In their second year, the Center for Medicare & Medicaid Innovation’s 32 Pioneer accountable care organizations (ACOs) are gleaning many nuggets of wisdom in their bid to achieve the triple aim of improved care, improved health and lower per-capita costs.
Pioneer ACOs are cutting edge among Centers for Medicare & Medicaid (CMS) ACO programs in their efforts. In 2012, Pioneer ACOs began testing various payment arrangements that offer higher levels of risk and reward as compared to other ACO programs, including the Medicare Shared Savings Program. To that end, ACOs are held financially accountable for the care delivered to their patients, as well measurable health outcomes for these individuals.
“I liken Pioneer ACOs to a poker hand,” says Brian Hodgkins, PharmD, executive vice president of Heritage ACO, a pioneer ACO covering 90,000 beneficiaries in central and southern California. He spoke during a California Healthcare Foundation webinar in April. As the risks will be higher, the need for strong IT strategies is especially essential to positively impact quality measures. “We’re starting to see that data are everything. Data and IT systems are probably going to be the most strategic parts of any ACO,” he says. “Success is within your ability to manage data, and understand population management shifts and risk stratification.”
For Pioneer ACOs, strong data strategies are critical to making progress on improving CMS’ quality measures. However, these ACOs are reporting many stumbling blocks in optimizing IT systems.
In the Michigan Pioneer ACO, which encompasses 800 primary care physicians (PCPs) and 1,200 specialists who cover 23,000 Medicare beneficiaries, the move to a new EMR proved challenging.
“Change is always hard. We had a homegrown EMR that was customized to our clinical workflows and our physicians were well versed in how to use that but it lacked a lot of functionary that is necessary for Meaningful Use,” Timothy A. Peterson, MD, MBA, medical director of population health and medical director of Pioneer ACO at University of Michigan Health System, told Clinical Innovation + Technology in reference to his organization—a major player in the ACO.
From an IT perspective, he says reporting on quality measures proved difficult as participating providers operated in a variety of EMRs.
“One private office still is on a partial paper system,” Peterson says. “It’s increasingly clear that it’s imperative that EMRs figure out a way to talk to each other. It is not going to be a long-term, sustainable solution for each physician group or health system to be locked into an EMR with a proprietary software system that cannot trade information with all other software systems.”
Lack of interoperability also surfaced as a major issue at Beacon Health, a Pioneer ACO that includes more than 14,000 Medicare beneficiaries from the Eastern Maine Healthcare System (EMHS) and other organizations.
During the first year, the EMHS providers used the same inpatient and outpatient records, but as more outside entities joined the ACO, IT challenges came to the fore.
Iyad Sabbagh, MD, MBA, medical director for accountable care activities at EMHS, reported on the struggle in handling a multitude of EHR systems at a February webinar hosted by the statewide coalition Maine Quality Counts.
“Year two brought challenges because all the new organizations that came on board had different systems and different platforms. One lesson we are learning right now is how to input information and extract it from the EHRs and how to capture and report it,” he says.
The differing connection speeds at the organizations also posed challenges, and the ACO had to factor in how fast data flowed in and out of Maine’s HealthInfoNet, the state’s health information exchange (HIE), Sabbagh adds.
The Maine ACO developed a framework that moved IT through four different levels including case management, panel management, operation analytics and strategic analytics.
“Our IT department initiatives are in place for our accountable care collaborators,” he says, explaining that they built electronic tools that provide data on patients. Once they receive the beneficiaries’ claims files, they pull quality data from the HIE and that tool allows risk analysis and predictive modeling of the patients, leading to better care coordination, he explains.
Risk stratification & care coordination
Using data to target beneficiaries that are high utilizers, or those with complex and chronic diseases that influence the quality measures, is critical, says Hodgkins.
“If you’ve got 1,000 patients assigned to your ACO, odds are it’s not realistic or cost efficient to wrap care coordination systems around all 1,000,” says Karen Driskill, RN, vice president of Heritage Provider Network and vice president of Heritage ACO, who also participated in the California Healthcare Foundation webinar. “You need to take the data and run them through algorithms.”
Data—including EMR, claims, pharmacy and laboratory information—should be scrubbed and stratified “at least monthly” to identify high-risk beneficiaries, she advises.
Once obtaining that list of high-risk beneficiaries, Heritage ACO clinical staff reach out and perform assessments by phone or face-to-face to obtain baseline information on the patients.
For patients leaving the hospital, timely communication of transition care plans to all stakeholders is vital, Driskill explains. Post discharge, she says managers within inpatient teams review follow-up instructions to patients with a focus on self-management within 72 hours and pharmacists reconcile medications within three to 10 days. She emphasizes the importance of clarifying in writing all the elements of the wraparound care coordination for both the beneficiary and care team, and making a contact person available at all times to answer questions.
“People remember 10 percent of what they are told when transitioning out. It’s inherently important that everything is in writing,” she says, adding that this work to proactively address gaps also prevents readmissions.
A transparent IT infrastructure through which a care team member can log into a portal and learn about a patient’s history is essential, Driskill says.
“The whole point behind coordinated care systems is to frantically get in front of the coordination process.”
“Every 15 minutes we get a new data feed of any encounter, acute or ambulatory,” she says. Getting real-time reports of emergency department encounters, readmissions and ambulance encounters instead of waiting for claims to come in 30 to 60 days later is “the single, most critical element.”
At the Michigan Pioneer ACO, efforts to date have centered on adding resources to their primary care network to bolster care management, according to Peterson.
Care managers—inclusive of social workers, dieticians and pharmacists—work together to coordinate care. In particular, he says the ACO is creating a pharmacy program where clinical pharmacists work directly in PCP offices.
“Pharmacists act as a nice intermediary to the physician and help the physician change the medical regimen of the patient so it’s more tolerable, easier to maintain and easier to afford,” Peterson says. E-prescribing platforms that recommend generics have led to an increase of generic prescribing rates at the ACO, he says.
“Our patients are thrilled with the pharmacy interventions they get in the clinic. They report to us they are taking their medications better than they used to, and the pharmacists report to us that they have had substantial impact in helping patients get on their regimens,” he says.
Because patients can use providers outside of the ACO network under the Pioneer ACO program, “it’s really key to have real-time, actionable clinical data wherever a patient travels in the healthcare system. That’s going to be absolutely imperative to the success of any real meaningful change in the coordination of patient care as they travel across systems,” he says.
Peterson reiterates that interoperability hurdles hinder efforts.
“The single greatest frustration we have from a care coordination perspective is getting timely, meaningful and reliable data that can be integrated from one health system EMR or even into our analytics data software that we use in a separate data warehouse,” he says, adding that it is a problem widely reported among all Pioneer ACOs.
The Pioneer ACOs report strong satisfaction among beneficiaries covered under the program.
“Patients are surprised we are finally connecting the dots and that the right hand knows what the left hand is doing. That element didn’t happen five to 10 years ago,” Sabbagh says about the Maine Pioneer ACO experience.
The ACO already has seen improvement in 19 out of 23 clinical measures, he says. They have embedded care management at PCP practices and are currently adding more partners. “We saved money for the first six months and had positive outcomes.”
Peterson likewise reported Michigan’s Pioneer ACO project is going well, and it positions them for whatever payment model ultimately is adopted in the future.
“We’re confident that fee-for-service will go the way of the dinosaur. This creates that imperative to move our whole organization in a direction that’s more nimble and that’s more pointed to the future.”