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Monday, October 24, 2011

Got ACO? You will still need EHR and HealthIT

OK, so I've just finished plowing through nearly 700 pages of the ACO Final Rule.  I also bookmarked the Preview copy, so you can download it from Google Docs for your own reading enjoyment ;-)

As a patient, my main focus in reviewing the rule is what it does for me.  There are few changes from my original review that really impact patients here, except in:

  1. How ACO providers are measured on quality (the final rule uses 33 measures phased in with respect to performance, whereas the proposed rule had 65),
  2. The requirement that a certain percentage of ACO providers were meaningful users of HealthIT.
  3. That Federally Qualified Health Centers and Rural Health Centers can now form (by themselves) and better participate in ACOs (which is great if you happen to live in a rural or underserved area). 
In general, the requirements for patient engagement, and patient participation in ACO governance are still present.

From the Health IT side, I was interested in how the changes impacted the Health IT industry.  They removed a specific requirement on the number of ACO Professionals who are Meaningful Users, but that doesn't really worry me.  Measure 11 has double weight, and is "% of providers who are meaningful users", so that will still have an ACO program impact.

My 140 character summary of the ACO rule from a Health IT perspective?  "Got ACO? You'll still need EHR and HealthIT, even if the regs don't require it."  

The reason for that is the amount of coordination that will be needed by members of the ACO.  The point of shared savings is that the providers actually get a benefit for not duplicating work.  So, if the lab was already done, and provider A has it, then provider B (and everyone else) can potentially benefit from the savings when Provider B uses the existing result.  Recently my wife had knee surgery.  The surgeon wanted a recent EKG.  He would have been incented (under the savings model), to reuse the one my wife already had.  Perhaps not as much as he might have earned from doing it over, but the world is not perfect.

There are a couple of places where Health IT and EHRs will really matter to ACOs:
  1. Assessing the health needs of the patient population.
  2. Identifying High-Risk Individuals and support of individualized care planning
  3. Supporting the use of evidence based medicine (e.g., through clinical decision support).
  4. Reporting on Quality Measures
  5. Managing care through an episode, including transitions between providers
  6. Dealing with monthly claims data and quarterly aggregates
Page 178 of the Final Rule points out that coordination of care between ACO participants and non-participants is one way to accomplish ACO goals.  Amusingly enough, some commenters were looking for CMS to fund some of the IT Investments needed.  CMS points these commenters to the Meaningful Use program for Health IT and EHR incentives.
  

For those of you who are interested in how ACOs will be measured, Table 1 from the final rule shows the quality measures (You can also find this on page 324 of the final rule text in the Federal Register Preview).

 
Table 1 Measures for Use in Establishing Quality Performance Standards that ACOs Must Meet for Shared Savings

