Accountable care is, broadly defined, a set of clinical and payment reforms that tie provider reimbursements to quality metrics and reductions in the overall costs of care. Under accountable care, groups of care providers coordinate their efforts to treat patient populations and may be at financial risk for the quality and efficiency of the care provided.
As Tripathi points out, numerous models are springing up both in the government and commercial sectors under the ACO guise. In his state, for example, Blue Cross Blue Shield of Massachusetts began in 2009 paying participating health care provider groups under the "Alternative Quality Contract," instead of traditional fee-for-service payments. In this arrangement, providers receive fixed payments for patient care, plus rewards based on savings generated and clinical performance targets reached.
At the federal level, Medicare has launched several similar models, each of which is designed to reimburse based on outcomes, not sheer productivity. Tripathi-and many others in the industry-wonder if these various models will align and if providers can realistically embrace the financial risk involved.
One thing is clear: For any model to succeed, it will need to facilitate data sharing across diverse, and often, disconnected care settings. The chronic communication disconnects among inpatient, ambulatory, long-term and hospice settings, as well as communication breakdowns between insurers and providers, have stymied the best efforts of the industry to provide the care needed at affordable levels.
And the inability to coordinate efforts has providers bleeding red ink treating a relatively small but incredibly expensive patient population. Robert Berenson, M.D., contends that rising costs can be largely attributed to treating patients with multiple chronic conditions. "Nineteen percent of Medicare beneficiaries account for 77 percent of spending," says Berenson, a fellow in the Urban Institute, a Washington, D.C. think tank. "You have people seeing 14 physicians a year with 100 prescriptions. All sorts of things fall through the cracks. There's redundancy and inconsistency. A crucial aspect of the ACO is having somebody to reconcile all this for doctors who are doing their best-but doing it in isolation."
The many flavors of ACOs-including the patient centered medical home, bundled payment arrangements, and shared savings-attempt to facilitate that very kind of coordination. No doubt, there will be a substantial role for health I.T. in these models, as electronic health records, health information exchanges and perhaps even personal health records are prerequisites to success.
But many question marks loom around the proper role and responsibility of patients as the industry begins the shift away from productivity-based payment. In addition, there's the open question of who's going to lead the transition to accountable care. For Berenson, the natural-if not best suited-leaders would be physicians. "A hospital-oriented ACO will be challenged," he says. "They want to keep beds full and do procedures. Physicians like the status quo and they're feeling threatened. But you need somebody in charge."
In the Northern Adirondack Region Medical Home Project, that "somebody" is a primary care physician. Launched two years ago in rural upstate New York, the effort has two key purposes, says Karen Ashline, director of one of the multiple initiatives under the widely dispersed effort. First is recruiting primary care physicians to an underserved area. Second: improve outcomes and reduce costs-the cornerstones of accountable care.
Based in Plattsburgh, N.Y., the project spans 26 small group practices, five hospitals and nine commercial and government payers. The payers have chipped in extra reimbursement, which the group distributes to practices based on meeting certain financial/clinical criteria.
The initial criteria, Ashline says, was attaining certification from the National Committee for Quality Assurance (NCQA) as a medical home (29 of 31 have attained Level 3, the highest). Later, payments will focus will meeting certain quality thresholds, adds Heidi Moore, M.D., a participating pediatrician serving on the effort's executive board. In the medical home model, a primary care physician keeps tabs on a patient, serving as the central coordinator of care across specialties as needed, says Moore, one of four physicians practicing at Mountain View Pediatrics, also in Plattsburgh.
Two I.T. components are vital-an EHR and a data exchange, Moore adds. The participating primary care practices all run ambulatory EHRs-seven different products in total-and are connecting to a statewide regional data exchange. Through the data exchange, physicians can download hospital discharge summaries, see a record of emergency department visits, and access medication lists, Moore says. Practices also use their EHRs to initiate lab orders, view results, and prescribe medications.
Electronic transactions around medications are a big safety boost, Moore adds. "Medication errors are a cause of readmission. The EHR makes the medication list easier to coordinate between the hospitalization, the ED visit and the primary care office."
For Moore, the EHR's ability to trap quality metrics so clinicians can act on shortcomings in their treatment efforts is the critical first step toward accountable care. In essence, before the medical home practice can serve as conductor for other providers, it must get its own house in order. "I can sit down and look at the quality reports with other physicians," she says. "I can say, 'Look, either you're not asking about smoking cessation or you're not documenting it.'"
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.
In these arrangements, physicians were pre-paid for treating patients, but often lacked the resources to closely monitor their patients' health status and treatments provided outside their practice. Now, payers are attempting to play a bigger role in providing data to providers to help them hold down costs, by identifying at-risk patients, for example. "You can still run a fee-for-service practice within an ACO model," says Shields. "The ACO is attractive to physicians who are nervous about capitation. But the ACO is not for the faint of heart. Providers need to be serious. If you have not already done the work with quality, patient safety and cost effectiveness with a network of doctors, the ACO is not a good place to start."
