Accountable Care Organizations

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1 Accountable Care Organizations Myth, Reality, Facts Why =System Failure Low Quality - IOM report High Cost Quality Cost disconnect Low Value Problems Disconnect between Quality and Cost Care is fragmented and poorly coordinated Payment system is Volume based rather than Value based IOM report Timeline Initiatives, Demonstration projects IQR, PQRI, HER incentive under HITECH Patient Protection and Affordable Care Act (3/23/10) Health Care and Education Reconciliation Act (3/30/10) Private Sector initiatives CMS ACO Proposed Rules (4/11) 1

2 Affordable Care Act (ACA) Provisions designed to improve QUALITY Support the establishment of NEW PAYMENT MODELS Provision for ACCOUNTABLE CARE ORGANIZATIONS QUALITY Expand VALUE-BASED PURCHASING links payment directly to the quality of care provided Broaden quality reporting Improve performance feedback to suppliers Create incentives to enhance quality Improve outcomes Increase value Value- Based Purchasing Link payment directly to the quality of care provided Transform the current payment system Reduce growth in health care expenditures Primary Data Resources - Toolkit CMS Accountable Care Organization Proposed Rules AMGA Annual Meeting 2011 New model ACCOUNTABLE CARE ORGANIZATION Greater accountability Improved value Align payments, benefits and other health care policies with measurable, meaningful progress in improving health care while lowering costs Principles Clear PATIENT-CENTERED AIMS Provider accountability through TRANSPARENT PERFORMANCE MEASURES PAYMENT REFORMS that use the measures to align provider support with the aims 2

3 ACO s Collaborations of primary care providers and other health service providers Organized around the capacity to improve health outcomes and quality of care while slowing the growth in costs of a population of patients Capable of measuring improvement in performance and receiving payments that increase when such improvements occur Configurations Integrated delivery systems Multi specialty group practices Physician-Hospital organizations Independent Practice Associations Regional collaboratives KEY DESIGN FEATURES Local accountability to their patients and communities Legal structure measure and improve performance Primary Care focus Sufficient size Investment in delivery system improvements Shared savings Performance measurement BASIC FUNCTIONS Develop a patientt care process that crosses service settings Negotiate ACO payment models with payers Methodology for shared savings disbursement Enhance information technology and data analysis infrastructure Calculate performance metrics Learn and enhance Patient attribution Budget development Key Functions Payment models and incentives Performance measurement Patient Attribution Essential for performance measurement Methods select from panel vs. beneficiary methods Prospective vs retrospective Critical mass 3

4 Budget Development Measure the financial performance = ability to control cost Analyze historical utilization and cost ID areas for performance improvement Develop benchmark spending targets Cohort vs budget projection models Payment Models and Incentives Shared savings Threshholds quality and savings Level of risk Selection Targets Performance Measures Performance calculations Validation Public reporting = transparency Stages Claims Data > Clinical Data > patient generated information > data across multiple care settings > outcomes CMS Quality Performance Measures ACO Regs 65 Pt /Care Giver Experience Care Coordination/ Transitions Care Coordination/ Information Systems Patient Safety Preventive Health At Risk Populations (three for COPD) ACO Emerging Federal Rules Accountable for overall care of beneficiaries Three year participation Formal legal structure Primary care grouping for at least 5000 pt s PCP and SCP participation Processes for EBM, reporting and coordination of care Patient centered ACO Working Definition A provider led organization whose mission is to manage the full continuum of care and be accountable for the overall costs and quality of care of a defined population 4

5 Goals of ACO Reduce the growth of health care costs Maintain or improve the health of a population Improve in both clinical quality and patient experience and satisfaction Opportunities for Improvement Improved prevention and early diagnosis Reductions in unnecessary testing procedures, and referrals Reductions in preventable ER visits and hospitalizations Reductions in infections and adverse events in the hospital Reductions in preventable readmissions Use of lower cost rx s, settings and providers ACO Infrastructure Data exchange and data sources Tools for timely communication with physicians and patients Tools for tracking performance and costs Tools and services integrated Patient and Family Clinical Systems Advanced Primary Care Medical Home Medical group and enterprise level Medical Village ACO Patient and Family Personal health record Patient portal Health risk assessment Patient engagement and activation Attribution Advanced Primary Care Medical Home Prevention and wellness Point of care analytics and Clinical decision support Cost effective medical management and service utilization Access Patient satisfaction and loyalty Provider and staff satisfaction Gap management Population management and Chronic Care Registries 5

6 Med Group and Enterprise Medical Neighborhood PCP/SCP incentives Network development Care Management (Acute, Chronic, Inpatient, SNF) Health Care Teams Health Coaching Transitions of care ER avoidance programs Accountable Care Organization Ancillary services SNF Home care Hospitals Hospice DME ACO Attribution of population Data exchange Measurement sets Payment mechanisms Core process Care process Network process Transition Coordination 6

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