Expert Q&A: ACOs continue to evolve

In 2011, the U.S. Department of Health and Human Services (HHS) released rules under the Affordable Care Act (ACA) in an effort to help healthcare delivery organizations, including doctors, hospitals, and other providers, cut costs by coordinating care using Accountable Care Organizations, or ACOs.

In 2014, there were 626 ACOs and 20.5 million lives covered, according to Leavitt Partners, and the number grew to 728 and 23 million lives covered in 2015. 2016 saw an increase to 838 with 28.3 million covered by an accountable care arrangement.¹ Leavitt Partners is a consulting firm created by Michael O. Leavitt, former head of HHS, to advise clients in the healthcare sector.

The value of ACOs is supported by several influential organizations in the healthcare industry. The National Association of ACOs says ACOs are proving to be one of the most promising solutions to bend the cost curve and provide high-quality patient care.

And in early 2017, the Centers for Medicare and Medicaid (CMS) implemented the Next Generation ACO Model. The model authorizes CMS, through its Center for Medicare and Medicaid Innovation (CMMI), to “test innovative payment and service delivery models that have the potential to reduce Medicare, Medicaid, or Children’s Health Insurance Program expenditures while maintaining or improving the quality of beneficiaries’ care.”

CMS also has released Accountable Care Organization 2017 Quality Measure Narrative Specifications.² The document presents the 31 quality measures that assess ACO quality performance and the quality performance stand­ard for the 2017 performance year for the Shared Savings Program and the Next Generation ACO Model.

CMS measures the quality of care using 31 nationally recognized quality measures in four key domains:

• Patient/caregiver experience (eight measures).
• Care coordination/patient safety (10 measures).
• Clinical care for at-risk population: Diabetes (two measures scored as one composite measure), Hypertension (one measure), Ischemic Vascular Disease (one measure), Depression (one measure).
• Preventive Health (eight measures).

But while there have been many success stories surrounding ACOs, there have been a number of failures too, particularly by early adopters and ACO mergers. The lofty goals of managing and delivering coordinated care have been hindered by the challenge of delivering coordinated care successfully without a strong data warehouse.

One of the largest stumbling blocks is the lack of shared IT systems that can gather the many sources of data records and systems. The effort to track patient behavior, their compliance to prescribed treatment regimens, care costs, and patient outcomes needs a strong set of tools to gather and analyze these patient records.

Health Management Technology talked with three sources of ACO tools that could help organizations with their ACO successes.

Q: There has been a lot of focus this last year on the lack of success in a number of ACOs. Why do you think they are failing, and how could your software tools help them succeed in 2017?

Some ACOs are falling short because they don’t have adequate technology partners. Many population health solutions only provide analytics, inundating ACOs with data that isn’t actionable and leaving them with marginally improved quality scores at costs that remain high. Moving the needle on cost and quality is extremely burdensome and requires services that can identify patients in need of care, create workflow efficiencies, engage patients and coordinate their care, and free up staff time and resources. This combination of analytics and services is why we refer to athenahealth Population Health as a comprehensive, end-to-end population health management service.

Q: Does your cloud-based platform integrate with your EHR platform as well as others?

All of athenahealth’s services, including our EHR, athenaClinicals, and athenahealth Population Health, are cloud-based and connect users to the athenahealth network. But most medical groups and healthcare networks managing patient populations need to connect to multiple data sources.

The athenahealth Population Health service helps organizations integrate complex amounts of data, including payer claims data; financial data from practice management systems; clinical data from laboratory providers; clinical and administrative data from disparate EHRs; patient and event information from urgent care or emergency facilities; and feeds from other consolidated sources like health information exchanges, enterprise systems, and other data warehouses.

Out of that complexity, we create a single source of truth and consolidated workflows in our “virtual desktop,” helping organizations gain insight into their data, and most importantly, take action.

Q: What quality measures does your service capture?

The quality measures are too vast to enumerate, but in short, we help organizations categorize and align patient data to the specific quality metrics for which they’re held accountable. athenahealth Population Health analyzes population data to generate quality reports for the National Committee for Quality Assurance, ACOs, specific payers (including Medicare), and even specific networks.

Q: How does your platform analyze shared risk benefits?

