1 Accountable Care Organizations: Evidence is Essential for Success Susan A. Levine, DVM, PhD Senior Vice President, Health Technology Research and Consulting Winifred S. Hayes, PhD President and CEO 157 S. Broad Street, Lansdale, PA Copyright 2011 Winfred S. Hayes, Inc.
2 Contents Introduction... 3 Definition of ACOs... 3 Goals of the ACO Model... 3 Essential Elements... 4 Evidence resources... 4 Commitment to evidence-based practice... 4 Functional health information technology (HIT)... 5 Quality measures... 6 Summary... 6 Information on Hayes... 6 Bibliography
3 Introduction Hayes, Inc. is a company founded on the concept that the use of evidence as the foundation for healthcare decisions will lead to an improvement in the quality, consistency, and overall cost effectiveness of healthcare. We are encouraged to note that a number of healthcare delivery models that incorporate evidence-based practice are being introduced and evaluated. We also understand the challenges that these new care delivery approaches will encounter and offer some thoughts related to the use of evidence in one of these models, accountable care organizations (ACOs). Definition of ACOs The Patient Protection and Affordable Care Act, commonly known as the health reform law, includes a provision that encourages the formation of accountable care organizations (ACOs) as a method of healthcare delivery system reform (Title III, Subtitle A, Part III, 3022 [Medicare shared savings program]). 1 An ACO is a network of service providers and suppliers that share responsibility for providing and coordinating care to Medicare fee-for-service beneficiaries. In the new law, an ACO would agree to manage all of the healthcare needs of a minimum of 5000 Medicare beneficiaries for at least 3 years. The ACO model includes the concept of value-based purchasing, in that providers of healthcare are accountable for both cost and quality of care. In theory, if physicians and hospitals work together to coordinate care for patients and to avoid unnecessary tests and procedures, they can reduce healthcare costs, while improving the quality of care that patients receive. Goals of the ACO Model The goals of the ACO model are to: o Improve quality of care for individuals o Improve health of populations o Reduce growth in healthcare spending ACOs are supposed to provide patient-centered healthcare, engaging patients in shared decision making and respecting individual preferences. To achieve these goals, ACOs are required to implement evidence-based medicine or clinical practice guidelines and processes. The guidelines and processes must cover diagnoses with significant potential for the ACO to achieve quality and cost improvements, taking into account the circumstances of individual beneficiaries. All ACO participants and 3
4 suppliers/providers must agree to abide by these guidelines and processes, and will be evaluated for their compliance. Essential Elements Evidence resources For the ACO evidence requirement to be feasible and effective, a number of elements are essential. First and foremost, it will be critical for providers to have access to sources of credible and objective evidence about what tests and treatments work. The evidence must be current and must be comprised of the best available clinical studies. Comparative effectiveness reviews that provide conclusions about which test or treatment options are the most accurate or offer the most benefit will also be essential, since much of medical practice involves selecting the right care option for the individual patient. There are a number of different sources of evidence and ACOs should be given some latitude in selecting the specific resources that are most useful in supporting evidence-based practice. However, it is imperative that these resources be current, unbiased, comprehensive, and based on synthesis of high-quality evidence. Recently, several studies evaluating nominally evidence-based clinical practice guidelines have concluded that the evidence base for these guidelines is weak or nonexistent. 2,3 Therefore, it is not sufficient to simply state that evidence sources and clinical practice guidelines are being used; these resources must meet accepted standards of quality. 4,5 In some cases, there will be insufficient clinical evidence to know if a certain diagnostic, therapeutic, or preventive intervention works, or to know what works best for a patient s condition. In those cases, the healthcare provider must rely on practice experience and clinical judgment until the questions can be answered by research studies. Given the emphasis currently being placed on comparative effectiveness research and patient-centered outcomes, there should be a mechanism by which ACOs and other entities committed to evidence-based practice can alert organizations such as the Agency for Healthcare Research and Quality (AHRQ) and the Patient Centered Outcomes Research Institute (PCORI) to these evidence gaps. Commitment to evidence-based practice Adequate evidence and an accessible high-quality evidence resource are not sufficient to implement the ACO evidence requirement. Healthcare providers and healthcare consumers must understand how to use evidence to inform decisions about care, and they must also be willing to be guided by evidence they must have philosophical agreement with the idea of evidence-based practice and be in alignment with respect to an evidence standard. This will be 4
