The Centers for Medicare & Medicaid Services (CMS) states one in four Americans – and two out of three over the age of 65 – has multiple chronic conditions. These account for 93 percent of Medicare’s fee-for-service expenditures, and efforts to better coordinate their care were the impetus for the Department of Health and Human Services (HHS) to lay the framework for accountable care organizations (ACOs) on March 31, 2011.
According to CMS, “ACOs are groups of doctors, hospitals and other healthcare providers who come together voluntarily to give coordinated, high-quality care to the Medicare patients they serve. Coordinated care helps ensure that patients, especially the chronically ill, get the right care at the right time, with the goal of avoiding unnecessary duplication of services and preventing medical errors. When an ACO succeeds in both delivering high-quality care and spending healthcare dollars more wisely, it will share in the savings it achieves for the Medicare program.”
Healthcare.gov states that, each year, one in seven Medicare patients admitted to a hospital has been subject to a harmful medical mistake in the course of his or her care. And nearly one in five Medicare patients discharged from the hospital is readmitted within 30 days – a readmission many patients could have avoided if their care outside the hospital had been aggressive and better coordinated.
“This is one of the most exciting and important elements of the Affordable Care Act when we think about the goal of transforming American medicine into the kind of care that we want for ourselves and our loved ones,” says Don Berwick, former CMS administrator and one of the architects of ACOs. “American medicine is fragmented right now – you get lost in the slats – because we built the system that way, we pay for it that way, we train for it that way and institutes manage themselves separately. That’s not what patients need. We want continuity and seamlessness.”
Berwick is often credited with coining the term “Triple Aim,” which refers to establishing better health and better care at a lower cost. He says components of an ACO should include:
“We don’t want them skimping on care,” Berwick says. “The ACO has 33 measures of care we’re going to watch very closely.”
According to an analysis of the proposed regulation for ACOs, Medicare could potentially save $960 million over three years.
Here’s what out experts had to say on the topic.
|Oleg Bess, M.D.,
founder and CEO, 4medica
MPIs help ACOs avoid population identity crises
Individual identity is critical in an accountable care organization. As if tracking a single patient within a hospital wasn’t hard enough, in an ACO, “individual” doesn’t always mean patient, and hospitals are part of much larger care continuums.
Big organizations generate and manage big data to deliver the right point-of-service care to the right patients in the right care setting. Doing that reliably calls for bringing big data down to the level of individual patient information, where it can help drive better quality of care and validate it for optimum reimbursement.
Master patient indexes (MPIs) are the traditional solution to matching patients with their information. As the link that tracks an individual’s activity within an organization and across the continuum of care, the MPI is an even more important resource in an ACO. Whether the MPI exists at the single-system, facility, enterprise or HIE level, standards and interoperability are key to building and maintaining it. As such, it demands active data stewardship, data governance and many collaborative processes.
Traditional MPIs, however, aren’t designed for the increased array, amount and alacrity of the big data that comes with ACOs. They simply are too expensive, too slow and too inaccurate. Today’s patient-centric ACO needs a new kind of MPI, able to process huge amounts of data to link the activities of all individuals – patients, providers or health plan members – to coordinate care within the organization and across the continuum.
|Charles Kennedy, M.D., CEO,
Accountable Care Solutions
Building a technology framework for ACO success
A major difference between today’s accountable care models and the HMOs of the 1990s lies in the technology available to share patient information, coordinate across different care providers and better involve patients. Without the right technology, providers will be unable to enhance proactive, population-based medicine.
Deploying health information technology that allows the care team to share and act on patient information among disparate care providers is crucial. Technology supports a team-based approach to care in other ways, including:
Advanced analytics to identify and manage risk. The right analytics help flag at-risk individuals and find gaps in care. As a result, organizations can make more targeted interventions, assess overall performance and improve care.
Real-time clinical analytics at the point of care. Integrating clinical and claims data and analyzing it for consistency with individualized evidence-based recommendations helps providers improve an individual’s care and can improve provider productivity through an easier understanding of the patient’s history.
Patient engagement tools. Online and mobile applications support patients between office visits and promote healthy lifestyles. These tools help encourage individuals to use the healthcare system efficiently, make lasting health improvements and better manage their chronic conditions.
