Earlier this year, The Centers for Medicare and Medicaid Services announced some 450 participants in its bundled payment program, one of many flavors of accountable care. The bundled payment model aims at improving outcomes and reducing costs for a select group of procedures and related services.
If nothing else, the announcement gave a shot in the arm to the accountable care movement, offering a concrete example of just how broad the shift away from fee-for-service to fee-for-value is. “It’s the largest voluntary Medicare accountable care model,” notes Rob Lazerow, a senior consultant at the Advisory Board Company. “It has nearly twice as many provider organizations compared to those participating in the shared savings program. It represents a big spike in experimentation.”
To Lazerow, 2013 is emerging as the year of accountable care. He notes that in addition to the Medicare efforts, a large number of commercial health plans are forging partnerships with providers with the same goals.
Although falling under the ACO framework, which reimburses based on outcomes, not productivity, these arrangements are widely varied, he says. “Some are contractual or incentive models; some are joint ventures,” he says. “We are starting to see many partnerships, with payers and providers coming together.”
Regardless of the model in play, the I.T. challenges are many, as data capture, sharing and analytics form the cornerstone of reimbursement reform. Following are snapshots of three ACOs currently under way with both commercial and public payers.
Provider:Bon Secours Medical Group, Richmond, Va.
Payer:Cigna, Bloomfield, Conn.
Project:Collaborative Accountable Care
When it comes to I.T., Bon Secours Medical Group has changed dramatically in just three years, says Robert Fortini, vice president and chief clinical officer. “Three years ago, we had 187 docs and no one live on an EHR,” he recalls. “We are now totally electronic.” As physicians increasingly opt for employment, the group has also ballooned to 440 physicians, who are now part of seven-hospital Bon Secours Virginia Health System. The group’s I.T. portfolio is centered around Epic, which provides Bon Secours’ ambulatory EHR, its inpatient cousin, a patient portal, and disease registries.
Fortini was hired in part to help the practice gain NCQA recognition as a patient-centered medical home, a designation which verifies the presence of EHR tools, patient access policies, and quality programs. To date, Bon Secours has secured NCQA Level 3 (the highest) status at 11 of its 40 primary care sites, with the remainder on target for the certification during the next 18 months. Bon Secours is adapting its various primary care specialties to the NCQA program, seeking certification around such measures as adolescent asthma, obesity and diabetes management.
Bon Secours’ medical home program caught the eye of Cigna, which insures a relatively small portion of Bon Secours’ patients-about 10,000 out of nearly 500,000 total. After Fortini laid out the plans to gain the medical home certification, Cigna offered what it calls a “collaborative accountable care” program, which the payer says has the same population health goals as Medicare’s ACOs.
The Cigna-Bon Secours partnership was launched in April 2012. For its part, Cigna has helped fund the infrastructure costs of an ACO, says Fortini. “Cigna pays a care coordination fee upfront as part of our per-member per-month reimbursement,” he says. “It helps defray the cost and is part of payment reform that is integral to sustainability.” Bon Secours used the money to hire a nurse case manager to help orchestrate and oversee care of high-risk patients.
The nurse is not working in a data vacuum, however. As part of the deal, Cigna provides various reports to Bon Secours on a daily, weekly, monthly and quarterly basis that reveal aspects of care and offer insights into necessary interventions. The analytics provided by Cigna help bolster the data native to Bon Secours’ own EHR, such as a daily summary of patients discharged from its own facilities, Fortini says. “We can only see patients under our sphere of influence,” he says. “Cigna shows us patients that get services from outside our health system.” Cigna also provides a discharge report, which summarizes patients who have left another hospital or visited another ED. “We can see who the high utilizers were. Someone might be using the ED for primary care. We will help them avoid those ED visits and keep the total cost of care down.”
In addition, Bon Secours can use the Cigna data-which is based on claims-to identify care gaps. “If a patient is lacking a prevention screening, such as a mammogram within a five year period, we need to reach out to the patient,” Fortini says. The nurse care manager peruses Epic data in tandem with Cigna data to hone in on at-risk patients. The Epic EHR has been customized to generate registries of patients in need of close scrutiny-such as those with multiple chronic conditions. “Patients who are diabetic, have hypertension and are also obese are walking time bombs,” he says. “They need the most attention and we will reach out to those patients regularly.”
The Bon Secours project is one of many primary care-centric ventures Cigna has launched nationwide, says Frank Brown, M.D., the commercial payer’s executive medical director over its mid-Atlantic region. “We have 52 accountable care initiatives in 22 states with over 500,000 members involved,’ he says. To participate, Cigna requires a patient-centered medical home designation, “which implies an EHR,” and at least 5,000 Cigna members in its patient pool, says Brown. Cigna provides both patient-specific reports, which show care gaps, readmissions, and ED visits, as well as reports at the practice level, which show how well the practice is meeting various quality and cost metrics. “The cost is broken down into inpatient, outpatient, professional series and other costs, such as ambulances and durable medical equipment,” Brown says.
Bon Secours will be rewarded on two fronts. First, if it can meet various quality measures, such as keeping diabetic patients’ blood scores in control, it will receive incentive payments, says Brown. Second, if the overall cost of treating patients is lower than predicted by Cigna’s customized predictive expense modeling system, Bon Secours will receive a gain-sharing payment in the form of a higher per member per month payment.