R O I R e s e a r c h i n H e a l t h c a r e R e t u r n o n I n v e s t m e n t f o r A c c o u n t a b l e C a r e O r g a n i z a t i o n s F e b r u a r y 2 0 1 2
Message from our President & CEO HIMSS, a 51-year old, cause-based non-profit organization, focuses on the best use of IT and management systems to transform health and healthcare. The executive management teams of healthcare organizations play a driving role in this transformation. As a CEO, I understand first-hand the challenges an executive team experiences in assessing and documenting IT return on investment. It is a complex issue that impacts everyone across an organization, and there are too many examples of disappointment, frustration, and outright failure. Our role is to equip you a member of a healthcare executive management team to realize ongoing financial viability through the best use of IT and management systems. As payment models begin to change, clinicians clamor for increased use of mobile IT, and those paying for the care seek proof that care treatment plans are of greatest efficacy, executives must understand the strategic opportunities and pitfalls of IT. At the end of the day, without ongoing financial viability, a healthcare organization will fail. To that end, this white paper is the second in a series that focuses on what research teaches us about how to maximize IT s return on investment. Our November 2011 white paper addressed the acute setting indicating classic ROI methodologies are insufficient for a health setting. In this white paper, senior provider executives from three separate focus groups teach us about their IT return on investment perspectives in considering participation in an Accountable Care Organization. We will continue to provide ongoing ROI IT research again, all focused on the needs of senior healthcare executives. We will look at ROI in the ambulatory setting, and how executives can harness the power of IT to envision a successful future that today seems beyond imagining. Together, our generation will transform healthcare. H. Stephen Lieber, CAE President and CEO 2012 HIMSS Analytics ROI Research in Healthcare: Return on Investment for Accountable Care Organizations 3
ROI Research in Healthcare Return on Investment for Accountable Care Organizations Table of Contents Introduction... 5 Study Design... 6 Reasons for Participating in an ACO... 6 Financial Considerations... 7 Quality of Care... 7 Tools Necessary to Successfully Participate in an ACO... 8 Foundational technologies... 8 Integrating technologies... 8 Analytical tools... 9 ROI Analysis... 10 Investment in Clinical Practices... 10 ACOs and Soft ROI... 11 Challenges and Concerns with Computing ROI... 12 Conclusion... 12 Appendix HIMSS Resources... 13 End Notes... 14 2012 HIMSS Analytics ROI Research in Healthcare: Return on Investment for Accountable Care Organizations 4
Introduction The concept of an accountable care organization (ACO) was invented in late 2006 during a discussion at a public meeting of the Medicare Payment Advisory Commission (Medpac) 1. Today, ACOs are a cornerstone of the federal government s current healthcare reform agenda. ACOs are groups of care providers, including physicians, hospitals, and other health care providers, who voluntarily come together to coordinate high quality care for the patients they serve. Coordinated care helps ensure patients receive the right care at the right time; it also helps to avoid unnecessary duplication of services and prevent medical errors 2. The entire premise of an Accountable Care Organization is based on the fact that organizations will provide enhanced quality of care in a more cost effective manner through a shared savings model. In order to qualify for shared savings, an ACO must meet more than 30 measures of quality performance. These measures can be grouped into four quality domains Patient Experience of Care, Care Coordination/Patient Safety, Preventive Health, and At-Risk Population 3. In order to achieve success, ACOs need an information technology (IT) infrastructure the supports the coordination of care across a variety of healthcare settings. This might include technology that supports the electronic exchange of health information, technology that facilitates the collection and analysis of data, and technology that measures progress against quality goals. According to one report, the technology elements that have been determined as critical for participation in an ACO are 4 : Standards-based information exchange Application-agnostic interoperability Interoperable EMR/HIS applications Clinical and Business intelligence solutions ACO management technologies Clinical decision support functionality Technologies that promote integration with personal health records Standardized data sets Population health management tools 2012 HIMSS Analytics ROI Research in Healthcare: Return on Investment for Accountable Care Organizations 5