We stratify and identify gaps in care; provide care management tools to help care managers communicate with patients; consolidate workflows to help care teams coordinate care; and provide custom dashboards and analytics to track and manage costs, utilization, and outcomes. All of these tools help organizations analyze shared risks and benefits and make informed decisions.

Q: Do you have any success stories that you could share?

Organizations using athenahealth Population Health experience on average 55% lower cost growth than the industry average, 47% improvement in Medicare Shared Savings Program (MSSP) ACO quality scores, and a 16% improvement in network retention.

Q: Are there other benefits of your tools you would like to share?

We offer the industry’s only success guarantee for the Medicare Shared Savings Program (MSSP).

Q: Is your ACO Explorer designed to provide an analysis of patient trending? Can it help a hospital identify what portion of their population has potentially avoidable hospitalizations?

ACO Explorer helps monitor the overall trends in your at-risk populations. Monitoring patient trends falls under a broader umbrella of work that is critical to doing well in an ACO by managing high-cost and high-risk patients.

Health Catalyst provides a suite of care management tools (workflow and analytics) to support that effort. One of the five tools in that suite is called Patient Stratification, and it allows you to not only identify high-risk cohorts, but also to drill in to review individual patient trends.

We also are actively developing a tool called CAFÉ (Comparative Analytic Framework & Exchange) that helps customers prioritize opportunities across different areas of the health system. The tool allows participating members to compare outcomes metrics, detailed process metrics, and balanced metrics between health system organizations and national benchmarks in a de-identified manner, removing personal health information, but still keeping the clinical data. It can provide a collaborative framework for organizations to learn and share how they achieved their results by sharing what operational changes, clinical changes, and organizational changes were made.

Q: What quality measures does your platform capture?

Our goal is to provide a comprehensive measurement solution that supports your organization in monitoring performance against government, payer, and internal priorities. With Health Catalyst’s ACO Measures tool, you can drill into your performance on CMS regulatory measures, but you’re also equipped to build (or we can customize) payer-specific measures.

The capability to measure performance and drill into each measure anytime, not only after a required reporting period, provides the capability to identify inefficiencies and opportunities for improvement in a timelier manner.

Some of the standard measures we include that you’ll want to keep an eye on, regardless of payer, are things like high-cost imaging utilization, length of stay (LOS), admissions,
and readmissions.

And finally, by delivering standardized information about a group of patients who share a similar clinical condition or experience, your organization can provide care management teams a focused set of patients to work with. Registries are a key tool for monitoring cohorts of patients. We also provide standard cohorts out of the box with the capability to modify as you like.

For most organizations, cohorts are simply patients that fall within a specified group of administrative codes, such as ICD or CPT. But if you rely solely on administrative codes, you will find they often exclude patients who should have been included in the cohort and miss targeting them for a particular population health management strategy.

Q: How does your platform analyze shared risk benefits?

One of the most fundamental elements of being able to do a good analysis of your performance in a shared risk contract is to have the most complete data set that you can. Your analysis is only as good as your data.

By accurately discerning your per member per month (PMPM) performance, your organization can identify performance trends. The PMPM Analyzer tool allows you to look at a single contract or across all of them, so that you can identify worrisome trends, costly leakage, or major areas of utilization that you want to work to improve.

We’re also doing some really interesting work around bundled payment analytics and HCC optimization—you wouldn’t want to provide great care for a high-risk patient only to find that you’re not getting credit for it because you forgot to code them appropriately.

Q: Do you have any success stories that you could share?

Mission Health, North Carolina’s sixth-largest health system, recognized that the goals of ACOs were in alignment with its mission and formed an MSSP ACO called Mission Health Partners (MHP), which is responsible for 40,000 patient lives.

MHP knew that its manual approach to data collection and reporting would not be sufficient for the required ACO quality metrics. By leveraging a previously implemented enterprise data warehouse platform and applying an ACO MSSP analytics application, MHP was able to automate the processes of data gathering and analysis and align the data with ACO quality reporting measures.

The visibility and transparency of near real-time, online performance data coupled with focused process improvement have resulted in subsequent improvement in all of the ACO metrics, especially in the percentage of patients receiving the appropriate preventive screenings. Improvements have included a 9.6% increase in compliance over all reported ACO metrics, with more patients receiving recommended treatment or screenings. There also was a 40% increase in the number of patients receiving any cancer screening, including a 46% improvement in the number of patients receiving colorectal cancer screening. It also resulted in a 456% increase in the number of patients getting fall risk screening.

