CONTENT

Pillars for Accountable Care

PCMH versus ACOs

Core competencies

Six core structural components of successful ACO deployment

Pioneer ACO burn and learn lessons

Barriers & root cause analysis

Patient attribution

Five modes of Accountable Care

Early value-based adopters

Value discovery assessment

Modified Triple Aim

GPRO

Breakdown by 33 Measures

PILLARS OF ACCOUNTABLE CARE

Provider-led

Providers and payers co-own responsibility for the cost and quality of care provided to a defined population; shifts both rewards and risks to aligned, integrated care systems

Population attribution to ACOs, with opt-outs and choice

Health engagement/wellness initiatives that are tailored to the individual

Diverse group of providers, including hospitals, specialists, primary care, and post-acute care, that can coordinate across settings

Robust health information technology infrastructure and performance measurement capacity

Providers and payers share population-based data on a timely basis

Long-term partnerships with a range of payment options

DIFFERENTIATING PCMH FROM AN ACO

P A T I E N T C E N T E R E D

M E D I C A L H O M E

Created in 2007 to better access, care coordination to build strong relationship between the PCP and patient.

Payers provide a per member per month bonus for PCP services

A C C O U N T A B L E C A R E

O R G A N I Z A T I O N

Strong PCP core also, but comprised of many medical homes.

ACOs are accountable for cost/quality within and outside the PCP relationship

ACO CORE COMPETENCIES

SIX CORE STRUCTURAL COMPONENTS OF SUCCESSFUL ACO DEPLOYMENT

A commitment to providing care that puts people at the center of all clinical decision-making

A health home that provides primary and preventive care

Population health and data management capabilities

A provider network that delivers top outcomes at a reduced cost

An established ACO governance structure

Payer partnership arrangements

PIONEER ACO BURN AND LEARN LESSONS

Mortality rate was high. One-third dropped.

Of that one-third, seven re-organized and entered the MSSP.

One of the key challenges for hospitals and physicians is that the incentives are to

reduce hospital stays, emergency room visits and expensive specialist and testing

services — all the ways that hospitals and physicians make money in the current fee-

for-service system.

All 32 Pioneers succeeded in improving quality and performed better than fee-for-service

Medicare in 15 quality measures

CURRENT BARRIERS & ROOT CAUSE ANALYSIS

Multispecialty group formation, umbrella alignment is difficult with income dispersion

Size of the patient population, with a 5,000 as minimum ante to play

Cultural: human centered, physician-led, continuous improvement, flexibility

Resources, PCPs drive-but specialists operate the pedals

Staffing, PCP shortage

Lack of measure continuity, different payouts with different models at once

Market-based, disease specificity and prevalence will never allow for a one size fits all

Legal: anti-trust, anti-kickback, and self-referral Stark Law

PATIENT ATTRIBUTION IN ACOS

Patient-based vs. Episode Based

Patient-based holds the provider accountable for the entire spectrum

Episode assigns provider (s) from symptoms onset to completed treatment

Single attribution vs. Multiple attribution

SA assigns to provider with highest percentage of patient’s cost, minimum

threshold 25-35%, while MA is assigned when threshold is not met typically

Prospective (historical claims) vs. Retrospective (actual utilization)

Blend

RISK STRATIFICATION IN POPULATION HEALTH MANAGEMENT

Wellness scores answers the question of who are my ACO patients that could

benefit clinically and financially from an engagement campaign. Over 100

variables affect this score, but here are a few examples:

Patient's health risks as identified by a health risk appraisal form or other

questionnaire

Clinical diagnoses

Utilization data from insurer or other source (lab, pharma, PACS, claims,

mHealth or remote monitoring)

Clinician’s personal knowledge related to a patient’s social, financial,

mental, or physical condition

FIVE MODES OF ACCOUNTABLE CARE

ACO READINESS ASSESSMENT

Questions designed for your initiative and readiness around:

Organizational structure and commitment

Proposed network

Value-based experience

Open component technologies

Quality and care management

Retention strategy and growth plan

DATA SHARING

Q U A R T E R L Y A G G R E G A T E

R E P O R T S

Will be based on previous 12

months of data and include:

• Financial performance

• Quality performance scores

• Aggregated metrics on the

assigned beneficiary

population

• Utilization by Subpopulation

M O N T H L Y C L A I M S D A T A

Can request a standardized

dataset:

• Procedure codes

• Diagnosis codes

• Dates of service

• Provider/supplier ID

• Part D data

ACTIVATING ACCOUNTABLE PATIENTS

Patients need to share in their own accountability, and some tips reside here. Much can be

achieved through a comprehensive Patient Portal with these ACO quality metrics satisfied:

CAHPS: Getting Timely Care, Appointments, and information

CAHPS: How Well Your Doctors Communicate

CAHPS: Patients’ Rating of Doctor

CAHPS: Access to Specialists

CAHPS: Health Promotion and Education

CAHPS: Shared Decision Making

CAHPS: Health Status/Functional Status

ACO MEASURES: CARE COORDINATION/ PATIENT SAFETY

Measure Care Coordination/ Patient

Safety

Physician Description & Objectives

8 All Condition Readmission Avoid readmissions by seeing your patients within 7 days following

inpatient discharge

9, 10 COPD, Asthma & CHF Avoid unnecessary admission of COPD, Asthma and CHF patients by

seeing them on a monthly basis

11 EMR Incentive Program

Payment in 2014

Attest for Meaningful Use in 2014 (either Medicaid or Medicare)

12 Medication Reconciliation Physician must perform med rec and document that he/she is aware of

inpatient facility discharge meds and will either keep or change meds

13 Screening for Fall Risk Screen patient for falls risk in office

ACO MEASURES: PREVENTIVE HEALTH

Measure Care Coordination/ Patient

Safety

Physician Description & Objectives

14 Influenza Immunization Provide or document that patient received infu imm

15 Pneumococcal Vaccination Provide or document that patient received pneu vac

16 Adult Weight Screening

AND Follow-up

Calculate BMI – If abnormal, document follow-up plan (education, Rx

intervention, diet & exercise, etc.)

17 Tobacco Use Assessment

AND Tobacco Cessation

Intervention

Screen for tobacco use – If user, provide & document cessation counseling

(includes counseling & pharmacotherapy

18 Depression Screening AND

Follow-up

Screen for Depression – If patient is depressed, document and provide

follow-up (additional evaluation, Rx intervention, suicide risk assessment)

19 Colorectal Cancer Screening FOBT – last 12 months, Flex Sig – Last 4 years and Colonoscopy – last 9

years

20 Mammography Screening Mammogram performed within the last 24 months

21 Pressure Measurement AND

Recommended Follow-Up

Plan is Documented

Screen for high blood pressure – If patient has BP greater than 120/80,

rescreen and provide lifestyle modifications (i.e. NA intake, diet and

exercise, etc.)

ACO MEASURES: AT RISK POPULATION

Measure At Risk Population Physician Description & Objectives

22 Hemoglobin A1c Control

(<8 percent)

Control DM patient’s HbA1c - below 8%. Follow ACO’s HbA1c goal

attainment protocols

23 Low Density Lipoprotein

(<100)

Control DM patient’s LDL - below 100. Follow ACO’s LDL goal attainment

protocols

24 Blood Pressure (<140/90) Refer to measure 21

25 Tobacco Non Use Advise patient to quit tobacco use

26 Aspirin Use Provide patients with DM and IVD a daily aspirin or

antiplatelet medication

27 Hemoglobin A1c Poor

Control

(>9 percent)

Control DM patient’s HbA1c with goal of below 8%.

Follow ACO’s HbA1c goal attainment protocols

28 Blood Pressure Control

(<140/90)

Control HTN patient’s BP with goal of <140/90

29 Complete Lipid Profile AND

LDL

Control (<100 mg/dl)

Document and complete lipid profile AND control LDLC

(<100 mg/dl)

ACO MEASURES: AT RISK POPULATION

Measure At Risk Population Physician Description & Objectives

30 Use of Aspirin or Another

Antithrombotic

Provide patients with IVD a daily aspirin or

antithrombotic medication

Heart Failure

31 Beta-Blocker Therapy for

LVSD

(EF <40%)

Patients with Dx of HF and w/ a LVEF <40% should be

on beta blocker therapy (bisoprolol, carevdilol, or

sustained release metoprolol succinate)

Coronary Artery Disease

32 Drug Therapy for Lowering

LDLCholesterol

Patients with CAD need documented plan for LDL

control

33 MediACE Inhibitor or ARB

Therapy

for Patient with CAD and

DM

and/or LVSDcation

Reconciliation

ACE Inhibitor or ARB Therapy for Patient with CAD and

DM and/or LVSD (LVSD - patients with EF <40%)

GPRO

The majority of measurements require submission through the CMS GPRO web

interface tool, and you will need architecture to map data and populates the

GPRO for reporting of measurements. There are a few recommendations for

vendors I will make, but all accomplish the following:

Prepares and sends the report to the CMS GPRO web interface

Provides a flexible reporting tool

Assembles EMR data with Primary Care Physician data behind the scenes

Displays CMS feedback from the GPRO

MODIFIED TRIPLE AIM

Care Experience

Per capita cost

Patient/Provider Satisfaction

Population Health

Satisfaction of the patient

and provider is paramount

with ACO final rule

For a free copy of this deck, ROI

spreadsheet, or the Discovery

Assessment, please contact:

CJ Fulton

618-579-9192

healthideation@gmail.com