Data Needs of Accountable Care Organizations

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1 Data Needs of Accountable Care Organizations Karen Bell Director, Center for Sustainable Health and Care, JBS International, Inc. Brian Hodgkins Executive Vice President, Heritage California ACO Craig Schneider Senior Health Researcher, Mathematica Policy Research 29 th Annual NAHDO Conference

2 The Data Needs of Accountable Care Organizations NAHDO Annual Conference San Diego, October 9, 2014 Craig Schneider Senior Health Researcher Mathematica Policy Research

3 Agenda Introductions Overview of ACOs Background on Learning Systems for ACOs Project Pioneer program ESCO program Shared Savings Program 3

4 Panelists Karen Bell, MD, Director, Center for Sustainable Health and Care, JBS International Brian Hodgkins, Pharm.D., Executive Vice President, Heritage Accountable Care Organization Craig Schneider, Ph.D., Senior Health Researcher, Mathematica Policy Research 4

5 History CMS Bridges to Excellence Prometheus Mass. Payment Reform Forum Learning Collaborative innovation grant 5

6 What is an ACO? (or, isn t this the same as a 1990s HMO?) 6

7 No, ACOs are Not the Same as 1990s HMOs Providers held accountable Quality improvement as well as savings Multiple provider configurations small practices to IDNs Primary care has key role Flexibility in financial arrangements Transparency Data available from EHRs Patients not locked in 7

8 Growth of ACOs ACOs are no longer a pilot or niche program: 626 ACOs nationally More than 20m covered lives Pioneer 670k 5.3m SSP 2.1m Medicaid 12.4m commercial Source: Peterson, et al, Growth and Dispersion of ACOs: June 2014 Update, Leavitt Partners 40% of commercial payments now value-based (Catalyst for Payment Reform report, 10/ 14) 8

9

10 Learning System for ACOs: Overview 10

11 Learning System Model Pioneer ESCO SSP/AP Core Competencies Online Webinars Innovation Pods Tech. Assistance Identify & Prioritize Learning Needs Develop Curriculum Modalities In- Person IPLCs F2F Self Evaluation Participant Feedback Input from CMS Input from SMEs Analysis of Dashboard, L&M Reports, and Other Sources Written Case Studies Change Package 11

12 Curriculum Topics Care coordination Primary care, improve transitions, avoid readmits, reduce disparities Provider engagement Payment incentives, data feedback, contracting, support transformation Quality improvement Understand measures, respond to quality data, patient safety, PDSA cycles Patient-centered care Pt engagement, info follows pt, chronic care mgmt, improve bene experience of care 12

13 Curriculum Topics (2) Health information technology HIT infrastructure for accountable care, clinical decision support, data analytics Managing population health Risk stratification, evidence-based medicine, working with community on PH Leadership Measure costs of care, manage risk, partner with payers, role of Board and executive leadership, practice transformation, clinical/financial integration 13

14 Logic Model INPUT S INTERVENTIONS DATA SOURCES CQI OUTCOMES Data Mining CMS guidance and policies Training Webinars Topic-focused LGs Feedback Virtual focus groups Collab. website Modify LS in real-time Dynamic adaptive system Implement best practices throughout ACO program Mathematica Project Team Mathematica CHS CFMC FMQAI/HSAG IHI Premier TransforMED Learning Systems Strategy Curriculum Implementation Performance measurement Information sharing Self-evaluation Peer-to-peer learning In-person LCs Virtual meetings Site visits Support problem solving Action-focused groups Office hours/ coaching Virtual collaboration website Implementation guide Self-study Resource library New materials Archived resources Dashboard Quality measures Per capita costs Benchmarking Surveys Interviews Post-intervention surveys Interaction Liaison w/ ACOs Faculty input Project team learning CMS input Disseminate Newsletter Case studies for ACOs Public use dataset Report Up-to-date delivery models Case studies Lessons learned Emerging themes Database Identify exemplars Identify high performers Recognize high performers Database of exemplars Best practices Triple Aim Better health Lower costs Higher quality 14