This research sought the perspectives of senior healthcare executives in order to explore the return on investment that organizations expect to gain from their investments in IT to support the development of an ACO environment. Study Design The perspectives of these executives were gathered through a series of focus groups; all executives worked for a hospital-based organization. While this research did not require that a hospital have formal plans to move forward with an ACO at this time, the research was concentrated on those healthcare organizations that might be most likely to participate in an ACO in the future. As such, executives at healthcare organizations that were either participating in the new Pioneer Accountable Care Organizations (ACOs) initiative made possible by the Affordable Care Act 5 or had achieved Stage 6 or Stage 7 on the HIMSS Analytics EMR Adoption (EMRAM) Model SM were extended invitations to participate in this research. A total of 15 individuals participated in three telephone-based focus groups that were hosted in January 2012. The study population included seven IT executives, four Chief Operating Officers, two Chief Medical Information Officers, two Chief Executive Officers and one was a VP of Government Relations. While the majority of facilities in this sample are general medical/facilities, academic medical centers, pediatric hospitals and a critical access hospital are also represented. HIMSS Analytics executives and content experts developed the focus group discussion guide and a HIMSS Analytics executive conducted the focus groups. While the results of these focus groups are not meant to be a definitive assessment of the market, they are valuable in informing the market about the perspectives these executives have with regard to the IT investments needed for successful participation in an ACO. Reasons for Participating in an ACO Respondents were asked to identify whether or not they were going to participate in an ACO. While most respondents indicated that their organization had had conversations about whether or not an ACO was the right strategy for their organization, none of the organizations in this study were actively participating in an ACO pilot program at this time. Some 2012 HIMSS Analytics ROI Research in Healthcare: Return on Investment for Accountable Care Organizations 6
respondents noted that participating in an ACO was their long-term goal, while others noted that they were taking a wait-and-see approach. The reasons respondents noted that they would participate in an ACO can be categorized into two broad categories those whose evaluations were based on financial considerations and those who were trying to coordinate and improve the quality of care. For many respondents, participating in an ACO was a strategic combination of achieving both objectives. Financial Considerations The first category includes financial reasons. Successfully implemented ACOs will change the way in which healthcare providers are reimbursed for the services their organization provides; it is expected that organizations will be allotted a percentage of the revenue, based on a pre-determined shared savings model determined by all participating organizations. For many respondents, preparation to participate in an ACO is a proactive strategy. These organizations are attempting to strategically prepare their organization to retain financial health as they move forward with this model. These organizations do not want to participate in an ACO unless they have the opportunity to create the rules. As one respondent whose organization is preparing to become an ACO noted, what it really comes down to is with a decreasing share of reimbursement coming to us all, we are looking at this as a means to maintaining our operating margins while keeping our competitive advantage and continuing to establish a reputation on great quality and good efficiency. Quality of Care The second category revolves around the enhanced provision of care to patients. ACOs are designed with the goal of providing coordinated care, which can result in a wide variety of cost saving measures, including decreased length of stay, preventative care and reduced readmissions. However, in an ACO model, improved care and a focus on preventative care and population health management should lead to an environment in which care is provided more economically. While this is good for the patient, it represents a fundamental shift in the reimbursement model that hospitals have been using for years. Thus, a focus on improved care will be beneficial for patients, but it could be detrimental to hospitals by reducing their inpatient revenue, requiring them to find additional ways to pay for their services. 2012 HIMSS Analytics ROI Research in Healthcare: Return on Investment for Accountable Care Organizations 7
