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!

Informatics for IPAs

Some of the IPA customers we talk to, all say the same thing. "I don't have the data to defend my contract negotiations". So how can an IPA integrate data to better negotiate terms in a "shrinking profits" landscape?

Step 1: Remember step 1? METRIC? (Measure Everything That Really Impacts Customers"? Yes, step 1 hasn't changed. Not one bit. In this particular case, since your negotiations are probably based on HEDIS and PQRI measures, that's the first thing you want to list out. Which of those measures will help you show your quality of care and performance.

Step 2. Collect Data. If you are like most IPAs, you have 5 or more EMRs to deal with that are being used within the physician practices. Most EMRs, save a few, have ODBC compliant databases. Solutions like ours can pull data directly from those systems. And for the others, you can integrate data using the more traditional, "flat file" approach. This is more technical than anything else.

Step 3: Define your reports. What reports will help you better negotiate rates? If you find anomalies with regards to physician performance, how can you get that one practice up to speed with everyone else so that you can negotiate better? How often do you need these reports? Define these and the next time you walk into contract negotiations and the payer tells you that your Physician performance is "this" based on claims data, you can confidently say, "no, our data shows a different picture".

So negotiate away, you IPA samurais, and bring up that profitability level!

Accountable Care Organization - Achievable?

What is an ACO?

Here is a recent example of an ACO definition taken from a 2010 article co-authored by Elliot Fisher:

ACOs consist of providers who are jointly held accountable for achieving measured quality improvements [note that “measured quality improvements” is synonymous with report cards] and reductions in the rate of spending growth. Our definition emphasizes that these cost and quality improvements must achieve overall, per capita improvements in quality and cost, and that ACOs should have at least limited accountability for achieving these improvements while caring for a defined population of patients.

ACOs may involve a variety of provider configurations, ranging from integrated delivery systems and primary care medical groups to hospital-based systems and virtual networks of physicians such as independent practice associations. All accountable care organizations should have a strong base of primary care. Hospitals should be encouraged to participate, because improving hospital care is likely to be essential to success. But in contrast to others’ definitions, we believe that this need not be an absolute requirement for all ACOs (Mark McClellan et al., “A national strategy to put accountable care into practice,” Health Affairs 2010;29:982-990).

Hmmmm....confused enough? Well, in my ongoing quest to simplify or "Englishify" everything, I'll take a stab at it in my own way. The basic premise of an ACO is this:

1. Improve Quality of Care

2. Reduce Cost

3. We will hold you accountable for 1 and 2. Simple enough? Not so fast....

Someone once told me, "if you ask a question once, you might look dumb. But if you don't ask it, you'll stay that way". So here are the questions:

1. Who is going to hold you accountable? (Let's say CMS)

2. How are they going to hold you accountable? (Let's say they come up with measures that you have to track and report)

3. Define "defined patient populations"? (This my friends, I have no idea what it means)

So my real question is, if they do come up with the answers to the questions above and define ACOs, is it an achievable goal? The answer is, Absolutely! Improving quality of care while reducing cost of care is a very achievable goal. In fact, you should do it before they make you do it! The technology exists today. All you have to do is take one look at our KnowledgePath report and go home happy knowing that you have the technology and reporting capabilities available at your fingertips.