ACCOUNTABLE CARE ORGANIZATION (ACO): SUPPLYING DATA AND ANALYTICS TO DRIVE CARE COORDINATION, ACCOUNTABILITY AND CONSUMER ENGAGEMENT

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1 ACCOUNTABLE CARE ORGANIZATION (ACO): SUPPLYING DATA AND ANALYTICS TO DRIVE CARE COORDINATION, ACCOUNTABILITY AND CONSUMER ENGAGEMENT MESC 2013 STEPHEN B. WALKER, M.D. CHIEF MEDICAL OFFICER

2 METRICS-DRIVEN SYSTEM OF CARE Background Medicaid Initiatives Information Thirsty ACOs: Language 2013 CNSI 1

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4 NO ACO ROADMAP? 2013 CNSI 3

5 1990s- INTEGRATED DELIVERY NETWORKS FAILURE IDN failures are still palpable to many healthcare leaders, many of whom may point to accountable care organizations and say, "déjà vu." A new study published in November 2012 issue of Health Affairs compares ACOs with integration efforts in the 1990s, finding ACOs will fare best if they are not oversold as the silver bullet. Like IDNs, unclear of ACO capabilities: Achieving Triple AIM population health consumer experience affordability Provider organizations executing Sustainability 2013 CNSI 4

6 CHARACTERISTICS Integrated Delivery Network (IDN) (1990s) Vertically consolidating networks linking physicians, hospitals and alternative care sites Hospitals purchasing physician practices, creating joint ventures with medical staff and physicianhospital organizations Coordinating care using employed or contracted primary care physicians as well as disease management programs and capitated risk contracts Accountable Care Organization (ACO) (Today) Networks of providers assuming risk for quality and total cost of care deliver Medicare focus, spreading to commercial and Medicaid Health care information technology Disease management programs (metrics-driven) Care coordination (enhanced) Aligning payors, physicians and hospitals incentives for via shared savings Non-physician providers - nurse practitioners and other health professionals Patient-centered medical homes (care coordination) Pay-for-value 2013 CNSI 5

7 SOME LESSONS LEARNED FROM THE 1990s Wrong assumption - hospitals can control the referrals of physician practices they acquire Performance and market data matters only if you act on them Too much too quickly. First mover advantage often comes with a sea of red ink Timing is a critical element in implementation plans Overestimating economies of scale and costs savings Patience and cash are requirements for new models Relied on structural integration to achieve results resulting in no integration from consumer perspective For integration to have value, must have integrating clinical delivery processes and sound financial business mode Poor management competencies and culture shock A good idea is not a competitive advantage need change management, six sigma, etc. Misalignment of incentives of new partners Realigning incentives needed to make value-based contracting work Value equation did not resonate with payers (reduced cost) or with consumers (added engagement) Ultimately, what customers want really does matter 2013 CNSI 6

8 2013 CNSI 7

9 REGULATORY CMS (November 2, 2011) finalized new rules under the Patient Protection and Affordable Care Act (Affordable Care Act) Help doctors, hospitals, and other health care providers better coordinate care for Medicare patients through Accountable Care Organizations (ACOs) Section 3022 of the Affordable Care Act added a new section 1899 to the Social Security Act that requires the Secretary to establish the Shared Savings Program Medicare Shared Savings Program (Shared Savings Program) will reward ACOs that lower their growth in health care costs while meeting performance standards on quality of care and putting patients first. Participation in an ACO is purely voluntary 2013 CNSI 8

10 ELIGIBILITY REQUIREMENTS FOR AN ACO Final rule defines an ACO as: group of providers and suppliers of services (e.g., hospitals, physicians, and others involved in patient care) working together to coordinate care for the Medicare Fee-For-Service beneficiaries Goal of an ACO is to deliver seamless, high quality care for Medicare beneficiaries, instead of the fragmented care that has so often been part of Fee- For-Service health care The ACO will be a patient-centered organization where the patient and providers are true partners in care decisions ACOs are part of traditional Medicare Fee-For-Service Program and beneficiaries continue to have ability to choose any provider The final rule calls for Medicare to assess the ACO s quality and financial performance based on a population s use of primary care services Does NOT involve member enrollment 2013 CNSI 9

11 MEDICARE OFFERS SEVERAL ACO INITIATIVES Types: Medicare Shared Savings Program - a fee-for-service program Advance Payment Initiative - for certain eligible participants in the Shared Savings Program Pioneer ACO Model - population-based payment initiative for health care organizations and providers already experienced in coordinating care for patients across care settings 2013 CNSI 10

12 Why We May Be Successful This Time 2013 CNSI 2013 CNSI 11

13 ACO DELIVERABLES Information must: Relevant Real-time (close to) (infrastructure building) provide quality at point of the encounter influence a caregiver s treatment path Omnipresent Formula for ACO success (Health IT prospective) Care delivery Integration (analytics connectivity across whole ACO system of care to improve collaboration) Population health management 2013 CNSI 12