Tools Necessary to Successfully Participate in an ACO Respondents were asked to identify the technology applications that were necessary to participate in an ACO. In general, the tools identified by respondents can be grouped into three broad categories. For the purposes of this research, these categories will be considered foundational technologies, integrating technologies and analytical tools. Foundational technologies Most respondents identified an EHR as a key component of environment that collects information about patient care. Ideally, an EHR should exist not only in the acute care environment, but also in other types of facilities at which care is provided, including ambulatory clinics, sub-acute care settings and home health agencies. Over the past five years, the acute care market has been making great strides in adopting an EHR. HIMSS Analytics has been tracking the EMR adoption in U.S. hospitals since 2006. At the end of 2006, the only healthcare IT used in most U.S hospitals were the three primary ancillary systems (pharmacy, laboratory and radiology). But by the end of 2011, most U.S. hospitals had progressed to having a clinical data repository where all their orders and results were captured, stored and reported and were using nursing documentation systems. Additionally, 5.2 percent of hospitals had achieved Stage 6 and 1.2 percent had achieved Stage 7, which represents a virtually paperless environment 6. Adoption of EMRs in hospital-owned physician practices has also increased in the past several years. In 2009, 54 percent of these practices had an EMR; by the end of 2011 this had increased to 62 percent 7. Integrating technologies In order to achieve success, ACOs need an information technology (IT) infrastructure that supports the coordination of care across a variety of healthcare settings. While it is essential that data exists in an electronic format, such as in an EHR, data are much less valuable if they exist in a silo limited to a single department or care facility. Thus, it is necessary to have information technology that closes the gap between the hospital and outpatient settings and facilitates the exchange of electronic health information across those settings. The focus group respondents, indeed, identified technologies that facilitate a process to bring this data together into a single location. A number of respondents identified the importance of a data warehouse that could store information from all of the facilities participating in an 2012 HIMSS Analytics ROI Research in Healthcare: Return on Investment for Accountable Care Organizations 8
ACO. Other respondents also indicated the need for information exchange technologies, such as those that facilitate participation in a health information exchange as critical to the tools they would identify as important in participating in an ACO. HIMSS Analytics data supports the perspectives provided by the focus group respondents. The use of both clinical and financial data warehouses have increased by approximately ten percent in the past three years 8. This supports not only what the respondents said was driving them to eventually participate in an ACO. Analytical tools One of the challenges that has plagued the healthcare system most recently is how to best analyze the exponentially growing amount of raw healthcare data stored in disparate information systems and data warehouses. In order for ACOs to be successful, information technologies are needed to access those data stores and translate those data into actionable information. An entire class of additional tools with analytical capabilities is needed, not only to enable the conversion of data into information, but also to provide for the analysis of data so that progress can be measured against quality goals. Respondents identified a variety of tools in this category, including risk stratification tools, population health management tools, clinical surveillance tools and chronic disease management tools. These solutions would allow data to be examined across an entire patient population, without regard to care setting, enabling better clinical care by identifying trends in the overall patient population. These tools can thus improve care in numerous ways, including: Ability to perform quality measurements and comparisons across care settings & clinicians Improved consistency, quality and effectiveness of care at the point-of-care Reveal opportunities for performance and clinical improvements Take into consideration evidence-based guidelines 2012 HIMSS Analytics ROI Research in Healthcare: Return on Investment for Accountable Care Organizations 9
