Starting an ACO: IT Lessons Learned

Transcription

1 Starting an ACO: IT Lessons Learned Robert Slepin, PMP, VP and CIO John C. Lincoln Health Network Nathan Anspach, SVP and CEO John C. Lincoln Accountable Care Organization John C. Lincoln Physician Network 1

2 John C. Lincoln Health Network Overview 2

3 John C. Lincoln Hospitals North Mountain Hospital 262 Beds Trauma Center Magnet Designation Deer Valley Hospital 203 Beds 3

4 Physician Network: At a Glance 120 primary care providers Additional planned growth 20 specialists 34 locations NCQA PCMH Accreditation In-Process Patient Visits , , ,000 (projected) 4

5 Accountable Care Organization Approved by CMS July ,000 Medicare Shared Savings Program (MSSP) and Commercial members 5

6 JCL ACO Provider Distribution PCP 30% Employed 35% Subspecialist 70% Independent 65% Providers

7 7 Brief MSSP ACO Primer

8 Organization of Health Care Providers Primary care and subspecialty physicians Hospitals Acute care Rehabilitation Post-acute providers Home health organizations 8

9 Health Care Providers (cont.) Disease management Mental health Health and wellness Patient engagement 9

10 Reimbursement in a Medicare ACO All participating providers continue to be reimbursed by Medicare on a fee-for-service basis Patients attributed to an ACO can continue to seek care from any Medicare participating physician, hospital or provider If a Medicare ACO is able to reduce the cost of caring for assigned Medicare patients and meet required quality standards, a possibility of shared savings exists 10

11 Options for Medicare ACO Shared Savings Tier 1 Limited risk Tier 2 Risk-bearing In either risk model, all providers continue to bill Medicare fee-for-service using the normal Medicare fee schedule. 11

12 Calculate Shared Savings Step One: Determine Base Spending Level 1. Determine the number of Medicare beneficiaries in the ACO. We will use 15,000 in our example. 2. Determine the average annual spend per beneficiary. In Phoenix, that figure is approximately $9, Multiply 1 times 2 and the result is a very large number - $135M. This is the base spending level

13 Calculate Shared Savings Step Two: Reducing Cost 1. Hypothetical: average cost is reduced by 7.5% to $8,333 per beneficiary. 2. Multiply $8,333 times same number of members. Total Spend is now $125M. 3. Subtract $125M from $135M and savings are $10M. The ACO takes half, or $5M, up to a maximum amount

14 Shared Savings Possible, Not Easy Requires reporting performance on 33 quality measures At least 50% of participating primary care physicians using an electronic health record Costs of care have to be reduced, but beneficiaries are not limited to ACO partners 14 14

15 Four Domains of Quality Measures Patient/Caregiver Experience of Care 7 measures Patient Safety/Care Coordination 6 measures including electronic health record At-Risk Population 12 measures, focused on diabetes, heart failure, hypertension and coronary artery disease Preventive Health 8 measures, include a variety of screenings 15 15

16 ACO Start-Up 16 16

17 ACO Cycle CMS EHRs Process Data FAX Improve Identify, Attribute & Stratify Report Measures Engage Patients Coordinate Care 17 17

18 IT Challenge #1 CMS transmits attribution file to ACO ACO locates patient demographic information ACO sends prescribed letter to attributed patients Update to CMS with patient data sharing preferences Patients respond/don t respond to letter 18 18

19 IT Challenge #2 Disease Registries CMS Data Transmission Third Party Data Analysis Tool High cost Beneficiaries High ER Utilizers 19 19

20 IT Challenge #3 PCP office visit Patient Information Disease Registry Create and file HCC Support patient outreach, care management, and data collection workflow 20 20

21 IT Challenge #4 Encounter data refreshed quarterly 21 21

22 IT Challenge #5 Clinical quality measure reporting Data Sources Numerator/ denominator calculation GPRO web site data entry 22 22

23 Strategic IT Considerations 23

24 Core ACO IT Capabilities Data Applications Infrastructure Other CMS files Data acquisition Member registry Attribution Stratification Disease registries Data warehouse Analytics and reporting Predictive modeling Quality measures Beneficiary communications EMR Clinical decision support Referrals Formulary eprescribing Care management Disease management Patient portal Physician portal Secure communications Telehealth Financial Security Enterprise master patient index HIE Mobile/wireless 24 IT governance IT leadership IT skills Change management 24

25 Technology Platform? Options Integrated ACO platform: Optum, Aetna or other Best-of-breed ACO platform: EHR, HIE and other pieces Enterprise EHR Our approach Leverage enterprise EHR to fullest extent Supplement with in-house development and third party software-as-a-service where needed o Claims data processing o Population health analytics 25

26 Single or Multiple EHRs? Ideal: One EHR Reality: Many EHRs and paper Options Require all participants to adopt single EHR Two-three preferred EHRs Any EHR, take your pick Our approach Single EHR for JCL hospitals and physician practices Longer term preferred EHRs and Health Information Exchange 26

27 FTE, Consultants or Outsource? Existing IT staff likely fully committed Significant IT resources needed Options FTE hiring/ramp-up time Consultant costly, and you lose investment in know-how Outsourcing high risk Our approach Dedicated consultant project manager rapid start Leverage central IT organization for other skills 27

28 Patient Engagement? Options Personal Health Record (PHR) Patient portal Monitoring devices Mobile apps or text Our approach Leverage EHR patient portal Promote adoption at practices and via marketing Improve value to encourage interactions and create value 28

29 Claims or Clinical Data? Claims Good picture of most but not all encounters Time delay Clinical Richer data not available in claims Real time Our approach Both sources of data are necessary for success 29

30 CMS Measure Reporting? Options Leverage core EHR Third party reporting tool Custom software Manual workaround Our approach Extract data from core and legacy EHRs Manual compilation of measures Plan for automation for Year 2 30

31 Health Information Exchange (HIE)? Options Public Private Both None Our approach Start without HIE Next step private HIE Future expand to public 31

32 IT Organization? CEO CEO ACO & PN CIO COO CMO PMO EMR Data & Reporting Options Integrated with corporate IT Separate IT Our approach Fully integrated single CIO 32

33 33 Questions?