Are you “ACO IT-Ready”?

First things first, I believe the push for accountable care is here to stay. I do not think that it is a fad that will come and go as many other attempts at healthcare reform have. Having said that, I also strongly believe that very few organizations are positioned to start realizing the benefits that will come from this reform any time soon. It’s not for lack of trying, as many organizations are already recognized as Pioneer ACO’s. But the hard part is not being established as an ACO – it’s proving you’re reducing costs and improving quality for targeted patient populations.

The first step will being January 1st, 2013. Some ACO’s will be required to start reporting quality measures – for instance the Shared Savings program from CMS for both the one-sided and two-sided models require reporting 33 quality measures. Notice I said “reporting”. So for the first year, it’s “pay for reporting”. Years 2 and 3 is when the rubber really meets the road and it becomes “pay for performance”. “Don’t just show me you are trying to reduce costs and improve quality, actually reduce and improve or realize the consequences.“

With ACO’s come reporting requirements. We in healthcare are used to reporting requirements. And those of us willing to publicly acknowledge it, more reporting means more waste. Why? Because there is job security in paying people to run around and find data…and to eventually do very little with it other than plug it in a spreadsheet, post it to a SharePoint site, email it to someone else, or well, you get my drift. Regardless of your view on these new requirements, they’re here to stay. So the $64,000 question is, are you ready to start reporting?

There is a wide range of both functional and technical requirements that healthcare providers and payers will need to address as they start operating as an ACO.  Many of the early and emerging ACOs have started the journey from a baseline of targeted patient panels to the optimized management of a population, progressing through a model with some or all of the following:

These are 7 simple questions you must be able to answer and report on DAY 1:

  1. Can you define and identify your targeted patient populations?
  2. Are you able to measure the financial and quality performance and risks of these patient panels and populations?
    1. Can you quickly, easily and consistently report quality and financial measures by Physician, Location, Service, or Diagnosis?
  3. Can you baseline your expenditures and costsassociated with various targeted patient populations?
    1. How will you benchmark your “before ACO” and “after ACO” costs?
  4. Can you accurately monitor the participation, performance and accountability of the ACO participants involved in coordinated, collaborative patient care?
  5. Will you be able to pinpoint where and when the quality of care begins to drift, so as to quickly intervene with care redesign improvements to limit the impacts on patients and non-reimbursable costs?
    1. Are you able to detect “patient leakage and provide your organization the information for its’ management? (Patient leakage is when a patient that you are treating as an ACO for a bundled payment, leaves the network for their care)
      1. Is a particular provider/provider group sending patients outside of the ACO?  If so, is it for a justified reason?
      2. Does the hospital need to address a capacity issue?
  6. Can you reconcile your internal costs of care with bundled reimbursements from payers?
  7. Are you positioned for population health management and achieving the Triple Aim on a continuing basis?

In order to answer these questions you must have a highly integrated data infrastructure. It seems I’m not the only one who agrees with this tactical first step:

  • The Cleveland Clinic Journal of Medicine agreed as it listed as one of its’ 5 Core Competencies Required to be an ACO “Technical and informatics support to manage individual and population data.”
  • Presbyterian Healthcare Services (PHS) has been a Pioneer ACO for over a year. Tracy Brewer, the lead project manager was recently asked by Becker’s Hospital Review, “What goals did you set as an ACO in the beginning of the year and how have you worked to achieve them” and her answer – “One of the major ones [goals] was updating our administrative and IT infrastructure. We had to make sure we had all the operational pieces in place to function as ACO. We also completed some work on our IT infrastructure so that once we received the claims data from CMS, we could begin analysis and really get value from it.”

The ACO quality measures require data from a number of different data sources. Be honest with me and yourselves, how confident are you that your organization is ready? Is your data integrated? Do you have consistent definitions for Providers, Patients, Diagnosis, Procedure, and Service? If you do, great you don’t have much company. If you don’t, rest assured there are organizations that have been doing data integration for nearly two decades that can help you answer the questions above as well as many more related to this new thing they call Accountable Care.

What I Learned Last Week in Cambridge, MA at the World Congress Health Care Quality Conference

The subtitle for last week’s conference was “Moving from Volume to VALUE Based Care”. The theme’s that emerged from the speaker panels, presentations, and one-off conversations I had seemed well aligned:

  1. Healthcare is currently experiencing a paradigm shift from the traditional provider-centric mentality to that of a patient-centric framework
  2. One of the biggest challenges providers face in the pursuit of higher quality is figuring out how to appropriately leverage all of the data they’re currently collecting, manually and electronically
  3. Emerging opportunities for reigning in costs and improving quality including ACO’s, AQC’s, PCMH’s, and others will only be effective if there are standards for implementation and measuring effectiveness consistently across the country
  4. There are a handful of healthcare providers and payers who have taken significant strides in controlling costs while improving quality by implementing technology solutions that integrate data from across the continuum of patient care.

I was encouraged by the level of enthusiasm in the room. Dr. Allan H. Gorroll from Massachusetts General Hospital and Harvard Medical School made it clear that advancing the quality agenda will require significant investments in primary care; Dr. Kate Koplan spoke about Atrius Health’s push to reduce the problems of over testing and unnecessary treatments; Dr. John Butterly from Dartmouth Hitchcock Health discussed the Patient Centered Medical Home (PCMH) and suggested to all providers that they “have a patient on the team responsible for understanding how to establish the PCMH”; and Micky Tripathi the President and CEO of Massachusetts e-Health Collaborative mentioned the challenges of turning data into actionable information with problems like free text data, inconsistent data collection across care settings and the fear many clinicians have of “change” getting in the way.

I too was a co-presenter at the conference and was delighted by the response to our presentation. My counterpart Neil Ravitz, Chief Operating Officer for the Office of the Chief Medical Officer at the University of Pennsylvania Health System, and I discussed a recent solution we designed and implemented. We were able to automate the collection, integration, calculation, presentation and dissemination of 132 inpatient safety and quality measures across 3 hospitals and 7 source application systems. This new tool consolidates measures from across these hospitals and systems into one place for reporting and analysis through the use of dashboards and dynamic, drill down reports. The major benefits of the solution include:

  1. Changed the focus of quality and decision support analysts from data production to data analysis and action;
  2. Automated quality data collection to enable better accuracy and more timely data; and
  3. Enabled a faster quality improvement cycle time by front line leaders

Dr. Atul Gawande recently suggested in an article in the New Yorker that healthcare should be prepared to start implementing standards for nearly all of the care delivered, from total hip replacements to blood transfusions. As we all know, he is a fan of checklists, one logical tool for standardization. He also states, “Scaling good ideas has been one of our deepest problems in medicine”. When I attend healthcare conferences like the one last week in Cambridge, I’m excited by the progress I see organizations making. When I leave the conference though, I’m quickly reminded of the grim reality of healthcare and Dr. Gawande’s point. And then I wonder, at what point will “patient centric”, “accountable care”, “value based purchasing” and all the other catch phrases of the past few years become the industry standard – and not the exception limited to conferences, New Yorker magazines, and headlines that are only ever heard or read, and rarely ever experienced.