ROI Analysis When asked about the capability of conducting an ROI analysis to move forward with the technologies that are specifically required to participate in an ACO, most of the respondents noted that they have not embarked on a formal ROI analysis. Just because they have not embarked upon a formal ROI analysis does not mean that these organizations are not fully strategically evaluating the financial impact of purchasing technology for the purpose of participating in an ACO. Many of the respondents noted that their organization has been discussing ACOs from a strategic perspective at executive team meetings and IT governance meetings for some time. Furthermore, many of the technologies that are required for participation in an ACO, such as EHRs, data warehouses and integration tools are also tools that are needed to qualify for Stage One of the CMS meaningful use. As such, many respondents reported that the decision to invest in these technologies is not limited to the ability to participate in an ACO. At this time, many of the senior executives in this research largely view many of the IT investment costs of participating in an ACO as simply the cost of doing business or a sunk cost. As one respondent noted that a formal ROI was not required for purchases related to ACOs because any technology purchases would be considered a strategic investment into the future, and as such, would be funded outside of the typical capital IT function. Participation in an ACO at this time is voluntary. However, ACOs are the cornerstone of the federal government s healthcare reform strategy and as such, there is a perception among a number of study respondents that participation in an ACO is essentially a government mandate. For some respondents, this takes some of the choice out of their ultimate participation in an ACO. Investment in Clinical Practices In order for there to be a successful exchange of information between healthcare organizations, it is critical that all organizations are collecting information electronically. In an ACO environment, it is necessary that there is a coordination of care between different healthcare entities in a region, including clinical offices, home health agencies and payers. While about two-thirds of hospital-owned physician organizations have an EHR, utilization of 2012 HIMSS Analytics ROI Research in Healthcare: Return on Investment for Accountable Care Organizations 10
EHRs in non-owned physician practices is much less extensive, providing a substantial challenge to the exchange of information. As such, a number of the focus group participants indicated that one of their organization s strategic initiatives was to work with both their employed and non-employed physicians to ensure that their ambulatory practices had access to an electronic health record. For those that own clinical practices, this includes extending their organization s EHR into those environments. Additionally, many of the respondents reported that a large number of the physicians that they work with are not employed by their organization. However, the relationship with these organizations has been identified as strategic to the organization for a number of reasons, including the solidification of the referral relationship between the physicians and the hospital and the exchange of information between care providers. As such, most of the respondents have noted that their organizations are providing EHR software to the practices under the HHS provisions for exemptions to the physician self-referral prohibition law (Stark). ACOs and Soft ROI Financial return is not the only element of an investment that healthcare organizations need to take into consideration in order to evaluate the value and ROI that will be generated as a result of an investment. Known as soft ROI, these investments include things like improved efficiency, improved quality of care and improved patient safety. Many healthcare organizations are starting to reap benefits in this category 9. The entire premise of an ACO is built around the concepts that are detailed in soft ROI. ACOs are organizations designed to promote improved healthcare by creating a mechanism to improve coordination of care for patients. ACOs create incentives for healthcare providers to work together across the continuum of care to treat patients, regardless of care setting. ACOs that are successful at lowering healthcare costs while improving quality of care and putting patients first will be rewarded. Thusly, while many of the respondents in this research indicated that they viewed the purchase of technologies that would support ACOs as either a sunk cost or the cost of doing business, they are clearly considering the soft ROI benefits that their organizations will reap as a result of making this type of investment. As one respondent noted, We are approaching this as a way to provide good quality care, safer care to our patients. 2012 HIMSS Analytics ROI Research in Healthcare: Return on Investment for Accountable Care Organizations 11