15 Pioneer ACO Model Physician-led, may include hospitals orgs agree to take on risk for eligible FFS beneficiaries Agree to share financial savings/losses above/below a certain level Agree to meet certain quality standards Receive information about FFS Medicare benes meeting certain eligibility criteria in order to plan, coordinate care $147m in savings (est. was $87m), exceeded all FFS quality measures (Pham et al, JAMA, 9/17/14)

16 Simplified Pioneer Payment Model BY1 (2009) BY2 (2010) BY3 (2011) PY1 (2012) PY2 (2013) PY3 (2014) Baseline Period Historical costs are gathered for alignmenteligible beneficiaries Performance Periods Actual costs are compared to [historical costs + a trend factor] to determine whether shared savings or losses have been achieved. Quality is measured annually. Trend Factor: For each performance period, a trend factor is added that calculates a 50/50 blend of the absolute $ change and % change of regional Medicare spending.

17 Medicare SSP ACO Program: Not a CMMI pilot official part of Medicare (Section 3022 of ACA) Subset (34 orgs) received advance payments to invest in systems for AC Legislation specified program details, including core competencies Less financial risk than Pioneers Vast majority are Track 1 payment model, with one-sided, upside-only risk Quality measures same as for Pioneers

18 SSP Payment in Three Easy Steps 1. Estimated Medicare Part A and B per capita cost benchmark for ACO s attributed beneficiaries 2. Comparison of actual costs to the benchmark determines savings (subject to minimum threshold) 3. Portion of savings is shared with ACO, based on quality performance Saved $345m in first payment year, improved on 30 of 33 QMs (CMS 9/16/14)

19 ESRD Seamless Care Organizations Create financial incentives for dialysis facilities, nephrologists, and others to improve outcomes and reduce per capita costs Developed under the authority of CMMI (ACA Section 3021) Third RFA released in April 2014 Targeting ESCOs LDOs: applications were due in June SDOs: applications were due in September Minimum of 350 beneficiaries Aggregation possible for SDOs First touch beneficiary matching Two-sided payment track for LDOs & one-sided payment track for SDOs 19

20 Challenges for ESCOs Shared savings might be inadequate to cover costs of setting up, operating ESCO Level of risk involved in ESCO model HIT infrastructure - interoperable EHR capabilities, HIE Recruiting nephrologists Few markets in which dialysis provider willing to implement ESCO Clarity regarding program rules (waivers enabling physician participation, outcomes for which held accountable) 20

21 What We ve Learned About the Data Needs of ACOs HIT Need EHRs/HIE, and means for interoperating Analytics Real-time data timely, relevant, accurate, transparent for analytics Provider engagement Ability to disseminate data to docs Physician report cards compare vs. peers Physician training in utilizing data Patient engagement How address benes who opt out of data sharing Condition-specific plans for pts to take home Risk stratification Predictive analytics - risk stratification, risk assessment for HUG pts Validate physicians perception of risk 21

22 What We ve Learned About the Data Needs of ACOs (2) Identify high-risk/high-cost ( frequent fliers, HUG ) Turning data into meaningful information Identify benes in the HMO Quality improvement Capturing data for quality measurement Quality metric analysis which quality measures contribute to success? Care coordination Coordinated care management system Identify benes for care management Getting info from hospital when bene discharged Behavioral health Integrating BH services with physical care 22

23 Project Dashboard Mathematica is creating an electronic dashboard that will: Provide opportunities to assess trends Compare performance on key cost metrics: Total costs, costs by line of service; also reported as percentages Cost data to be aggregated at ACO level; blinded data for peers Drilldowns of cost metrics Compare performance on 33 GPRO/PQRS quality measures For Pioneers and ESCOs ACOs to see their own data compared to benchmarks; CMS to have program-wide view 23

24 Dashboard Prototype User Interface (UI) 24

25 Dashboard Prototype Drilldown 1 25

26 Dashboard Prototype Drilldown 2 (ACO View) 26

27 Summary ACOs growing rapidly 3 types of Medicare ACOs Mathematica and partners supporting them with learning system curriculum and dashboard (soon) Need for real-time data to perform analytics for QI and risk assessment (can your HDO help?) Data critical for provider engagement and pt engagement 27

