Some things are already relative clear about the development of accountable care organizations (ACOs), while others remain a bit more murky: that much was agreed on by industry leaders participating in a panel on population health that took place Oct. 8, as part of the Health IT Summit in Washington, sponsored by the Institute for Health Technology Transformation, or iHT2. (Since December 2013, iHT2 has been in partnership with Healthcare Informatics, through the Vendome Group LLC, HCI’s parent company.) The Health IT Summit in Washington is being held at the Westin Arlington Gateway, in Arlington, Va.
The panel, entitled “Key Pillars of Technology for Successful ACOs,” was moderated by Rob Lott, deputy editor of Health Affairs, and included as panelists Micky Tripathi, Ph.D., president and CEO of the Massachusetts eHealth Collaborative; Mark Jacobs, chief information officer of the Delaware Health Information Network; Wen Dombrowski, M.D., aging, healthcare, and technology advisor at Resonate Health, a consulting firm; and Michele O’Connor, director of sales operations, identity, and information governance, for QuadraMed.
ACO discussion panelists (l. to r.): Rob Lott, Mark Jacobs, Micky
Tripathi, Ph.D., Michele O'Connor, Wen Dombrowski, M.D.
Tripathi, an industry-wide leader in health information exchange, health IT policy, and the development of community networks of different kinds, offered strong opinions when asked what some of the key components are and will be in laying the foundation for successful ACOs and similar organizations nationwide. “From a business perspective,” Tripathi said, “what’s needed is to get the alignment into place from the top down. The Pioneer ACO Program” created by the Medicare program under the Affordable Care Act “focused people very quickly. From what we’ve seen, you need to get focused across the board, align everyone, and think very carefully about who the other organizations are that you’ll be working with, either through your direct contract or for other reasons.”
Tripathi added that “You need to focus on the organizations whose work will affect your care delivery directly, and focus on connecting with them first. You can live with paper-based processes with secondary contact organizations at first, but you have to focus right away on major partner organizations and connecting with them electronically.”
Delaware Health Information Network’s Jacobs reported that “A number of ACOs are beginning to form in Delaware. And if you look at the Pioneer ACO program,” he said, “you see a significant growth from year 1 to year 2. And despite some problems, overall, you see about 360 ACOs—Pioneer and MSSP [Medicare Shared Savings Program] together [there were 338 MSSP ACOs and 19 Pioneer ACOs, as of September, after several Pioneer organizations dropped out]—and each is starting to show increases in measured quality, and some are starting to show savings. But as the providers and ACOs begin to act like insurers and get systems and technology for actuarial and population health improvement, you’ll see steady improvement in those areas.”
Asked about critical success factors, consultant Dombrowski said, “On a high level, there are several key success factors. One is having internal capacity—the lead organization really needs to have strong administrative and clinical leadership. And interoperability is a recurring theme with ACOs I’ve worked with, as well as with colleagues affiliated with ACOs. Even though there are HIEs across the country, they’re often not conveying all the information needed to do care management.”
Dombrowski underscored the idea that “Having medication lists and problem lists really isn’t enough. You need the capability to transit and share information across the continuum- of post-acute care—nursing homes, rehab, and so on. And even things like senior centers and social service agencies and other stakeholders out there—I really encourage people to think about who those people are and how they can impact the lives of those most sick.”
Jacobs noted that “We’re small in Delaware, but the fact that we have a health information exchange and have all this data, there’s a big drive now to get the data shared to help manage populations. But we still struggle. You need a good foundation of membership participation and commitment from the community,” he added. “Just going out and buying an analytics solution won’t do it. So until providers learn how to manage risk pools as insurers have done, and learn how to comingle clinical and claims data, we won’t be fully successful.”
Tripathi went back to basics when he said that “I think that the first investment you have to make is in the right people. Forget about technology. There are four key areas,” he said. “First, you need someone who understands provider-network development, and who understands the local landscape. Second, you need someone who understands IT. Do not get fooled by the visualizations; anyone can make any bad data look really, really, good. The third need is for someone who understands care management; and the fourth is someone who understands analytics. What 95 percent of ACOs need is basic analytics: report creation, gathering data together, creating core capabilities. So to me,” he said, “it’s those four key things, and then figuring out very tactical solutions for figuring out how you’ll very practically generate and share data that’s actionable. It sounds really, really simple, but it’s actually really hard. I would focus on those things.”
Jacobs said that, “About six to eight months ago, I went to Dr. David Nash [David Nash, M.D., dean of the Jefferson School of Population Health at Thomas Jefferson University, and a noted thought-leader in U.S. healthcare], and said, where do you see ACOs going? And he said, I would ask them one question: how many actuarial experts do you have on your staff? And we’re creating a shared-savings program in Delaware. And just getting providers and plans together and just getting to consensus on a set of measures against which to measure performance, is very hard. Everyone’s saying, I have the best analytics solution, from those vendors who have never built any to those who have.”
Referring to ongoing capital funding limitations, Dombrowski noted that “Most ACOs don’t have any upfront funding, so they’re really just trying to scrape together what they can. And often, the current chief medical officer or the current chief information officer, are recruited from the current provider organizations. So people are being asked to do extra work in their current positions. So that leads people to become spread thin; or they’re only pulling from a pool of known people. And many of these people are coming from a fee-for-service background then, of course. So they don’t have the expertise they need in managed care work. And I would add to Micky’s point by saying you need policy understanding, too. You might build networks that work this year but maybe not in three to five to ten years from now.”
What’s more, Dombrowski noted, “In terms of care management, you need people who have expertise in high-risk patients. They’re the ones costing us the most money. And even if you have a huge team of IT and analytics gurus, but you don’t understand the factors around the highest-risk patients/plan members, you’re missing the boat.”
As for the near-term future, she added that “The hospitals that are really forward-thinking are trying to position themselves competitively in the local landscape, and they realize that even if they don’t have the human or financial capital now, they realize they need to move ahead. And there is that tension there on the planning and operational side because they don’t have the capital right now.” Yet in the end, she noted, “The shift from fee-for-service payment systems to value-based systems really is a broader movement. And a lot of people are saying, why don’t I wait two or five years and see what everyone else does, and buy things then? But becoming an ACO is more than just infrastructure; it’s a cultural change. You have to change the mindsets of clinicians and administrators, and even patients. It has to be more than just buzzwords in a strategic plan.”