IT Challenges in Implementing a Physician Directed ACO

William C Biggs, MD, FACE

Medical Director

Amarillo Legacy Medical ACO Closing the Loop

DISCLAIMER: The views and opinions expressed in this

presentation are those of the author and do not necessarily

represent official policy or position of HIMSS.

Conflict of Interest Disclosure

William C Biggs, MD

Has no real or apparent

conflicts of interest to report.

William C Biggs, MD

has received an

honorarium in the

past from

eClinicalWorks

© 2015 HIMSS

Objectives

• 1) Identify ways to reduce costs such as hospital admissions, home health and skilled nursing

• 2) Use analytics to provide actionable information across a multi-provider ACO.

• 3) Evaluate provider performance with Evidence Based Medicine measures.

Current ‘System’

“…an expensive plethora of

uncoordinated,

unlinked,

economically segregated,

operationally limited microsystems,

each performing in ways that too often create suboptimal performance.”

George Halvorson, CEO Kaiser Permanente

What an ACO could do to reduce costs

• Reduce Fragmentation of Care

– Health information exchange

– Referral messaging

– Care coordination at the group and ACO level

• Accountability for quality and cost at a group level

– Identify waste, fraud, or abuse

– Identify high value cost effective consultants, HHA, SNF

– Establish evidence based guidelines & measure use

– Identify population health trends, report epidemiologic events

– Find health risks for individuals or populations based on aggregate data

– Report quality data to providers to help them improve

• Incentivized to improve performance

– Develop a ‘Consumer Reports’ approach to vendors

– Allow providers to choose what they think is the overall best care for the patient, which usually aligns with lower cost.

Amarillo Legacy Medical ACO

6

Starting year 2013

14,372 lives attributed for 2015

6 Counties in the Texas Panhandle

11 independent medical group

participants

0 hospital participants

Benchmark per capita $8,644

2013 per capita spending $8,183

Generated savings 2013 $4,883,855

Patients this week

Patients this week w/ Massachusetts as benchmark

Assembling the Team Our doctors – pre ACO

EHR Meaningful

Use PCMH PCMH

recognized

Care

Management

Outpatient PCPS

Outpatient

Specialists

Indigent Care clinic

Hospitalists

Problem 1 Texas HIE Map

ORIGINAL PLAN ACTUAL RESULT

Created the region’s only Health Information Exchange

HIE incorporates :

eClinicalWorks

Allscripts

NextGen

Greenway

Planning for 2015:

Hospital data

ADT feed for care managers

Cerner

Siemens

New York Times, October 28, 1964 Business Section

Amarillo HIE

ALMA HIE Status – by June 2015

• HIE will connect

– 200 outpatient providers

– 6 Urgent Care Centers

– 12 Practice locations

– 1 SNF

– Two cities

• Two regional hospitals

– All Hospitalists

– All ER Physicians

Where are the expenses ?

1)Avoid ER when office

visit would be better

2) Do more office visits

if necessary, to avoid

ER or hospital

admissions.

3) Find out who does

best job on keeping

their patients out of ER

and hospital.

4) Avoid unnecessary

procedures

Amarillo Hospital Data Surgical procedures more than 90th percentile

Region

OVERALL

Hospital Discharges

per 1,000 Medicare

Enrollees

MEDICAL

Hospital Discharges

per 1,000 Medicare

Enrollees 2007

SURGICAL

Hospital Discharges

per 1,000 Medicare

Enrollees, 2007

Amarillo, TX 1.03 0.94 1.23

National Average 1.00 1.00 1.00

90th Percentile 1.18 1.21 1.16

50th Percentile 0.98 0.98 1.02

10th Percentile 0.79 0.75 0.86

Source: Dartmouth Atlas of Health Care

Amarillo Stent / Angioplasty rate 72% higher than Texas average percentile

Texas 0.98

Amarillo 1.70

National

Average 1.00

90th

Percentile 1.50

50th

Percentile 0.97

10th

Percentile 0.65

Source: Dartmouth Atlas of Health Care - 2007

Relative rate of percutaneous intervention – USA average = 1.00

Claims analysis from Medicare CCLF files Costs per patient for ischemic heart disease

0

2000

4000

6000

8000

10000

12000

14000

Group A Group B

BSA

Northwest

Both

N= 360

Not risk adjusted

Retrospective Analytics

– Identify patients for care management intervention

– Provider stratification

• Identify “Best Value” Providers of:

– Home Health

– Skilled Nursing

– Consultants

– Hospital care

– Assess Quality

• ER utilization

• SNF & HHA utilization

• Drug utilization

Source Data for Analytics

Significant benefit to ACO population health is the availability of both claims data and health data.

