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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 CEOJohn 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
2011 - 263,866 2012 - 323,144 2013 - 409,000 (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
Subspecialist70%
PCP30%
Independent65%
Employed35%
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 SavingsStep 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.
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Calculate Shared SavingsStep 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.
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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
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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
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ACO Start-Up
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ACO Cycle
Process Data
Identify, Attribute
& Stratify
EngagePatients
CoordinateCare
ReportMeasures
Improve
CMS
EHRs
FAX
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IT Challenge #1
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CMS transmits attribution file to ACO
ACO locates patient demographic information
ACO sends prescribed letter to attributed patients
Patients respond/don’t respond to letter
Update to CMS with patient data sharing preferences
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CMS Data Transmission
Third Party Data Analysis Tool
Disease Registries
High cost Beneficiaries
High ER Utilizers
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IT Challenge #2
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Patient Information
PCP office visit
Create and file HCC
Disease Registry
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IT Challenge #3
Support patient outreach, care management, and data collection workflow
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IT Challenge #4
Encounter data refreshed quarterly
Disease Registries
Q1
Q2
Q3
Q4
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Clinical quality measure reporting
Data Sources
Numerator/denominatorcalculation
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IT Challenge #5
GPRO web site data entry
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Strategic IT Considerations
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Core ACO IT CapabilitiesData
• 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
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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 neededo Claims data processingo 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 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?
• 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
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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
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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?
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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