust analytics, and generate insight about care processes.
While focusing on populations, ACOs and their providers will need to accomplish their goals one patient at a time. Results for a population will logically, and critically, result from countless individual care decisions and processes. Consistent with the CMS linkage of meaningful use to ACO qualification, it will therefore be critical that hospitals and health care professionals have robust electronic health records to enhance the care and management of their patients.
As the definition of an EHR has evolved from a market standpoint and under meaningful use-related certification criteria, many of the key HIT functions needed for an ACO will be found in certified EHRs, such as clinical decision support, CPOE, medication reconciliation, quality reporting, care coordination, and patient engagement. ACOs will, however, likely ask for more from their EHRs than is required under either certification or meaningful use, at least at the Stage 1 level. ACO providers are also likely to use specialized functionality, often not part of a EHR, focused on specific quality and cost challenges, for example surveillance and reduction of healthcare acquired conditions (HACs). Some of these functions will also be enabled via value-added HIE functionality. Overall, success as an ACO will result in a financial payoff for HIT use that can exceed the federal EHR incentives.
Finally, as payment models continue to shift from fee-for-service toward pay for value, ACOs will also need revenue cycle software that can manage new payment models, such as bundled and capitated payments, and that can help distribute shared savings. In some instances, ACOs will also need payer data and analyses of linked payer/ACO data, including estimates of projected costs and other metrics for the ACO’s patient population.
Navigating the challenges of accountable care can be done, but it will require a clear-eyed focus on the fundamental tasks at hand and recognition that there will be no single technology solution, but rather, a need for tailored combinations of HIT tools aligned with clinical and business strategies, and a rigorous focus on change management.