Challenges and Concerns with Computing ROI Respondents noted a number of concerns and challenges with regard to computing return on investment as they consider the implementation of technology to participate in an ACO. Many of these concerns are grounded in the uncertain future of ACOs. One big challenge to undertaking a formal ROI analysis with regard to the technology is the uncertainty that exists around how payments will be distributed in the shared savings model. ACOs are, by design modifying the payment structures that have existed in the market for decades. Many respondents reported concern that the level of reimbursement they will receive in a shared savings model makes it very unclear if there is going to be enough money to go around to all of the organizations that will be required to participate in a successful ACO. As such, many respondents do not believe they have enough information to conduct a formal ROI process. Another concern voiced by respondents is the amount of time between the time that the initial investment in technology is made and the time at which the benefit is received, particularly in an environment in which the future payment structure of healthcare is uncertain. As one respondent noted, the question is, can we survive that chasm? Finally, respondents reported having concern about committing resources to a program that has an uncertain future. As one respondent noted, we hate to commit large portions of our budget towards something that we are not sure is actually going to materialize and work. Conclusion ACOs will change the way in which healthcare providers are reimbursed for their services. The strategic challenge facing executive teams, and their Boards of Trustees, is to realize these changing realities and position their healthcare organization for future financial viability. IT is a key component of that strategic conversation; executives must first understand how IT can be harnessed to jointly improve outcomes, reduce costs, and generate new revenue. Then, executives must articulate the plan and keep staff relentlessly focused. 2012 HIMSS Analytics ROI Research in Healthcare: Return on Investment for Accountable Care Organizations 12
The future financial uncertainty of ACOs makes it very difficult for healthcare executives to determine the ROI for technology investments. Despite this, organizations are making investments in the technologies that can position them as an ACO because they consider these technologies to be strategically necessary it s the cost of doing business. For instance, providing the EHRs with integration to hospital systems is a strategic move that will ensure that physicians will refer patients to the hospital. ACOs offer the promise of improved quality of care through better coordination of patient care. Investing in the technologies needed to provide that care can put healthcare organizations in a position to provide enhanced care at their organization and throughout the population they serve. Appendix HIMSS Resources HIMSS frames and leads healthcare practices and public policy through content expertise, professional development, research initiatives and media vehicles designed to promote information and management systems' contributions to improving the quality, safety, access, and cost-effectiveness of patient care. Some of these resources are available to all HIT professionals; some are restricted to HIMSS members. Listed below are some key resources that HIMSS has produced regarding Accountable Care Organizations. HIMSS Accountable Care Organizations (ACOs) Homepage http://www.himss.org/asp/topics_accountablecare_aco.asp?faid=486&tid=101 HIMSS Response to Centers for Medicare & Medicaid Services Proposed Rule Establishing ACOs http://www.himss.org/policy/d/20110606_himss_cms_aco_nprm.pdf HIMSS G& Advisory Report: The Intersection Between Accountable Care Organizations & the Financial Network of the Future http://www.himss.org/content/files/medicalbankingproject/mbp_g7_advisory_aco_financial_interse ction.pdf Leaders & Innovators Program Website http://www.himss.org/innovators/ 2012 HIMSS Analytics ROI Research in Healthcare: Return on Investment for Accountable Care Organizations 13
End Notes 1 The History and Definition of the Accountable Care Organization http://pnhpcalifornia.org/2010/10/the-history-and-definition-of-the- %E2%80%9Caccountable-care-organization%E2%80%9D/ (Accessed January 2012) 2 Centers for Medicare and Medicaid Services (CMS) Overview of Accountable Care Organizations https://www.cms.gov/aco/ (Accessed January 2012) 3 Department of Health and Human Services, Centers for Medicare and Medicaid Services, Fact Sheet: Improving Quality of Care for Medicaid Patients: Accountable Care Organizations. http://www.cms.gov/sharedsavingsprogram (Accessed January 2012) 4 Technology Fundamentals for Realizing ACO Success. Medicity, Spetember 2010. http://www.himss.org/content/files/medicity_aco_whitepaper.pdf (Accessed January 2012) 5 HHS News Release: Affordable Care Act helps 32 health systems improve care for patients, saving up to $1.1 billion. http://www.hhs.gov/news/press/2011pres/12/20111219a.html (Accessed January 2012) 6 HIMSS Analytics EMRAM Model. http://www.himssanalytics.org/emram/index.aspx (Accessed January 2012) 7 2012 HIMSS/HIMSS Analytics Annual Report. www.himss.org 8 2012 HIMSS/HIMSS Analytics Annual Report. www.himss.org 9 HIMSS Leaders and Innovators ROI Research in Healthcare: The Value Factor in Returns on Health IT Investments http://www.himss.org/innovators/research.asp (Accessed January 2012) 2012 HIMSS Analytics ROI Research in Healthcare: Return on Investment for Accountable Care Organizations 14
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