Another example: As one of the largest healthcare systems in the Upper Midwest, serving 41 communities with 13 hospitals and 61 clinics, Allina Health knew that if it could reduce LOS while continuing to deliver high-quality care, it could realize significant cost savings. Allina also recognized optimizing LOS was one of the key drivers of its inpatient financial performance.

They developed the technical infrastructure and analytic capabilities to understand LOS performance by the minute and not the day, adjust LOS to account for patient acuity and compare performance to national benchmarks, make LOS data available to clinicians across the organization in near real time, and estimate the financial impact of LOS opportunities to enable targeted interventions for improvement.

By establishing these analytics, Allina leveraged its enterprise data warehouse and analytics platform and optimized LOS, yielding the following results in the first two years of its improvement efforts: 26,000+ inpatient days saved, $13.4 million in direct operating expenses saved, hospital capacity (bed availability) created for 5,000+ admissions, adverse patient events avoided, and total cost of care reduced.

Q: Are there other benefits of your tools you would like to share?

One of the things that makes Health Catalyst unique in this space is that we’re not just about tools, we’re about outcomes improvement. We want to be a partner to you along that journey to improving outcomes and succeeding in these contracts, which is something that’s reflected in how we work with our clients, often taking risk right along with them to show commitment to the process.

Q: There has been a lot of focus this last year on the lack of success in a number of ACOs. Why do you think they are failing, and how could your software tools help them succeed in 2017?

ACO success is complex, and the right technology underpinning is imperative. We need to take a broader approach to value-based markets and alternative payment models and encourage the use of a connected care platform to exchange, share, and route information.

Payers and providers are still struggling to figure out how to access data, work collaboratively, and get actionable information to curb costs while improving outcomes for their shared patients. Access to clinical information from disparate data sources is still the Holy Grail for applications that drive change.

Q: InterSystems has created HealthShare to help with clinical integration, analytics, and care coordination. What are the most advantageous touch points for clinicians in choosing the best care for their patients? How does your platform analyze shared risk benefits?

InterSystems HealthShare is a set of solutions, built on a health informatics platform, which has helped a number of clients move the needle from volume to value. Key ingredients include risk stratification, care coordination, predicting future high-risk patients, and alerts that notify care team members based on events such as an ED admission or an inpatient discharge.

Q: Do you have any success stories that you could share?

New York-based Northwell Health’s internally developed Care Tool uses our technology to bring together clinical, claims, and other data from multiple settings. This enables care coordination and collaboration, which drives down cost and improves the health of their high-risk Medicaid patients.

Coordinate My Care (CMC) is a clinical service for urgent care plans, hosted by the Royal Marsden National Health System’s Foundation Trust in London. It helps patients and family think through and document their wishes for urgent care and end-of-life plans and then share those plans with care providers, such as ambulance services. Using HealthShare to automate this information sharing, CMC is helping patients across the London region achieve their goals. At the same time, costs associated with that care are declining.

Healthix, one the largest health information exchanges in the nation, also uses HealthShare to provide valuable services to healthcare organizations across the greater New York City area. An example of this is Brooklyn Health Home, a New York State Medicaid Health Home. Healthix supports early intervention in the care cycle for high-risk behavioral health patients by alerting care managers when patients are admitted into an emergency room.

Q: What quality measures does your platform capture?

In a Harvard Business Review article, Michael Porter and Thomas Lee, M.D., outline six components of a strategic agenda to “fix healthcare,” predicated on moving from volume to value. The sixth component—“build an enabling information technology platform”—highlights the need for patient-centered data that is accessible and sharable across all settings of care.
Moving from our current delivery system to models focused on patient-centered value, such as ACOs, is still in its early stages, and quality measures are still in the formation. However, focusing on Porter’s sixth pillar can help clients accelerate the journey.

REFERENCES

1. Muhlestein, D., et al, “Projected growth of accountable care organizations,” Leavitt Partners, December 2015. http://leavittpartners.com/2015/12/projected-growth-of-accountable-care-organizations/ [free registration required to view]
2. “Accountable Care Organization 2017 Quality Measure Narrative Specifications, CMS, January 2017. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/2017-Reporting-Year-Narrative-Specifications.pdf