The health information exchange created via the medial home project opens up a window to patient activity outside the practice as well, Moore says, adding she can now receive reports of subspecialty care via the exchange. A centralized care management team was also assembled, Ashline adds, to help physicians better coordinate care among high-risk patients. This group includes a nurse, social worker, pharmacist and I.T. support staff. "When a patient is admitted and identified as needing support, the nurse will visit the patient in the hospital and make sure there is good follow-up after discharge," Ashline says. The care management team can also help physicians at the practice level, scouring the EHR for at-risk patients and contacting them to come in for testing. Care managers will be granted access to both the practice EHRs and the data exchange as the project unfolds, Ashline adds.
Building that connectivity via the HIE was not easy, however. And Ashline says the number of ambulatory systems in play made a challenging task even more difficult. "It has literally taken 18 months to get all the interface work done and the bugs worked out," she says. Moore even had to switch EHR vendors mid-way through the project, settling on MDsuite as the replacement. Reason? Moore's first vendor (whom she declines to name) did not want to create an interface to the HIE. "Our former vendor had no national vision," she says. "We had to make a horribly difficult choice to drop them."
There are many other versions of accountable care beyond the patient-centered medical home. Perhaps the most notorious is Medicare's Shared Savings Program, a controversial-and complex-reimbursement arrangement that drew widespread industry fire when it was first proposed early last year.
The Medicare ACO model ostensibly would reward providers for holding costs below certain levels, but the governance, quality metrics and infrastructure requirements were steep. "I read every page of the proposed program," recalls Jeff Bond, CEO of Cox Health Plans, a 45,000-member payer that is part of an integrated delivery system in Springfield, Mo. "It was a non-starter. It violated too many rules of risk management and health systems would never recoup the investment they'd have to make to participate."
A revised rule softened some of the requirements, but for some executives like Bond, the initial taste was enough. However, he still appreciates the imperative behind federal efforts to come up with an ACO model. "Learning how to exist in a non-fee for service world will be a key survival technique," he says. "Health systems are largely hooked on fee for service reimbursement."
Bond is looking to another ACO-like program from Medicare-the bundled payment pilot program from the Center for Medicare and Medicaid Innovation, an arm of the federal health program that was created by the Obama health care reform law. "It's a better catalyst to accountable care," Bond contends. Cox Health Plans submitted its letter of intent to participate last year, and is waiting on data from CMS to proceed. In the bundled payment program, Cox Health Plans will act as a "convener" of providers, meaning it oversees clinical activities, but Medicare will still act as payer, Bond says.
Cox Health requested CMS claims data on eight different "episodes of care," including total knee and total hip replacements, and diabetic care, Bond says. It will then analyze the data, and choose one or two episodes for which it thinks it can beat national cost averages. CMS would then pay a bundled sum for all care related to the episode, with Cox being at risk if it goes over budget. "It is like an ACO, but it lets the health system pick where they have the most opportunity," Bond says. "You'll have to do the same things as an ACO to remove cost-engage the member, make clean hand-offs of care, and have good records of medication compliance. That makes it less theoretical and more practical."
Cox Health has developed an extensive I.T. game plan. First, the health plan uses software from its core benefits administration vendor, Trizetto, to analyze its budgets. "We can use our data to come up with statistically valid annual budgets that are severity adjusted," Bond says. "We have evidence-based rules around what care the patient should get."
Beyond that, to keep the expenses in line with the budgets, Cox Health will have to track patients' whereabouts carefully. "For diabetics, the No. 1 avoidable complication is emergency department care," Bond says. "But the primary care physician has no idea they even showed up at the ED for uncontrolled diabetes." To plug that information gap, the health plan is beginning a pilot project with Trizetto this year that will create what Bond describes as a "virtual hub that will push out information to a network of physicians." Not only will providers be able to track the whereabouts of certain patients, they will be rewarded for avoiding complications.
"Primary care physicians are not paid now for taking care of co-morbid conditions," Bond says. "Primary care needs to be paid more. We will be in a jam if we don't."
Multiple efforts by commercial payers also dot the ACO landscape. Blue Cross Blue Shield of Illinois is launching an ACO joint venture with Chicago-based Advocate Health this year. It's a type of shared savings arrangements, in which Advocate Physician Partners, a 3,900-member physician/hospital organization, will be rewarded for meeting cost measures for a group of about 365,000 patients, says Mark Shields, M.D., senior medical director. It's an expansion of similar efforts, such as Advocate's risk contracts for treating HMO patients, he says. "In 2011, we began shifting our HMO patients to full risk for professional services and outpatient testing."
In addition, Advocate is analyzing the CMS shared savings program, Shields says. Before the industry can embrace new financial models that would reward better coordination, however, it will need to understand what's at stake, he says. Shields acknowledges that the classic risk models of capitated HMO payments were not appealing to physicians or patients.