The right type of data-sharing platform enables providers to better monitor and manage chronic conditions, deliver timely preventive care and improve outcomes. Together, these technologies deliver vital information how and when it is needed most. With access to actionable, real-time insight, every member of a patient’s care team can achieve the triple aim: improved quality, lower costs and a better patient experience.
|Jay Spence, VP of product and industry solutions,
Data analysis key to successful ACOs
Given the recent shift to affordable care and other value-based models, determining the cost of care is more important than ever. Finance execs at healthcare organizations across the country are feeling the pressure to revamp accounting and budgeting strategies so that they can operate more efficiently while effectively curbing costs associated with an ACO model. Traditional methods of financial planning, accounting and budgeting are simply insufficient because they are inadequate in measuring the true cost of care at the patient level.
More finance teams are questioning how their team can support their organization and overcome the challenges associated with the shift to value-based care and ACO models. Finance teams must shift their time away from tedious data aggregation functions and spend more delivering value-added analysis, identifying trends and using analytics to advise business decisions that impact profitability. Finance teams are turning to technology to help them streamline and automate budgeting, planning and costing processes, focusing on analysis and initiatives to reduce costs.
Effectively using service-line volume, costs and profitability metrics to support strategic business decisions are becoming requirements to supporting cost-containment initiatives and maintaining or even growing profitability. Hospitals are using this data to formulate integrated business planning across their lines of service and influence revenue, reimbursements and, most commonly, operational plans. Organizations relying heavily on data and analysis to better determine the true cost of care are making better decisions and are able to control costs without impacting the quality of care, an important step to participating in an ACO.
|Philip Spinelli, senior VP,
Redefining the source of care management delivery
The Accountable Care Act is driving significant change within the healthcare industry. To thrive in this new landscape, healthcare payers will need to redefine the source of care management delivery. They should put in place the proper IT infrastructure to facilitate care coordination and population health management, and interact with patients in an effort to manage costs more effectively.
As payers move to embrace the ACO model and drive patient engagement, a critical success factor will be the ability to deliver fully integrated data, in real time, for immediate insight. This will create the single consolidated view of patient data that is required to achieve the maximum benefit in terms of quality of care, patient safety and reduction in healthcare expense.
Additionally, payers will need to optimize the core capabilities needed to facilitate this changing care management model. This will include registering and managing a population as a defined entity or group, using predictive modeling to identify, stratify and prioritize care within that population, manage chronic disease rates, engage the patient, coordinate patient care among multiple professionals and regions or facilities, and provide access to evidence-based medicine guidelines and knowledge in real time.
The ability to integrate data into a single view and provide true insight in real time will be the key differentiators in today’s environment and thus fuel the need to modernize systems. Organizations that can implement this infrastructure quickly will have a strategic advantage over those that take a longer or more staged approach.
|Katherine Schneider, M.D., executive VP and CMO,
Three pillars for ACO success: strategy, people and technology
Hospitals moving toward becoming an ACO need to answer the following question: Is the ACO a service line within the hospital, or is the hospital a service line within the ACO? The answer determines your structure – from the right strategy and people to the right technology.
The first structural pillar of a successful ACO is strategic alignment. Simply put, your ACO strategy must change how you do business for the long term, to the ultimate benefit of patients. Therefore, aligning the right ACO strategy with organizational goals to transform care quality and cost effectiveness is critical.
The second pillar centers on people. To build a successful ACO, educate key people on the ACO strategy, and in alignment with that strategy, be sure you are measuring what matters to them. Additionally, ask providers if the data being captured contributes in a meaningful way to the outcomes you’re trying to achieve – for processes and patient care. Finally, gain buy-in from a leader who champions the ACO strategy, early adopters who embrace the change and a patient/family advisory council to provide user insight. A good litmus test of your success is the difference patients – not providers – feel as participants in your ACO. When done right, patients will notice a change for the better.
The third pillar hinges upon using the right technology to improve business and clinical decisions. Yet technology should not drive changes in patient care. Instead, patient care must drive innovation in technology, as it is only useful if it solves meaningful patient problems.
A successful ACO is all about improvement through measurement, so step back and look at your ACO in a non-traditional way. That way, through your strategic goals, people and technology, you can be sure you are measuring what matters.
