I saw a great presentation last week by Craig Behm, executive director of MedChi Network Services (MNS), a subsidiary of the Maryland Medical Society that is deeply involved in accountable care organization (ACO) work in rural settings. Behm talked about some of the challenges ACO participants face, especially since many of them are in very small practices with limited resources. He also described some IT and data management issues that have cropped up and the importance of data integrity to the overall mission of ACOs.
MNS is the owner and operator of three Medicare Shared Savings Program Advance Payment ACOs, one in Western Maryland and two on the Eastern Shore. The program is a one-sided model with no downside risk. The potential savings split is 50/50 with CMS.
From the outset, Behm said, it was obvious the ACOs would need robust IT systems. They must allow real-time data sharing in support of population and individual health management across multiple locations. “Without access to high-quality data, you are just working blind,” he said.
To help pay for the IT infrastructure, MSN got a federal non-recourse loan available to physician-led, rural ACOs. (The loan must be repaid with savings or will be forgiven if there are no savings.)
Among the barriers he cited for new participants is that they see ACOs as “just more work” when they already are dealing with meaningful use Stage 2, PQRS, ICD-10, etc.
“We have to avoid overburdening the practices,” said Behm, speaking during a webinar sponsored by health publisher MCOL. All the participants are primary care and independent. The largest is four physicians. “We knew they didn’t have analytics or care management infrastructure,” he explained. “We wanted to be very basic in the way we interacted.”
Luckily for the startup ACOs in Maryland, the state has a fully functioning and sustainable statewide health information exchange, CRISP, that supports Direct messaging and hospital ADT notifications. “The other good news is that only three of the practices don’t have electronic health records,” Behm said. “The bad news is that they use 15 different EHR types.” That brings up all kinds of issues, he added. Interoperability is still non-existent, he said, but at least the data is electronic.
MNS developed proprietary systems for data warehousing and data exchange. The goal is to provide practices with specific analytics regarding their quality and cost and supplement the data with improvement support. One challenge to overcome is that practices don’t want to engage with yet another portal.
Behm noted that enterprise case management/risk stratification systems are expensive. “We are doing some work on that in house,” he said, adding that the larger care management systems you buy out of the box are expensive and for the most part don’t do what they advertise.
A key issue, MNS found, is data integrity at the provider level. “Many practices don’t document EHR data consistently, Behm said. MNS did not foresee this would be a big hurdle, but it ran into lots of documentation issues, with physicians putting data in different places in the EHR. “The quality of data as entered is a huge barrier,” he said. Many EHRs don’t extract data properly, he added.
Among the ACOs’ goals are fewer hospitalizations/readmissions, better chronic disease management, and less emergency department usage. A physician-led ACO board determines policies regarding standard of care and interventions.
Last year, although two of the three ACOs MNS operates did generate savings of around 2 percent, the savings were not enough to split with CMS. (Any potential savings first pays CMS and then the remainder gets distributed, he explained.) The third ACO did not generate savings.
Nevertheless, Behm believes physician-led ACOs can succeed as CMS tweaks the program going forward. He cited some research that suggests small, independent physician groups have done better than larger counterparts at managing quality.
In closing, Behm stressed not being overly disruptive to physician practices. Implementing ACO programs cannot prevent physicians from seeing patients, he said. They are small businesses, and every minute they spend doing administrative work is time they are not earning revenue, he said. Another key is generating enthusiasm about the program. Physicians and staff must want to participate in innovate new programs. “The key to patient engagement is physician engagement,” he said. “You must get them excited about doing better.”
I left his presentation with a new appreciation of the complexity of practice transformation and success in the ACO program.