14 MEDICAID ACO DELIVERABLES July 10, 2012 Center for Medicaid and CHIP Services Letter RE: Policy Considerations for Integrated Care Models Dear State Medicaid Director: n Guidance on designing and implementing care delivery and payment reforms that improve health, improve care and reduce costs within Medicaid programs n Catalyzed by new opportunities in the Affordable Care Act, payers and providers are embarking on ambitious delivery system reforms that move from volume-based, fee-for-service (FFS) reimbursement to integrated care models with financial incentives to improve beneficiary health outcomes n Flexibility of federal authorities can help facilitate state innovation goals through Medicaid care models that place beneficiary health at the center of delivery systems 2013 CNSI 13

15 MEDICAID ACO DELIVERABLES Using term Integrated Care Models (ICMs) to describe these initiatives, which may include (not limited to) medical/health homes, Accountable Care Organizations (ACOs), ACO-like models and other health care delivery and financing models Emphasize person-centered, continuous, coordinated and comprehensive care Guidance is to describe policy considerations and relevant statutory authorities for implementing ICMs A state plan option to facilitate the efforts of states that wish to pay for quality improvement in FFS programs without a waiver PATHWAYS TO ICMs To implement ICMs within Medicaid programs, states may seek to explore new initiatives or enhance existing efforts under a Medicaid state plan, or use demonstration or waiver authority Existing Medicaid authorities allow states the opportunity to implement ICMs on a statewide basis or through a more limited approach based on geographic area, individual needs or through selective provider contracts 2013 CNSI 14

16 EMERGING MEDICAID ACCOUNTABLE CARE ORGANIZATIONS: THE ROLE OF MANAGED CARE Most Medicaid ACOs are currently at an early stage of development, as states engage in relatively lengthy planning and implementation processes, both to accommodate diverse stakeholder concerns and to address state and federal legislative and regulatory requirements The structure of Medicaid ACO initiatives is influenced by individual states history and experience with managed care, other existing care delivery arrangements within Medicaid, and the challenges inherent in serving low-income and chronically ill populations While Medicaid ACOs are a strategy to more directly engage providers and provider communities in improving care, cost-containment is also a significant motivating factor for many states It remains to be seen how states will balance short-term cost-containment pressures against investments in partnerships and delivery system redesign necessary for the success of Medicaid ACOs over longer term 2013 CNSI 15

17 EMERGING MEDICAID ACCOUNTABLE CARE ORGANIZATIONS: THE ROLE OF MANAGED CARE Little analysis of how current Medicaid context, including unique profile of populations program serves and delivery systems in place today, may influence development of ACOs in Medicaid. How ACOs may be structured and fit into states Medicaid programs, and to identify important differences between Medicaid ACOs and ACOs in Medicare and the private insurance market Previous analyses have sought to define Medicaid ACOs and discussed how states can promote their development 2013 CNSI 16

18 MEDICAID AND CHIP (MAC) LEARNING COLLABORATIVES (CMS) established the Medicaid and CHIP Learning Collaboratives (MAC Collaboratives) to achieve high-performing state health coverage programs, a goal that requires a robust working relationship among federal and state partners Collaborative workgroups, each consisting of six to 10 states plus federal partners and national experts, are addressing topics that are critical for establishing a solid health insurance infrastructure Collaborative focus areas and broad goals: Exchange Innovators in Information Technology Expanding Coverage Federally Facilitated Marketplace Eligibility and Enrollment Data Analytics: Encourage states to consider most effective approaches for performance measurement and data analytics to support program operations Promoting Efficient and Effective IT Practices: Enable states to design and efficiently develop IT infrastructure that supports high performing Medicaid programs, reducing total cost of ownership, project risk, and cycle time for new products and capabilities while improving business results. Value-Based Purchasing: Focus on building and financing the next generation of: (1) enhanced primary care case management and fee-for-service models, referred to as "integrated care models"; (2) innovative managed care purchasing strategies; and (3) managed care contracting mechanisms to ensure seamlessness across the new exchanges 2013 CNSI 17

19 VALUE BASED PURCHASING: MANAGED CARE INNOVATIONS The Value-Based Purchasing: Managed Care Innovations MAC Collaborative is working with state participants to design the next generation of contracting requirements for managed care organizations Collaborative activities are helping states to become more sophisticated purchasers of care by sharing strategies and identifying barriers and challenges to effective purchasing The collaborative is exploring: (1) innovative state contracting strategies; (2) alignment of Medicaid managed care with new integrated care models (accountable care organizations, health homes and patient-centered medical homes); (3) and value-based purchasing trends in private sector Participants will also address integration of complex populations into riskbased managed care, including individuals using long-term supports and services and behavioral health services, as well as federal and state program integrity and oversight of Medicaid managed care programs. Collaborative activities began in October CNSI 18

20 INTEGRATED CARE MODELS IN MEDICAID: CONCEPT Medicaid agencies facilitating design and development of new integrated care models (ICMs) Value-Based Purchasing Medicaid & CHIP Learning Collaborative worked with CMS to develop this concept development toolkit. The toolkit is intended to help states conceptualize and articulate key concepts for proposed ICM programs States not required to use this toolkit as part of formal state plan amendment or waiver process It can assist states in thinking through ICM policy and reimbursement considerations and facilitating more efficient conversations with all stakeholders 2013 CNSI 19

