Accountable Care Organizations Explained

Here is a simple, easy to read ACO article on NPR
http://www.npr.org/2011/04/01/132937232/accountable-care-organizations-explained

ACO Fact Sheet

National Committee for Quality Assurance (NCQA) recently published a fact sheet on Accountable Care Organizations. Read the Fact sheet here (http://www.ncqa.org/tabid/1312/Default.aspx). This gives you a good overview of why you should consider becoming an ACO.

More Regulation - ACO!

If you are like me, you are probably jumping up and down in joy that there is more regulation afoot (not!). ACO (accountable care organization) regulations came out last week. You can read all 696 pages and sift through the data or I can try to provide you a snapshot. Here you go:


Measurements
Quality measurements reduced from 65 to 33! Well, that is reduced in half. Got to be a good thing. Yes, it is a good thing. The measures are now categorized into 4 domains, namely:
- Patient/Care Giver experience (7 measures)
- Care Coordination/Patient Safety (6 measures)
- Preventive Health (8 measures)
- At Risk Population (12 measures: 7 measures, including 5 component diabetes composite measure and 2 component CAD composite measures)


Pretty Simple, eh? Each domain is given a weightage percent of 25% each and then reported for each of these measures.) In the next blog, we will take a deeper dive into the measurements. And if you want to go straight into implementation, see how Meta Analytix can help you here: http://www.metaanalytix.com/page.php?page=36



Who is eligible?

The newly added section 1899 of the Social Security Act or SSA provides examples of groups of service providers and suppliers that may form an ACO, including 

(i) physicians and other health care practitioners (ACO professionals) in a group practice, 

(ii) a network of individual practices, 

(iii) a partnership or joint venture arrangement between hospitals and ACO professionals, and 

(iv) a hospital employing ACO professionals. ACOs eligible to participate in the MSSP (Medicare Shared Savings Program) will manage and coordinate care for their assigned Medicare fee-for-service beneficiaries.

What are the requirements?
According to the IRS (IRS?? - http://www.irs.gov/pub/irs-drop/n-11-20.pdf), the type of organizations wishing to become ACOs must meet the following criteria.



1) The ACO shall be willing to become accountable for the quality, cost, and overall care of the Medicare fee-for-service beneficiaries assigned to it.


(2) The ACO shall enter into an agreement with the HHS Secretary to participate in the program for not less than a 3-year period (the MSSP( (Medicare Shared Savings Program) agreement period).


(3) The ACO shall have a formal legal structure that would allow the organization to receive and distribute payments for shared savings under § 1899(d)(2) to participating providers of services and suppliers.


(4) The ACO shall include primary care ACO professionals that are sufficient for the number of Medicare fee-for-service beneficiaries assigned to the ACO under § 1899(c). At a minimum, the ACO shall have at least 5,000 such beneficiaries assigned to it under § 1899(c) in order to be eligible to participate in the MSSP.


(5) The ACO shall provide the HHS Secretary with such information regarding ACO professionals participating in the ACO as the Secretary determines necessary to support the assignment of Medicare fee-for-service beneficiaries to an ACO, the implementation of quality and the other reporting requirements under § 1899(b)(3), and the determination of payments for shared savings under § 1899(d)(2).


(6) The ACO shall have in place a leadership and management structure that includes clinical and administrative systems.


(7) The ACO shall define processes to promote evidence-based medicine and patient engagement, report on quality and cost measures, and coordinate care, such as through the use of telehealth, remote patient monitoring, and other such enabling technologies.


(8) The ACO shall demonstrate to the HHS Secretary that it meets patient-centeredness criteria specified by the Secretary, such as the use of patient and caregiver assessments or the use of individualized care plans.


That's about it. If you have questions, feel free to call me. If I am on the golf course, I am not answering my phone!

ACO Series, Part I

So, people have been (I hate saying "people", it's like saying "they say...". My first question is, "Who are the famed "they"? In this case, who are these "people"? But for the purposes of this post, I can't take names, so "people" ) have been asking me about ACOs and the role of analytics in it. I read a recent study done by American Hospital Association and McManis consulting titled "Activities and Costs to Develop an Accountable Care Organization". If you haven't read it, it is a good read. In the report, they break it down into four major categories:

1. Network Development and Management

2. Care Coordination, Quality Improvement & Utilization Management

3. Clinical Information Systems and, my favorite

4. Data Analytics.

Now, it is interesting that they broke out Data Analytics as a separate entity. In my humble opinion, Data Analytics has implications in all three of the other areas. For example, the stated definition of ACOs is: "intended to manage the health of a defined population and to be held accountable and reimbursed based on measurable improvements in quality and patient satisfaction, plus reductions in costs". Sound familiar? If you have been reading my blogs for the last two years, you would have heard these two terms repeatedly:

1. Improving Quality of Care

2. Reducing cost of care

And why do I think Analytics has implications in all three? Well, let's put it this way. You don't throw money at something and hope that it sticks do you? If you answered yes, well...you are reading the wrong blog, but if you didn't, then read on.

Let's take a look at section 1 of the study, Network development and management. The study details about 9 activities that you have to do to achieve the goals of this section. I am not going to go into details of all of them. But let's examine a couple.

* Recruiting/acquiring primary care professionals, right-sizing practices

Great goal. But how do you achieve this? Do you want to acquire every PCP that is associated with you? Probably not. You want to acquire the "best" ones. You criteria for defining the "best" might differ from your neighbor's, but you still want to acquire the best and drop off the dead weight. (Remember the fact that you are trying to "reduce costs" through this activity). So how do you know who is your best target for acquisition? Historical data of course! So, define the metrics which allow you to define your "best case scenario", run those metrics against your historical data and see who pops up at the top! You might be surprised. If I were a betting man, I would bet a dollar on it!

* Compensating physician leaders

Uh oh! Yes, I went there. This is a touchy subject. Well, the question is, how do you define a "leader"? Is it the physician who can do 40 surgeries, play 18 holes of golf, take the kids to soccer practice and have dinner with the family all in a day? Could be. It could also be the physician who has the least infection rates. It could also be the physician with a 100% patient satisfaction rate. So now we have a combination of metrics (weighted, of course to come up with the definition of a "leader"). Again, run these metrics against your historical data ( you do have historical data as much you think you may not), and see who pops up at the top. Again, I will bet a dollar that you might be surprised.

So you see, analytics is not a separate "reporting only" solution. You can use it to make intelligent decisions. But if you are reading this blog and haven't slept yet, you already knew that. That is why I think analytics has implications in all three of the major categories in achieving a true ACO.

ACO Series Part II: Care Coordination, Quality Improvement and Utilization Management

Coming soon to a blog near you.