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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
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John C. Lincoln Health Network
Overview
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John C. Lincoln Hospitals
North Mountain Hospital 262 Beds Trauma Center Magnet Designation Deer Valley Hospital 203 Beds
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Physician Network: At a Glance
120 primary care providers Additional planned growth 20 specialists 34 locations NCQA PCMH Accreditation In-Process Patient Visits ,866 ,144 ,000 (projected)
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Accountable Care Organization
Approved by CMS July 2012 18,000 Medicare Shared Savings Program (MSSP) and Commercial members
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JCL ACO Provider Distribution
401 Providers
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Brief MSSP ACO Primer
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Organization of Health Care Providers
Primary care and subspecialty physicians Hospitals Acute care Rehabilitation Post-acute providers Home health organizations
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Health Care Providers (cont.)
Disease management Mental health Health and wellness Patient engagement
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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
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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.
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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 $9,000. 3. Multiply 1 times 2 and the result is a very large number - $135M. This is the base spending level. 12
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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. 13
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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
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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
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ACO Start-Up 16
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Identify, Attribute & Stratify
ACO Cycle CMS Process Data Identify, Attribute & Stratify Engage Patients Coordinate Care Report Measures Improve EHRs FAX 17
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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
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IT Challenge #2 Third Party Data Analysis Tool Disease Registries
CMS Data Transmission High cost Beneficiaries High ER Utilizers 19
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IT Challenge #3 PCP office visit Patient Information Create and file HCC Disease Registry Support patient outreach, care management, and data collection workflow 20
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IT Challenge #4 Encounter data refreshed quarterly
Disease Registries Q1 Q2 Q3 Q4 21
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IT Challenge #5 Clinical quality measure reporting
Data Sources Numerator/ denominator calculation GPRO web site data entry 22
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Strategic IT Considerations
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Core ACO IT Capabilities
Data CMS files Data acquisition Member registry Attribution Stratification Disease registries Data warehouse Analytics and reporting Predictive modeling Quality measures Applications Beneficiary communications EMR Clinical decision support Referrals Formulary ePrescribing Care management Disease management Patient portal Physician portal Secure communications Telehealth Financial Infrastructure Security Enterprise master patient index HIE Mobile/wireless Other IT governance IT leadership IT skills Change management 24
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Technology Platform? Options Our approach
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 Claims data processing Population health analytics
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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
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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
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Patient Engagement? Options Our approach 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
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Claims or Clinical Data?
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
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CMS Measure Reporting? Options Our approach 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
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Health Information Exchange (HIE)?
Options Public Private Both None Our approach Start without HIE Next step – private HIE Future – expand to public
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IT Organization? Options Our approach Integrated with corporate IT
CEO CEO – ACO & PN COO CMO CIO PMO EMR Data & Reporting Options Integrated with corporate IT Separate IT Our approach Fully integrated – single CIO
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Questions?
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