ACO’s and Health IT:True Delivery System Reform

or

Another Round of Unintended Consequences?

Comments & Reflections for Your Right Hemisphere

Rick MacCornack, PhDCSIO, Northwest Physicians

NetworkCEO, Rainier Health Network

rmaccornack@npnwa.net

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

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).

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

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

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

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

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

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

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

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

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

Reality:Primary Care Coordination

ComplexityFFS 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.

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

Why We Started Thinking This WayPuget 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 anACO

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

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

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.

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”.

Rainier Health Network

Rainier Health Network

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

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

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

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

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

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

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

From Our Limited ACO Experience:

A Disruptive Innovation and its EffectsWeb-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

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”

           

  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

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

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

Supporting 21st Century Patient Care

Analytics

Care Management(Process of Care)

Clinical Source

Hx, Dx,Tx

PatientCare Team

Clinic

Systemperformance

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

A Way to Think About This

Simon Sinek on TED ~ YouTube Knowing Your “Why”

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?

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

Your Turn!