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A Model for ACOs

April 4, 2011
by Karen van Wagner and John Gorman
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Applying best practices from an IPA’s Medicare risk business to ACOs

Lately, there has been a great deal of attention paid to Accountable Care Organizations (ACOs). And for good reason: the health care industry’s strides toward adopting the ACO model are being driven by the desire to reduce Medicare costs by improving coordination and continuity of care. Applying the ACO model can help improve the quality of care for a specific population of patients while reducing costs over time. This trend may eventually help push the Centers for Medicare and Medicaid Services (CMS) and its providers a step closer to value-based purchasing of healthcare.

However, achieving ACO status is a large undertaking, and the right organization design must be implemented to ensure success. A good model can be found in independent practice associations (IPAs), and particularly those who manage Medicare risk populations. IPAs offer best practices and lessons learned from their long history of managed care contracting and its affiliation of independent practices, which operate as a virtual network. As healthcare organizations across the U.S. plan their ACOs, examining working models for coordinating care and managing quality—such as the one in place at North Texas Specialty Physicians (NTSP), a 600-physician IPA headquartered in Fort Worth—can reveal critical areas where investments must be made.

NTSP faced challenges managing its at-risk managed care population due to physicians’ reliance on a paper-based claims reporting system for viewing a member’s health history. Recognizing the inefficiencies in this reporting system, NTSP committed to transforming its model of patient care by providing its physicians with electronic health record (EHR) systems connected to a community-wide health information exchange (HIE). This connected system now enables the independent practices of NTSP to share patients’ health information, access evidence-based care guidelines adopted throughout the IPA, and, therefore, proactively manage the care of their patients.

Improving Quality of Care Through an ACO
Health provider organizations working toward ACO status will have challenges similar to those faced by NTSP in the management of its risk-based managed care business. Physicians need a clear picture of the defined patient population they are managing in order to provide the highest-quality of care. They must be able to view a patient’s full medical and treatment history across all settings at the point of care. Physicians must be proactive in how they manage these patients because the risk adjustment process begins even before the patient steps into their office.

However, achieving substantial improvement in health outcomes in the current highly fragmented healthcare system is not a simple task. Even though the federal and state governments are promoting the adoption of EHRs, physicians are often limited to the data in their own EHR system, which is only one piece of the patient’s history.

What physicians need in order to truly transform their model of patient care is the ability to access the patient’s longitudinal health record through an HIE-enabled EHR system. This system architecture enables care providers to see a broader, more complete picture of a patient’s health record. With this type of complete system, physicians can see the discharge reports from a recent hospital stay, which allows them access to critical information at the time and point of care. When a primary care physician is able to view diagnosis and medications prescribed from a patient’s recent visit to their cardiologist, clinical decision making is improved.

Continuity of care also depends on physicians who can share, discuss, and monitor the diagnoses and treatments of their patients across a now interconnected network. This care management model is anchored by close relationships among physicians, who can coordinate care efficiently and achieve quality targets using advanced HIE technologies. To assist its physicians in identifying and treating those patients with gaps in care more quickly and efficiently, NTSP developed a point of care quality application that is driven by the rich clinical content of their HIE. For example, the application highlights specific patients who have failed to have a mammogram at the recommended interval, allowing providers to track adherence to recommended care at the point of care or in an automated fashion prior to the point of care.

Physicians need the tools to clearly see how their patients are adhering to care guidelines, and track measurable action in improving care for chronic conditions and disease management. It is essential that evidence-based guidelines are integrated into the workflow and point of care and that those outcomes are measured to improve quality and reduce unnecessary costs. There should also be built-in transparency. Clinicians must have a clear status of where they stand and how they compare to their peers caring for a comparable population.

All these tasks are achievable by investing in an HIE-enabled EHR infrastructure and using it consistently. An EHR by itself, operating in the “silo” of a physician’s practice or clinic, does not provide the longitudinal record of a patient’s health that is critical to providing continuity of care. NTSP not only has invested in EHRs, but also in an HIE, which enables its providers to coordinate and, therefore, improve the quality of care of its patient population base.