Five tips for successful accountable care
The excessive costs of healthcare and regulatory reform are changing the way healthcare is delivered and paid for in the United States. Patient engagement efforts have become increasingly important to the financial sustainability and clinical success of physician practices, and as healthcare organizations move toward an accountable care model. Here are ways they can succeed:
- Formalize the organizational structure. Establish processes to promote quality of care, report on costs and coordinate care. Determine a governance and management structure for decision making, and legalize how the team plans to work together, get paid and develop the operational plan relative to technology.
- Design an effective workforce. The ability to design and allocate a healthcare workforce is critical to an ACO. The ACO must manage physicians’ patient workload (empanelment) and encourage productivity in a team-based incentive structure so that all stakeholders are aligned in achieving the triple aim.
- Invest in technology. Hospitals and physician practices today are realizing the true potential of technology in changing the way both physicians and patients approach disease management. Assuming that physicians have already implemented an electronic medical record (EMR) system, ACOs need to invest in technologies that help identify gaps in care, align the physician and the patient, and monitor patient adherence and compliance. Together, these tools can help an ACO coordinate care more meaningfully and sustainably.
- Know your population, manage your risk. Managing risk is a vital element to the financial sustainability of the ACO, and as organizations move toward value-based models, the patient outcome will have direct correlation to the economic health of the organization. It will be important for physicians to be able to stratify their population of patients to know how to prioritize the time and attention of care team resources to drive improved patient outcomes.
- Engage patients in care. Physicians must understand that it is important to engage patients throughout the care continuum to help streamline care management and improve health outcomes. Patients who are involved in decision making about their health are more likely to become active in their healthcare, thus preventing hospitalizations and readmissions downstream. Patient engagement efforts have become increasingly more important to the financial sustainability and clinical success of physician practices.
|Kenneth Bradberry, chief technology officer, healthcare provider solutions,
Integrity assurance in EMR systems
Assuring the security integrity of any EMR system is non-negotiable.
For providers, it means maintaining a mindset toward the absolute security and integrity of the EMR, from design through implementation.
When you look at an EMR environment, there are a variety of areas that, if not designed properly, can create many of the issues we’re trying to avoid. These include incorrect firewall rules, putting the wrong content management system in place and other things that could open up security breaches.
And in addition to traditional security issues, there’s also another question that undoubtedly arises: Will my system be available? There isn’t a huge difference between an intruder accessing the network and denying service, and environmental crashes because of a misconfigured system; the latter results in a denial of service just as if it came from a security threat. The key is to incorporate all of these potential issues into a level of service that ensures the system is reliable and secure for the entire lifecycle.
The integrity of the system is also critical to a healthcare provider’s bottom line. If these organizations don’t trust their EMR systems, physicians won’t use them; it’s as simple as that.
That’s why there needs to be a strong focus not only on the integrity of the environment, but also on training and understanding the system.
What are at stake are a healthcare provider’s investment and the patient’s quality of care. Without proper controls, you have a system that loses a large percentage of adoption – leading to challenges that are going to affect the hospital’s bottom line and its ability to attract top talent.
|Roberta Katz, director,
healthcare solutions, EMC
Big data: An answer to accountable care
As healthcare providers shift to accountable care, broader networks of caregivers need to share data for patient care diagnosis. This collaboration necessitates the breakdown of traditional stovepipes, with big-data analytics playing a strategic role in meeting accountable care goals. There’s serious opportunity here: McKinsey estimates the annual potential value of big data is $300 billion.
Big data can be characterized by four “V’s”:
- Variety. EMR plus 100+ additional applications with unstructured and semi-structured data found in PACS, clinical research, doctors’ notes, pathology reports and more.
- Volume. Advanced medical imaging is big data. Providers are moving toward perpetual archiving, generating a rich payload of metadata embedded in these images.
- Velocity. Next-generation RFID providing continuous tracking to streamline patient flow, enable a better patient experience, lower supply inventories and reduce theft.
- Value. Providing fact-based answers to questions ranging from which therapeutic approaches work best, which patients are at highest risk for readmission, to physician performance in relation to quality and cost.
IT must too evolve. Approximately 75 percent of IT budgets are spent supporting legacy systems – just keeping the lights on. Providers are looking to implement more agile, flexible IT models delivered as a service to lower costs and free time to focus on the real innovation needed to make the transformation to accountable care. At the center of all this is the analysis of data coming from the many sources across the continuum of care required to further improve patient care outcomes, readmissions, population management and business intelligence. Big data is the answer.