Advocate began its march down the accountability path about a decade ago. "The ACO is something we have been trying to do all along, but we did not call it an ACO," Shields says. "We want to bring the physicians and hospital together to drive safety and cost effectiveness." Advocate measures nearly 160 performance metrics in broad categories, including clinical outcomes, cost effectiveness, patient experience and use of health I.T. In addition, it negotiates overarching insurance contracts, which offer bonuses for meeting various metrics. Money from the payers is pooled in a clinical integration fund, then redistributed to physician groups that form the PHO (2,900 are independent) based on how well they meet the criteria.
By building out its quality metrics, Advocate is in a better position to negotiate with payers, Shields adds. Rather than having to comply with multiple, and sometimes conflicting, metrics Advocate runs a single program with the same measures applying to all payers. But Shields emphasizes that quality improvement is a byproduct, not a starting point. "Don't start with measures, start with culture and then governance," he advises. Advocate distributes a quarterly report card to each practice, which injects an element of competition. Physicians pick the measures, bonus thresholds and credentialing standards.
Running the show
For some experts, putting physicians in control of the ACO effort like that represents the best stab at coordinating care. "There is opportunity in the ACO if physicians take the leadership role," says Paul Weygandt, M.D., vice president of physician services at J.A. Thomas, an Atlanta-based consultancy. "If you think the current regulatory environment is challenging, wait until you are regulated internally by a group of physicians at risk. They will not tolerate some of the behaviors in medicine today."
Weygandt says current financial incentives reward neither quality nor cost-effectiveness. "Right now there are so many silos of care," he says. "Hospitals are reimbursed by their case rate for Medicare so they want to get patients out as quickly as possible. Nursing homes are not paid to take care of sick patients, so they send patients to a hospital if someone sneezes. How many millions are spent transporting patients back and forth between nursing homes and hospitals? Most patients getting an orthopedic procedure get a new set of crutches. Why not ask if they could re-use an old pair?
"The reason is we're spending someone else's money. If the ACO recognizes every unnecessary procedure, that attitude might change."
The need for new standards in communication across care settings sets the stage for information exchange, which isn't as extraordinarily complicated as some believe, Weygandt adds. For example, a physician in a patient-centered medical home might give their cell phone number to a patient, instructing them to call if they are going to another physician for care, or to the ED. In fee-for-service models, physicians are reluctant to give out their phone numbers because they can't bill for the service, he contends.
To most observers, true care coordination entails at least three major types of health I.T.-the health information exchange, the electronic health record, and the personal health record or patient portal. "You need I.T. beyond the revenue cycle," says Jim Adams, managing director at The Advisory Board Company, a Washington, D.C.-based research and consulting firm. "You need unified messaging, direct communication between provider to provider, manager to provider."
Data exchange role
As the industry moves toward accountable care, health information exchanges will become a prerequisite to success, says Doug Dietzman, executive director at Michigan Health Connect, a commercial HIE funded by dues from 49 participating hospitals in the state's Lower Peninsula. Spanning some 750 physician practices (who pay no dues), Michigan Health Connect transmits some 830,000 lab results each month across its network and also enables specialty referrals. Using data exchange software from Medicity, it serves as an information hub, connecting nearly two dozen EHR systems via nearly 50 interfaces, Dietzman says. "Michigan Health Connect won't be an ACO, but our technology foundation and infrastructure will be a required underpinning of many ACOs that will spring up. We can all be leveraging common infrastructure to lower costs."
Michigan Health Connect has seen steady growth in transactions since its formation in March 2010, Dietzman adds. "Rather than going after the loftier ideas of HIEs, we started in the trenches," with such pragmatic services as lab results delivery, he says. "We wanted to build the tracks first."
The exchange's referral management capability, for example, helps streamline a cumbersome, labor intensive process. It was launched last May. In the ACO world, providers would need to keep track of patients they send to other specialists, monitor outcomes, and receive results. "We can help the referral coordinator who is in a sea of paper and phone calls," Dietzman says.
Using the data exchange, providers can log onto a central site and establish connectivity with the 200-plus physician offices (representing 140 specialties) who have signed up for the referral service. Referring physicians search by specialty for the office they want to send their patient to. They then click through to the office, where they find a list of all the referral documents required. They can append those files electronically, either as Word files, scanned documents, or directly from their EHR. The system also provides verification of receipt and notice of follow-up after the visit is completed.
Commercial ACO efforts in Michigan have yet to appear, although the patient-centered medical home model is beginning to catch on, Dietzman says. "Larger health systems are trying to make sure they are well-coordinated with providers in their communities that serve as their referral base," he says. And that care coordination sets the stage for ACO payment models, he adds.
Physicians looking to automate their practices with EHRs often have little understanding of the limitations of the technology and the need for an HIE, Dietzman says. "The EHR can do a great job in the physician practice, but it doesn't know who else has an EHR in the community or what is needed for a referral outside the practice," he observes. That's why, even with an EHR in place, managing referrals is a paper-centric process.