5 a challenge for ACOs because at the present time, evidence-based practice is neither universally accepted nor understood by either clinicians or patients. Hospitals and physicians may have competing interests that will pose roadblocks to adoption of evidence-based clinical care. These may include marketplace competition with other facilities and providers, desire to use the newest or most high tech treatments, experience-based preferences, and financial drivers or conflicts of interest. Organizations wishing to qualify as an ACO should be required to demonstrate a clear and detailed plan about how evidence-based practice will be incorporated throughout the organization and they should be evaluated at regular intervals for compliance with the plan. Healthcare consumers are unlikely to be familiar with the concepts of evidence-based medicine and comparative effectiveness and may fear that decisions about care are being driven by cost considerations or by government interference. Education about these concepts must be provided before the consumer or beneficiary becomes a patient patients are unlikely to be able to focus and understand concepts related to evidence-based practice when they are faced with a serious health issue. Therefore, ACOs must offer their members effective and proactive educational materials and communications about the principles and the benefits of evidencebased care prior to an episode of care. If consumers do not trust that they will receive the best care from the ACO, then they are likely to seek care outside of the ACO, which they are free to do. If this happens, then not only will the efficiencies of the ACO be lost, but coordination of care will become very difficult, and it is likely that the quality of care that the patient receives will be reduced. While physicians will be important participants in this educational effort, physician s assistants, nurse-practitioners, nurses, and other clinical staff can play a critical role in helping patients to understand evidence-based care and to participate in their own healthcare decisions. ACOs can also provide community education about evidence-based practice in a number of ways, including posting user-friendly materials on their websites or delivered directly via postal or electronic mail and offering educational programs at senior centers, community activities, and on social media sites. In addition to understanding how a clinician might use evidence in providing care, it is essential that Medicare beneficiaries learn how to use evidence resources themselves, so that they can fully engage in decisions about their own healthcare. Functional health information technology (HIT) The use of electronic health records that are accessible to all providers in the ACO is essential for continuity of care. Lack of coordination among multiple providers in multiple settings can easily lead to fragmented services and duplication of diagnostic testing for patients, particularly for vulnerable elderly patients; typical Medicare beneficiaries see an average of 7 physicians in 5
6 4 different practices in a given year, while those with chronic conditions may see up to 16 physicians each year. 6 To provide accessible electronic health records, ACOs will need to have a functional HIT system that is compatible across the organization. In addition, the ACO must implement processes and procedures that support consistent and timely entry of all relevant data into the health record. The HIT system will also be required for assessment of quality measures, which is a core requirement for ACOs and will be used to determine eligibility for performance rewards to the ACO. Quality measures The ACO regulations include 65 quality measures, spanning 5 domains, which will be used to establish the quality performance standard for ACOs. While many of these quality measures have been shown to improve healthcare quality, it is essential that they result in an improvement in clinical outcomes or patient experience, and are not simply process measures. Measures that have not been conclusively proven to reflect high-quality healthcare should be evaluated on a regular basis to ensure that they are aligned with best evidence-based practices and correlated with the intended clinical and patient outcomes. Summary If ACOs are going to achieve the promise of improved quality of care for individuals and improved health of populations combined with a decrease in growth of healthcare spending, they will need to adopt, incorporate, and embrace the use of evidence-based medicine. This will focus resources on tests and treatments that work, while reducing the use of ineffective or unproven technologies. High-quality evidence sources, education about and commitment to evidence-based practice, HIT infrastructure, and quality measures that reflect the evidence basis are key elements for accomplishing this challenging task. Information on Hayes Founded in 1989 by Winifred S. Hayes, Hayes, Inc. is an independent health technology research and consulting company dedicated to promoting better health outcomes through the use of evidence. Hayes performs unbiased, evidence-based assessments of the safety and efficacy of new, emerging, and controversial health technologies, evaluating the impact of these technologies on healthcare quality, utilization and cost. For more information, contact: Susan Levine, DVM, MS, PhD Chief Scientific Officer; Senior VP, Health Technology Research & Consulting; Editor-in-Chief 6
7 P: Bibliography 1. Government Printing Office. The Patient Protection and Affordable Care Act. PUBLIC LAW SEC MEDICARE SHARED SAVINGS PROGRAM. March 23, 2010:Page 395. Available at: 2. Lee DH, Vielemeyer O. Analysis of overall level of evidence behind Infectious Diseases Society of America practice guidelines. Arch Intern Med. 2011;171(1): Tricoci P, Allen JM, Kramer JM, et al. Scientific evidence underlying the ACC/AHA clinical practice guidelines. JAMA. 2009;301(8): Greenfield S, Steinberg EP, Auerbach A, et al. Clinical Practice Guidelines We Can Trust. Consensus Report. Standards for Developing Trustworthy Clinical Practice Guidelines. Updated May 1, Institute of Medicine (IOM). Available at: Accessed May 26, Eden J, Levit L, Berg A, Morton S, eds. Finding What Works in Health Care: Standards for Systematic Reviews Committee on Standards for Systematic Reviews of Comparative Effectiveness Research. Updated March 31, Institute of Medicine (IOM). Available at: Systematic-Reviews.aspx. Accessed May 26, Pham HH, Schrag D, O Malley AS, Wu B, Bach PB. Care patterns in Medicare and their implications for pay for performance. NEJM. 2007;356(11):