28 Contact Info Craig Schneider, Ph.D Senior Health Researcher Mathematica Policy Research (617)

29 Data and the ACO October 9, 2014 Brian Hodgkins Pharm.D., FCSHP, FASHP Executive Vice President Desert Oasis Healthcare and Heritage CA Accountable Care Organization

30 Dilemmas in health care

31 HPN 33 years innovation Patient centric physician led Risk bearing strengths Integrated care delivery 700,000 lives 2300 PCPs/30,000 specialists New York and Arizona Heritage California ACO Pioneer status 90,000 ACO lives Part of Heritage Provider Network 2 MSSP ACO s (AZ, NY)

32 Key Operating Principles Healthcare is local and should be delivered locally Use technology to scale and expand operations Share best practices and benchmark against best performers Patient first Solve problems for health plans and communities Partnership of centralized and regional management Continuous innovation Drives Long Term Success 32

33 Coordinating Care for Success Robust inpatient (hospitalist/nocturnist), SNF and outpatient management Physician-led utilization and quality management Focus on medical home and community care management Care coordination by interdisciplinary teams Rigorous real time decision support and data analysis All this must be connected and supported by data 33

34 BUT... In an HMO environment: You control utilization Prior authorization is required All doctors who are seen are part of the network You have full access to data on a close to real-time basis 34

35 In An ACO Patient can visit any doctor they wish There is no prior authorization Patients are going to doctors outside the network Much of the data you receive is months later So, THE JOB IS MUCH MORE DIFFICULT 35

36 So, What Can You Do? Prioritize patients by those for whom you can best change the care and cost trajectory. That requires three things: And understanding of who can be affected (remember 5% of patients are responsible for 50% of the costs); Robust data A way to sort and stratify the data to focus on the effectible population This does not require perfect data for all 36 beneficiaries

37 Who Can Be Affected Population health management - focus on known healthcare drivers: Registries Diabetes CHF COPD Active utlilization event based connections Passport, Emdeon Integration with EHR Quality measure closure 37

38 Robust Data You need to obtain as much relevant data, as quickly as possible Claims but comes months late Pharmacy need real time adjudication data Labs contracted provider interface Utilization data before you get it from claims Single source of healthcare related truth Care coordination and management vehicle 38

39 How to Manage Your Data HCACO System Goals Replicable across regions Enables scalable operations Supports clinical programs Reduces clinical variation Enforces compliance 39

40 q.aco Solution Stratifies populations into tiers Assigns tasks based on the tiers Allows tracking of actions taken by ICT member Gathers all information for the beneficiary in one place Tracks all communications with the beneficiary Incorporates compliance and quality in one place Not built as a information management system, but as a care management system. 40

41 41 q.aco Local Level

42 q.analytics Module 42

43 Real time admission data 43

44 Trends Age bands 44

45 Quality EHR integration Claims driven data 45

46 Care management module q.care 46

47 Bottom Line - Summary 47

48 Accountable Care Provider Organizations: ACO WG Recommendations

49 49

50 50

51 Care Coordination Care Coordination involves two different but related aspects of patient care. One provides information to the clinician who must be able to access from and provide relevant clinical data to multiple sources in order to determine and provide for appropriate next steps in diagnosis or treatment. The other is to assure that patients are in the appropriate setting as they transition among multiple levels of care. Both are important for providing high quality care as well as mitigating excess, both must incorporate patient needs and preferences, and both are highly dependent on the ability to quickly and easily send and query health information on a given patient to and from multiple electronic sources. 51

52 Major Challenges Many provider groups simply not ready Insufficient capital Governance Inadequate HIT systems No opportunity for a PCMH base Lack of integration with BH, LTPAC, PH, SS Not enough patients in risk contract Payers not aligned Different contracting arrangements Different performance metrics and contracting arrangements Different attribution algorithms Different types of partnerships 52