What Should an ACO Look Like?
Pioneers at the Brookings-Dartmouth Accountable Care Organization Learning Network describe an ACO as having four major components: population health management, care management, performance management, and payment mechanisms. NTSP addresses each of these components with its HIE-enabled EHR infrastructure.

Population Health Management—It is important to identify the patient population before prescribing any treatments. NTSP’s integrated EHR system allows all physicians to have a clear picture of the defined patient population. Providers can identify at-risk patients, stratify them into risk categories by disease, and make assessments of appropriate care interventions before patients are seen. This proactive view enables providers to assess risk and proactively manage the identified risk of the patients. By having access to the member/claims and electronic clinical data, providers can identify at-risk patients and stratify them into risk categories by disease. For instance, when a patient visits their primary care physician and has indications of diabetes, the provider is able to take the appropriate action, such as encouraging the patient to engage in a structured diabetes management program.

Care Management—A successful ACO will possess advanced care coordination through all facets of the patient’s care beyond the primary care physician. Specialty care providers, home health agencies, ambulatory care providers, and acute care facilities should all play an active role in the patient’s care management and accountability for outcomes. High quality, coordinated care management is anchored by close relationships among all care providers and is focused on reducing costs through clinical integration. It must be a patient-centered, evidence-based care model adopted by all medical practices for maximum effectiveness. Best practices for care are shared, discussed, and monitored across the virtual network, supported by rigorous reviews and the establishment of clear links between quality measures and reimbursement.

The longitudinal view of a patient’s care made possible with a HIE, including presentation of a comprehensive list of medications, can have a direct and significant impact on continuity of care. Possible medication adherence problems can be detected by NTSP’s quality management application. For example, a patient with diabetes and hypertension who is not refilling his or her anti-hypertension medication is flagged prior to the patient’s scheduled visit, regardless of the reason for the appointment. Diabetes complications can be avoided by giving providers access to these tools and the opportunity to initiate a conversation with the patient about challenges with adhering to the prescribed regimen. Physician-patient communication is improved and potential diabetes complications avoided.

Performance ManagementNTSP’s performance management applications are supported by a data warehouse that is populated by the transactions originating from the HIE. NTSP recognized early on that achievement of quality measure targets can only occur when physicians can see the underlying patient data affecting their performance and how they compare to other providers with similar patient panels. Physicians are able to access online dashboards providing an assessment of the patient panel in terms of key quality measures; detailed information on patients outside of the desired range for a particular measure is easily accessible to facilitate prompt action. In addition, quality scorecards presenting comparative analysis on key quality measures fosters adoption of care guidelines and changes in the practice to improve performance. The use of HIE-enabled electronic health records as the source of data for the data warehouse, in addition to health insurance claims, improves the usefulness of information used in quality improvement efforts and acceptance of quality reporting by the physicians.

Payment Mechanisms—Finally, most IPAs already have the contract management, service utilization, and provider payment processes in place that an ACO requires. A robust information technology infrastructure is needed to define projected cost savings, track actual results, and distribute payments to providers based on their performance on quality targets. The financial model implemented by the IPA, whether it be shared savings, bundled payments, or risk management, must be supported by an advanced HIT infrastructure that is able to assist the organization in defining parameters and tracking progress appropriately. Access to a comprehensive repository of the defined population’s utilization of services is an essential element of the financial models that the ACO will need to administer.

NTSP IPA: A Working Model for ACOs
The formation of ACOs in most markets will require affiliated organizations to establish unified governance, a shared health information technology infrastructure, and financial incentives that are aligned with a common set of quality goals. NTSP and other IPAs with at-risk managed care contracts as their core business have confronted these challenges and serve as a playbook for the independent network of health care organizations that is examining what needs to be done to form an ACO. The physicians at NTSP know their patient population; they have access to a universal set of care guidelines and the comprehensive record of a patient’s healthcare that is needed to make informed clinical decisions. The IPA’s investment in an EHR system supported by a health information exchange enables these capabilities and has contributed to savings in the management of its Medicare at-risk population. As a result, NTSP is poised to leverage these investments into becoming part of a successful ACO.

Karen van Wagner is president and CEO of North Texas Specialty Physicians, Fort Worth, Texas. John Gorman is CEO of the Gorman Health Group, LLC, Washington, D.C.

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