Claims: Medicare – CCLF files

Health: Health Information Exchange C-CDA

& ‘Adapters’ to report quality measures

Wellness Visit Assessment Example of dual data source

Obtain Medical and Family History

Allows Providers to Obtain Health Risk Assessment

Understand Functional Abilities; Physical and Cognitive

Schedule Screenings and Immunizations

Referrals for any Additional Services

Annual Wellness Visit (AWV) Reimbursement to Providers

22

Projects using both HIE, and Monthly Medicare CCLF files The Wellness Visit Project

• CCLF1 Part A Claims Header File CCLF2 Part A Claims Revenue Center Detail File CCLF3 Part A Procedure Code File CCLF4 Part A Diagnosis Code File CCLF5 Part B Physicians File CCLF6 Part B DME File CCLF7 Part D File CCLF8 Beneficiary Demographics File CCLF9 Beneficiary Crossreference File

CCLF5 Part B Physicians File are used to identify the CPT and

payment amounts.

CCLF8 Beneficiary Demographics File

CCLFs Used to Determine Wellness Visit

24

List of “G” Healthcare Common Procedures Coding System (HCPCS)

G0402 Initial Preventive Physical Exam

G0438 Annual Wellness Visit

G0439 Subsequent Annual Wellness

Medicare Wellness Visits – from Claims data

Amarillo Wellness Visit from EMR data

26

Increased Rate of Wellness Visit Completion

Better Risk Assessment for Referrals and Care Management

See Earlier Identification of Risks and Earlier Intervention

Better Coding of Patient Risk – Could Impact HCC Severity if

Coding is More Complete

27

Wellness Visit Project Expectations

Outcomes

Home Health Scoring

Value Index

ER visits

Hospital Admissions

Cost per patient

Home Health score

Home Health Scoring

CONFIDENTIAL - FOR INTERNAL USE ONLY

ER visits

% Hosp

Admits % ACO cost

per pt Patien

ts Total HHA

Cost Risk

Score Time Billed ALMA Value

Score Overall

Rank

A 7.8 2.1 $4,959.29 121 $600,074 3.4 14.5 0.684 3

B 13.6 6.1 $2,570.82 174 $447,323 3.9 10.8 0.846 5

C 9.5 4 $3,874.31 169 $654,759 3.7 15.4 0.737 4

D 0 0 $4,257.47 11 $46,832 3.5 12.4 0.290 1

E 4.9 1.3 $8,001.39 104 $832,145 2.7 18.2 0.970 7

F 15.2 0 $3,016.72 32 $96,535 2.7 15.2 0.664 2

G 8.4 4 $4,793.58 139 $666,308 3.2 16.2 0.896 6

H 10 4.2 $6,862.89 229 $1,571,601 3.6 17.5 0.980 8

I 10.5 4.5 $9,102.77 138 $1,256,182 3.6 16.4 1.162 10

J 7.1 5.2 $6,654.62 21 $139,747 3.1 17.8 1.148 9

K $8,081.50 6 $48,489 4 29.8

L $8,829.21 14 $123,609 3.9 19.9

M $13,033.4

3 7 $91,234 5.4 17.1

Amarillo SNF Cost & Utilization View

31

Amarillo SNF Readmission Scorecard

32

Example – Physician Practice Access

• NYU ED Utilization Algorithm

– Non Emergent

– Emergent / Primary Care Treatable

– Emergent / ED Care Needed / Preventable

– Emergent / ED Care Needed / Not Preventable

– Injury

– Psych

– Drug Related

Top Avoidable Diagnoses

Emergent Avoidable

(CHF = Bernheim’s Syndrome 428.0)

Non Emergent

(Albarran’s = Urinary Tract

Infection)

ER Visit Utilization

General Internist 2 - At

Site B

General Internist 1 -

At Site A

‘Closed Loop’ Analytics

‘Closed Loop’ Analytics

ALMA Hospital Admission Rate per 1000

323

302 291

281 274

251 248

0

304

0

50

100

150

200

250

300

350

Full year Q1 Q2 Q3 Q4 Q1 Q2 MSSPACO

2012 2013 2013 2013 2013 2014 2014 Median

Series1

Down 23.2%

Our Year 2013

Table 3: Shared Savings Award Calculation - One-Sided Shared

Savings Model

PY1

Total Savings and Minimum Savings Rate Calculation

[R] Assigned Beneficiaries 10,876

[S] Person-Years 10,603

[V] Per Capita Expenditures ($) 8,183

[W] Per Capita Expenditures Benchmark ($) 8,644

[X] Total Expenditures ($) 86,766,644

[Y] Total Benchmark Expenditures ($) 91,650,499

[Z] Total Benchmark Expenditures Minus Total Expenditures ($) 4,883,855

[AA] Total Savings ($) 4,883,855

[DD] Savings Realized ($) Savings

Shared Savings Calculation

[HH] Shared Savings ($) 2,441,928

[II] Shared Savings Cap ($) 9,165,050

[JJ] Sequestration Adjustment ($) 48,839

[KK] Earned Performance Payment ($) 2,393,089

Amarillo Legacy Medical ACO

William C Biggs, MD FACE

william@amarilloaco.com

Amarillo Medical

Specialists

Amarillo Family

Physicians

Cardiology Center of Amarillo

Family Medicine Centers

Panhandle Ob/Gyn

BSA Amarillo Diagnostic

Clinic

BSA Physicians

Group

BSA Harrington Physicians