For Robert Pearl, M.D., accountable care-a delivery model in which providers are rewarded on outcomes, not volume-is an idea whose time has come. “Health care is fragmented and it resembles a 19th century cottage industry more than an integrated delivery system,” says Pearl, chairman of the Council of Accountable Physician Practices, an offshoot of the American Medical Group Association. Doubling as CEO of the Oakland, Calif.-based Permanente Medical Group, Pearl says the council’s 30-plus large group practices-spanning such disparate locales as rural Montana and urban Massachusetts-face multiple common challenges in fulfilling the care coordination underpinnings of accountable care.
It’s a model in which providers may be at risk for the so-called “total cost of care,” meaning all services delivered to patients across the multitude of settings-the physician office, the emergency department, the hospital, the rehab facility and the nursing home, among others.
Four key factors underscore the challenge, Pearl says. First is the lack of overall structural integration. “The physician has his own office and they have a collegial relationship with other providers, but typically patients maintain multiple physician relationships,” Pearl says. “You need a structure to pull these people together.” Second has been an historic absence of economic incentives to reward providers on outcomes, Pearl says. That is changing under the ACO model, in which health systems can receive bonuses for delivering better outcomes and avoiding readmissions, if not hospitalizations themselves. The I.T. requirements are a third barrier, Pearl says. “If you can’t exchange information rapidly and follow the patient from inpatient to outpatient and back, it is very difficult to coordinate care.” The final challenge-and most critical, Pearl contends-is establishing leadership by physicians, “as opposed to accountants,” to drive and lead the effort.
Following are snapshots of four organizations embracing the ACO model.
Location: Marlton, New Jersey
Size: 4 hospitals, 250 employed physicians
Project: Medicare Shared Savings ACO
Challenge: Building Out an I.T. Portfolio
On the I.T. continuum, Virtua is highly advanced-earlier this year it garnered Stage 6 on the EHR adoption model of HIMSS Analytics, putting it among a small percentage of health systems nationwide in the seven-rung measurement of system capability. Supporting its multiple care settings and service lines, Virtua’s I.T. portfolio reads like a who’s who of the HIMSS conference vendor floor, thanks to a longstanding “best of breed” approach to systems acquisition. Virtua’s core systems include: Siemens (inpatient); NextGen (ambulatory); McKesson (document management); Cerner (lab); GE (PACS); Allscripts (home care); Compudata (nursing home); and Caradigm (data warehouse). Its ACO profile is equally diverse, as Virtua is involved in four overlapping efforts-a Medicare ACO with CMS (12,000 covered lives); its own ACO through a self-insurance plan for employees (10,500); a Medicare Advantage ACO with Aetna (1,100); and a pending project with a commercial payer (14,000). Beyond that, Virtua treats some 150,000 patients through its medical home effort, although quality-based reimbursement won’t commence until 2014.
To support these programs, Virtua needed even more tools, says erstwhile CIO Al Campanella, who now serves as executive vice president, strategic business growth and analytics. The health system has turned to yet another vendor, Alere, for four additional I.T. components-a private health information exchange, a clinical decision support and analytics application, a care coordination documentation system and some 500 home monitoring devices to track blood clotting remotely and feed data back via the HIE. Virtua picked Alere after a year-long review of 15 vendors. “We identified 90 requirements to administer these (ACO) programs. We didn’t want to rebuild our data warehouse infrastructure,” Campanella says.
While the technology package may seem staggering, for CMIO Jim Gamble, M.D., “I.T. is the easiest part. The ACO model changes the way practices operate. Even though we’re automated, we are used to taking care of one patient at a time. In this model, you still take care of patients one at a time, but now we are asking practices to manage patient populations.”
In the shared savings program with Medicare-Virtua’s 800-pound gorilla-the health system is embarking on a three-year journey. During that time, performance will be measured against 33 quality and patient satisfaction metrics that are universal among the 100-plus health systems nationwide participating in the program. For participating hospitals, CMS establishes a projected expense budget, and if hospitals meet the quality measures, and beat the anticipated outlays, they will share in the savings. The amounts may vary widely, but some larger health systems figure they could receive several million dollars in bonuses.
Like other ACOs, Virtua is creating new “care coordinator” roles to help monitor patients most at risk for complications and costly ED visits or hospitalizations. Among Virtua’s 12,000 core Medicare patients, perhaps 10 percent are at-risk, Gamble estimates. But as the program gets underway, Virtua will deploy various data mining tools to identify these populations more precisely, Campanella says. Such “risk stratification” analysis will help identify which patients to monitor most closely, the executives say.
Risk assessment is complicated affair, however. Alere’s “DiagnosisOne” rules engine will sit atop Virtua’s data warehouse and monitor select data marts to identify these patients, Campanella explains. The data mart receives a number of feeds, from Virtua’s internal systems, from external providers participating in the HIE, and from CMS, which will provide monthly claims data for patients attributed to Virtua. Figuring out which subsets of data to monitor is the next task, Gamble notes, but the goal will be to identify both gaps in care (such as a missing or overdue lab test) or triggering events (such as an ED admission or hitting a certain age that calls for screening tests). Those alerts will be published to a dashboard monitored by the care coordinators, a group of nurses who themselves specialize in various chronic conditions.
Care coordinators will document their efforts in an app from Alere, which will append to the NextGen EHR, Gamble says. But care coordinators have more to do than just monitor clinical conditions, Campanella notes. Virtua is deploying Microsoft software used to manage customer databases to serve as the care coordination administrative backbone. The tool will track the underlying business arrangements for the patients, including their membership in a care coordination contract and their completion of various consent forms. “There are many administrative attributes to keep track of and we could find nothing on the market to do it, so we are adapting Microsoft,” Campanella says.
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