A few years back when Lynn Barr, founder and CEO of the National Rural Accountable Care Organization (NRACO), was helping plan out a statewide health information exchange infrastructure in California, she came to a realization that ended up changing her life.
“When we completed the consulting report, we analyzed our rural partners and realized they were really going to struggle in being able to adopt health IT. They had [little to no] IT staff and they didn’t have the expertise to move forward. They didn’t have the capital to buy the products. Everything was going against them,” Barr recalls.
She worked on getting grant money from United Health and helped half of the state’s critical access hospitals go through the process of adopting electronic health records (EHRs). It was during this time that she came to realize the struggle most rural hospitals would face without some kind of aid. This challenge comes even though with a fixed population and strong relationships with patients, these healthcare organizations have innate strengths in population health.
With the right infrastructure, Barr is adamant that rural healthcare facilities could excel in initiatives like the Centers for Medicare and Medicaid Services’ (CMS) Shared Savings Program. From the genesis of this idea, NRACO was formed. It is an organization that helps rural organizations take the leap from volume to value. On the its website, an image of a fish jumping from a smaller bowl to a larger one perfectly depicts this tremendous challenge.
“No rural community has 5,000 Medicare lives and the cost of running an ACO is about a million or two per year,” Barr says. “In order to get into these programs, they can either partner with an urban partner, a tertiary hospital, a regional ACO or they can partner with similar communities and operate independently, but use a shared infrastructure to get the right number of lives and afford the operating expenses.”
The last option is NRACO. The organization, which started with California-based rural hospitals and has since expanded nationally, provides governance, IT support, payer and patient engagement, analytics, education, and a number of other resources for a yearly participation fee. By participating in Shared Savings, the organization claims participants make back, on average, $1.50 per every dollar invested.
Through the program, Barr says that these rural healthcare organizations are learning to be proactive, coordinate care, and better manage care locally. Importantly, they're reducing per capita admissions but not local admissions, she says. This has allowed them to take that scary leap from volume to value. "You can offset the reduced admissions by having better market share," she says.
The analytics platform is making it all work. NRACO, using a platform from the Irving, Texas-based Lightbeam Health Solutions, extracts clinical data from the rural organizations' EHRs and puts it in a centralized data warehouse and a population health management tool, where its combined with claims data. The tool, using near real-time data, can identify issues, benchmark different quality measures, and help providers drill down and find specific types of patients that should be targeted for care coordination.
"We give them full access to [the platform] and train the care coordinators extensively on how to use it to find patients that need support. We also create reports for them and just hand them over. Some people like you to get in and play with the data, and some don't," Barr says. "We put the data in front of the right people so they can do the right thing with it."
Not only can it help rural organizations make this transition but the analytics platform has helped NRACO uncover trends in post-acute care. Barr says the ACO has discovered incredible variability in post-acute care costs and outcomes. Ironically, she says, in the areas with good outcomes and lower costs for patients in skilled nursing facilities and rehabilitation, there is less utilization of those services.
"It's somewhat counter intuitive," she notes. NRACO plans on using this data to inform, educate, and learn from doctors on this trend. "The data allows me to show doctors their results, their patients, and understand why their an outlier in utilization. That changes the conversation."
Like everyone else, NRACO is dealing with interoperability woes that are impeding its progress. She says getting data out of every organization's different EHR system in a structured format is an incredibly hard task. With 30 different health systems in NRACO, the organization is dealing with 20 different EHR systems, she notes.
Furthermore, even in the new Shared Savings proposed rule, CMS is still not acknowledging that certain providers should be treated differently in this kind of reimbursement environment. "They're committed to moving everyone to risk and have made it attractive, but safety net providers don't have the financial reserves to provide risk," Barr says. Track three, the new double-sided risk model that CMS proposed, is where many of the changes NRACO wanted exist. However, the double-sided risk is still a problem.
"We would like to see another track, track four for safety-net hospitals, that gives us the tools we need, allows us to participate in the program for the long haul, but if we fail won't put us out of business," Barr says. She says that it's likely CMS doesn't understand how little rural hospitals have in financial reserves.
Overall, she says CMS has been kind to NRACO. The government agency has invested more than $250 million to support rural communities in ACOs through various grant programs. As the organization grows, more ACOs are forming from within. The 30 communities within NRACO will form six separate Shared Savings ACOs in 2015, she says. Barr has her eyes set wider beyond that.
"With those grant opportunities, we're trying to get a many people as possible into the program and hope to sign a couple of hundred communities in 2015," Barr says.