Despite such limitations, the EHR is the cornerstone of accountable care, many experts say. But more is not necessarily merrier. Bond, the CEO at Cox Health Plans, notes that its health system runs on one EHR, an inpatient system from Cerner, while physicians use an ambulatory system from GE. Under fee-for-service payments, neither side had incentives to coordinate care. But now, with pay for performance looming, the health system realizes that will have to change, Bond says, and add more robust data management tools to the mix. "We have recognized that we will need one record system," Bond says. "It's imperative."
Advocate is also looking to minimize the number of ambulatory EHRs in play. Four years ago, it began deploying an Allscripts EHR among its large group practice of employed physicians and mandating its use, Shields says. About 800 of the 1,000 physicians are now on the system. Its independent physicians, however, are gravitating toward a system designed for small practices from eClinicalWorks. About 400 physicians are on that system, whose cost Advocate is helping to subsidize via the Stark relaxation rule.
But all physicians, even those still on paper charts, are required to use a Web-based disease registry, from Intelligent Health Care. The registry takes data from lab visits, pharmacy, and claims, creating rosters of patients with various chronic diseases. The system will flag patients in need of certain tests, providing alerts to the physician practices. "A well-deployed EHR is highly desirable, but you can get a lot of mileage with a simpler, easy to deploy tool like the registry," says Shields, the senior medical director.
Advocate reinforces its efforts with a centralized group of 60 outpatient case managers who use the disease registry. The registry works in conjunction with predictive modeling software from ActiveHealth, flagging patients at high risk of hospitalization. The goal is more proactive management of care coordination around patients who need it most. Shields says that the next step will be better patient engagement with their own care. "We need to provide prompts and reminders to patients," he says. Among the technologies under consideration for a more expanded role is the personal health record.
Chris Van Pelt, the senior vice president and CIO of Indiana University Health, says the PHR has potential to influence patient compliance-but that it's no substitute for an EHR when it comes to care coordination. The health system is currently evaluating multiple ACO options. "The ACO is the right direction to head, but much is uncertain and defined," Van Pelt says. "The challenge is care coordination especially managing chronic patients. We are trying to focus on 'high-consumption' patient populations."
Van Pelt sees potential in chronic condition management clinics, a set-up similar to a medical home where one practice would serve as the care overseer. "But you still need to engage the patient so they don't end up in the ED," he says. The PHR is one way to engage patients, by giving them a vehicle to record their own data. And IU is sorting through three PHRs working in conjunction with various systems in play at its hospitals to see which offers the best patient experience. "Ideally we will be converging on a cloud-based PHR that operates agnostic of any EHR," he says.
PHR advocates say the technology could serve as a common source of information among different providers. In this view, patients serve as their own care coordinators, deploying their PHR as a common communication ground among their providers.
But Van Pelt says this vision may be a long time coming. "People are more interested in updating Twitter and Facebook than they are engaging with their electronic medical records," he says. "There is really low engagement for PHRs right now, but you don't abandon that space."
Wanted: I.T. Tools
Following is a short wish list of I.T. tools industry leaders say will be needed to support accountable care.
* Chronic condition surveillance. Chris Van Pelt, senior vice president and CIO at Bloomington-based Indiana University Health, says his organization would benefit by receiving electronic prompts every time one of its patients showed up at an out-of-network emergency department. "We need to get an alert that the patient presented at another ED and let the physician who owns that patient in the ACO model know," he says. "That would alert the physician to take action."
* Access to payer formulary. Having direct access to a list of preferred drugs supported by payers would enhance electronic prescribing already in place, says Heidi Moore, MD, a pediatrician who serves on the executive board of the Northern Adirondack Medical Home Project. Moore currently uses her EHR to prescribe meds. "It would be really nice if the list were there so I don't prescribe a nose spray and 30 minutes later get call because it is not on the formulary," she says.
* Home-based medical devices. Jim Adams, managing director of The Advisory Board Company, says home monitoring devices, which can relay data back to providers, will help enhance patient accountability in the ACO equation. Pointing to the potentially high cost of treating "dual eligibles," elderly, low-income patients enrolled in both Medicaid and Medicare, he sees the devices as expanding in importance in the years ahead-largely spurred by the shifting economics of care delivery and reimbursement. "Accountability will be pushed out to the patients via higher deductibles and co-pays."
Legal Barriers to Care Coordination
As the industry attempts to facilitate data sharing across disparate settings, it will encounter a multitude of applicable state privacy laws that will make the job challenging, says health lawyer Bernadette Broccolo, a partner in the health industry advisory practice of Chicago-based McDermott Will & Emery.
The federal HIPAA privacy law is fairly flexible in terms of releasing information for treatment, payment and operations, Broccolo says. But many states have rigorous laws controlling the release of sensitive patient information in such areas as drug use, mental health and genetic counseling. "A key to the ACO will be the ability to aggregate, share and analyze data," she says. "The legal and I.T. issues are intertwined. The legal requirements are complex."