21 2013 CNSI 20

22 NEW MEDICAL LANGUAGE Terms related to terminology include: Administrative code sets Clinical code sets Reference terminologies Interface (Fusion) terminologies Disconnect Between Clinician Language & Coding Sets 2013 CNSI 21

23 ADMINISTRATIVE & CLINICAL CODE SETS Administrative code sets Support administrative functions of healthcare Reimbursement and other secondary data aggregation. n International Classification of Diseases (ICD) and the n Current Procedural Terminology (CPT) n Each system is fundamentally different n ICD's purpose is to aggregate, group, and classify conditions n CPT is used for reporting medical services and procedures. Clinical code sets Encode specific clinical entities involved in clinical work flow, such as LOINC and RxNorm. Allow for meaningful electronic exchange and aggregation of clinical data for better patient care. Sending a laboratory test result using LOINC n Facilitates receiving facility's ability to understand result sent n Making appropriate treatment choices based upon laboratory result 2013 CNSI 22

24 REFERENCE TERMINOLOGY In general, reference terms are useful for decision support and aggregate reporting and are more general than the highly detailed descriptions of actual patient conditions Example, one patient may have severe calcific aortic stenosis and another might have mild aortic insufficiency; however, a healthcare enterprise might be interested in finding all patients with aortic valve disease. The reference terminology creates links between "medical concepts" that allow these types of data queries An important aspect of a well-constructed terminology is a concept, typically granular by nature and defined as "a unit of knowledge or thought created by a unique combination of characteristics" Example of SNOMED CT Hierarchy Relationship SNOMED CT is an example of a reference terminology, a concept-based kind of terminology. Below is an example of the aortic valve hierarchical relationship in SNOMED CT CNSI 23

25 PATIENT CENTERED CARE DELIVERY Interface (Fusion) Terminology makes Standardized Health Information possible Terminologies ensure that the 'languages of medicine' can be understood by both humans and machines Electronic health records (EHRs) are the industry standard for documenting patient care Industry initiatives and government legislation have facilitated EHR implementation and use. Most notable among them is the Health Information Technology for Economic and Clinical Health Act (HITECH) legislation, which incentivizes providers toward implementation and demonstration of meaningful EHR use 2013 CNSI 24

26 INTERFACE TERMINOLOGY ARCHITECHTURE Clinical Workflow Clinicians interact with interface terminology when documenting diagnoses and procedures in the patient's electronic record Physician performs searches using search functionality in designated locations in the EHR, which returns terms to provider to select the appropriate problem or procedure Physician selects the appropriate term to capture the clinical intent. The term(s) populate predetermined fields in the electronic record Selected term contains mappings to one or more industry standard terminologies, such as ICD or SNOMED CT Behind-the-scenes" mappings allow physician to focus on patient care while at the same time capturing necessary administrative and reference codes Each EHR vendor determines which codes are actually stored in the patient's record By storing the interface terminology code, an EHR can always retrieve most upto-date administrative and reference codes 2013 CNSI 25

27 2013 CNSI 26

28 ACO MEDICARE QUALITY MEASURES Under CMS ACO initiatives, before an ACO can share in any savings created, it must demonstrate that it met the quality performance standard for that year. CMS will measure quality of care using nationally recognized measures in four key domains: Patient/caregiver experience (7 measures) Care coordination/patient safety (6 measures) Preventive health (8 measures) At-risk population: Diabetes (1 measure and 1 composite consisting of five measures) Hypertension (1 measure) Ischemic Vascular Disease (2 measures) Heart Failure (1 measure) Coronary Artery Disease (1 composite consisting of 2 measures) The 33 quality measures are provided at-a-glance. For each measure, the table includes 1) the ACO measure number, 2) its domain of care, 3) the title of the measure, 4) its measure steward and National Quality Forum number (if applicable), 5) the method of data submission, and 6) when the measure is subject to pay-for-reporting versus pay-for-performance 2013 CNSI 27

29 MEDICAID HEALTH HOME CORE QUALITY MEASURES Health home provision authorized by section 2703 of the Affordable Care Act provides an opportunity to build a person-centered care delivery model that focuses on improving outcomes and disease management for beneficiaries with chronic conditions and obtaining better value for state Medicaid programs CMS is sharing a recommended core set of health care quality measures for assessing the health home service delivery model Health Home Core Quality Measures Adult Body Mass Index (BMI) Assessment Ambulatory Care - Sensitive Condition Admission Care Transition Transition Record Transmitted to Health care Professional, Follow-up after Hospitalization for Mental Illness Plan- All Cause Readmission Screening for Clinical Depression and Follow-up Plan Initiation and Engagement of Alcohol and Other Drug Dependence Treatment Controlling High Blood Pressure 2013 CNSI 28

30 STAY THE COURSE 2013 CNSI 29

31 THANK YOU! Corporate Office: Gaither Drive Gaithersburg, MD t: f:

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