53 Major Challenges No access to available administrative data to assess business case or manage care Full set of claims (total costs of care, financial management) ADT feeds Social determinants of health Real time Eligibility and Benefit information Inability to exchange clinical data and information Within ACO environment External to ACO environment Telehealth Remote monitoring devices 53

54 ACOs need APCD Data Negotiations Agreement on total costs of defined population; targets Patient attribution Identify potential clinical partners Business Intelligence Analyses Descriptive reports, dashboards, trends, monitoring, etc. Predictive applied statistics and modeling to identify priorities for care process interventions Prescriptive regression models to analyze options for planning purposes 54

55 APCD Data Program development and evaluation Prioritize resources Identify partners Demonstrate savings.or not Manage the business Develop alternative payment strategies internally Leakage/Keepage Quality based reimbursements Increase efficiency of reporting required measures Integrate with clinical data where possible 55

56 Recommendations: ACO WG to HITPC to HHS Encourage the development of state-level all-payer claims databases (APCDs) to support accountable care arrangements (inclusive of Medicare & Medicaid). HHS should use state-level mechanisms (e.g. SIM funding) to support the development of APCDs, ensure that Medicaid and private payers doing business in that state are contributing data to an all-payer claim database or other identified entity, and ensure that APCDs make data on their attributed patients available to provider groups taking on financial risk. A uniform quality assurance methodology to assess the reliability of claims integration processes should be independently developed as part of this program. 56

57 Recommendations: ACO WG to HITPC to HHS Develop and promote a common standardized methodology and approach to attributing patients in the ACO environment across all payers and providers. HHS should work with other payers and providers to develop a consensus driven standardized algorithms for attribution patients to a particular ACO that can be used by all payers and providers. 57

58 Recommendations: ACO WG to HITPC to HHS HHS should continue to explore ways to accelerate toward the vision of standardizing all measures required by various agencies, departments, and programs, so that all unique and relevant measures can be calculated and submitted once by a given provider to a single location, thus eliminating the need to report performance measures to multiple payers in multiple formats. HHS must ensure that this work includes and is aligned with efforts by private payers to increase efficiency for providers across commercial populations as well. 58

59 Recommendations: ACO WG to HITPC to HHS Articulate HHS future strategy around the infrastructure needed to integrate claims and clinical data to support accountable care. Integrating clinical data with claims, cost, and price data across participating payers and providers will support less burdensome reporting of quality metrics, increased capacity of providers to improve quality and reduce costs, and improved specificity of predictive modeling. HHS can advance progress toward these objectives by articulating a strategy for how the federal government will engage with the various qualified entities capable of receiving and aggregating these data at the local, regional, and state level (e.g., all payer claims databases, regional health collaboratives, health information exchanges etc.). This strategy should support: research into and development of integration processes that support a range of specific ACO use cases, mechanisms to ensure accountability and reliability of integration processes, and mechanisms for ongoing monitoring and evaluation of participating entities. 59

60 Recommendations: ACO WG to HITPC to HHS Issue additional guidance around sharing of information protected under 42 CFR Part 2 across participants in an accountable care organization. SAMHSA should consider issuing additional guidance to specifically address issues relevant to providers in the ACO environment in order to help further reduce misconceptions and variations in interpretation that persist among providers. For instance, SAMSHA could offer guidance on how ACO entities that include substance abuse facilities might establish QSOAs across participants with an administrative relationship to permit sharing of clinically relevant information, or clarify the conditions under which primary care providers conducting SBIRT services are considered Part 2 providers. 60

61 Apologies to Wayne Gretzky You can yell from the sidelines You can guesstimate where the puck will go You can be on the team that shoots it into the goal!!!! 61

62 Thank You! Access to the interactive CCHIT ACO HIT Framework with User s Guide Karen Bell MD. MMS Director, JBS Center for Sustainable Health and Care (cell) (office) 62

63 Save the Date: NAHDO s 30 th Annual Conference October 2015 Alexandria, Virginia 29 th Annual NAHDO Conference

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