#DomainMeasure TitleNQF Measure #/ Measure StewardMethod of Data SubmissionPay for performance
R = Reporting P=Performance
Year 1Year 2Year 3
AIM: Better Care for Individuals
1 Patient/Caregiver Experience CAHPS: Getting Timely Care, Appointments, and Information NQF #5, AHRQ Survey R P P
2 Patient/Caregiver Experience CAHPS: How Well Your Doctors Communicate NQF #5 AHRQ Survey R P P
3 Patient/Caregiver Experience CAHPS: Patients' Rating of Doctor NQF #5 AHRQ Survey R P P
4 Patient/Caregiver Experience CAHPS: Access to Specialists NQF #5 AHRQ Survey R P P
5 Patient/Caregiver Experience CAHPS: Health Promotion and Education NQF #5 AHRQ Survey R P P
6 Patient/Caregiver Experience CAHPS: Shared Decision Making NQF #5 AHRQ Survey R P P
7 Patient/Caregiver Experience CAHPS: Health Status/Functional Status NQF #6 AHRQ Survey R R R
8 Care Coordination/ Patient Safety Risk-Standardized, All Condition Readmission* NQF #TBD CMS Claims R R P
9 Care Coordination/ Patient Safety Ambulatory Sensitive Conditions Admissions: Chronic Obstructive Pulmonary Disease (AHRQ Prevention Quality Indicator (PQI) #5) NQF #275 AHRQ Claims R P P
10 Care Coordination/ Patient Safety Ambulatory Sensitive Conditions Admissions: Congestive Heart Failure (AHRQ Prevention Quality Indicator (PQI) #8 ) NQF #277 AHRQ Claims R P P
11 Care Coordination/ Patient Safety Percent of PCPs who Successfully Qualify for an EHR Incentive Program Payment CMS EHR Incentive Program Reporting R P P
12 Care Coordination/ Patient Safety Medication Reconciliation: Reconciliation After Discharge from an Inpatient Facility NQF #97 AMA-PCPI/NCQA GPRO Web Interface R P P
13 Care Coordination/ Patient Safety Falls: Screening for Fall Risk NQF #101 NCQA GPRO Web Interface R P P
AIM: Better Health for Populations
14 Preventive Health Influenza Immunization NQF #41 AMA-PCPI GPRO Web Interface R P P
15 Preventive Health Pneumococcal Vaccination NQF #43 NCQA GPRO Web Interface R P P
16 Preventive Health Adult Weight Screening and Follow-up NQF #421 CMS GPRO Web Interface R P P
17 Preventive Health Tobacco Use Assessment and Tobacco Cessation Intervention NQF #28 AMA-PCPI GPRO Web Interface R P P
18 Preventive Health Depression Screening NQF #418 CMS GPRO Web Interface R P P
19 Preventive Health Colorectal Cancer Screening NQF #34 NCQA GPRO Web Interface R R P
20 Preventive Health Mammography Screening NQF #31 NCQA GPRO Web Interface R R P
21 Preventive Health Proportion of Adults 18+ who had their Blood Pressure Measured within the preceding 2 years CMS GPRO Web Interface R R P
22 At Risk Population - Diabetes Diabetes Composite (All or Nothing Scoring): Hemoglobin A1c Control (<8 percent) NQF #0729 MN Community Measurement GPRO Web Interface R P P
23 At Risk Population - Diabetes Diabetes Composite (All or Nothing Scoring): Low Density Lipoprotein (<100) NQF #0729 MN Community Measurement GPRO Web Interface R P P
24 At Risk Population - Diabetes Diabetes Composite (All or Nothing Scoring): Blood Pressure <140/90 NQF #0729 MN Community Measurement GPRO Web Interface R P P
25 At Risk Population - Diabetes Diabetes Composite (All or Nothing Scoring): Tobacco Non Use NQF #0729 MN Community Measurement GPRO Web Interface R P P
26 At Risk Population - Diabetes Diabetes Composite (All or Nothing Scoring): Aspirin Use NQF #0729 MN Community Measurement GPRO Web Interface R P P
27 At Risk Population - Diabetes Diabetes Mellitus: Hemoglobin A1c Poor Control (>9 percent) NQF #59 NCQA GPRO Web Interface R P P
28 At Risk Population - Hypertension Hypertension (HTN): Blood Pressure Control NQF #18 NCQA GPRO Web Interface R P P
29 At Risk Population – Ischemic Vascular Disease Ischemic Vascular Disease (IVD): Complete Lipid Profile and LDL Control <100 mg/dl NQF #75 NCQA GPRO Web Interface R P P
30 At Risk Population – Ischemic Vascular Disease Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic NQF #68 NCQA GPRO Web Interface R P P
31 At Risk Population - Heart Failure Heart Failure: Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) NQF #83 AMA-PCPI GPRO Web Interface R R P
32 At Risk Population – Coronary Artery Disease Coronary Artery Disease (CAD) Composite: All or Nothing Scoring: Drug Therapy for Lowering LDL-Cholesterol NQF #74 CMS (composite) / AMA-PCPI (individual component) GPRO Web Interface R R P
33 At Risk Population – Coronary Artery Disease Coronary Artery Disease (CAD) Composite: All or Nothing Scoring: Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Patients with CAD and Diabetes and/or Left Ventricular Systolic Dysfunction (LVSD) NQF # 66 CMS (composite) / AMA-PCPI (individual component) GPRO Web Interface R R P

*We note that this measure has been under development and that finalization of this measure is contingent upon the availability of measures specifications before the establishment of the Shared Savings Program on January 1, 2012.


In case you want a quick summary of what's changed financially, Table 5 from the final rule summarizes the changes between the Proposed rule and the Final Rule.  You can also find this on page 396 of the Final Rule text  (in the Federal Register Preview).

Table 5: Share Savings Program Overview


One-Sided Model
Two-Sided Model
Issue
Proposed
Final
Proposed
Final
Transition to Two-Sided Model   
Transition in third year of first  agreement period  
First agreement period under  one-sided model. Subsequent  agreement periods under two- sided model
Not Applicable   
Not Applicable   
Benchmark 
Option 1 reset at the start of each  agreement period.
Finalizing proposal 
Option 1 reset at the start of  each agreement period.
Finalizing proposal. 
Adjustments for health status and  demographic changes                
Benchmark expenditures adjusted  based on CMS-HCC model.                
Historical benchmark  expenditures adjusted based on  CMS-HCC model.  Performance year: newly  assigned beneficiaries adjusted  using CMS-HCC model;  continuously assigned  beneficiaries (using  demographic factors alone  unless CMS-HCC risk scores  result in a lower risk score).  Updated benchmark adjusted  relative to the risk profile of the  performance year.    
Benchmark expenditures  adjusted based on CMS- HCC model.               
Historical benchmark  expenditures adjusted  based on CMS-HCC  model.  Performance year :  newly assigned  beneficiaries adjusted  using CMS-HCC  model; continuously  assigned beneficiaries  (using demographic  factors alone unless  CMS-HCC risk scores  result in a lower risk  score). Updated  benchmark adjusted  relative to the risk  profile of the performance year.
Adjustments for IME and DSH    
Include IME and DSH payments    
IME and DSH excluded from  benchmark and performance  expenditures  
Include IME and DSH  payments   
IME and DSH  excluded from  benchmark and  performance  expenditures
Payments outside Part A and B claims  excluded from benchmark and  performance year expenditures;   
Exclude GME, PQRS, eRx, and  EHR incentive payments for eligible  professionals, and EHR incentive  payments for hospitals  
Finalize proposal     
Exclude GME, PQRS, eRx,  and EHR incentive  payments for eligible  professionals, and EHR  incentive payments for  hospitals
Finalize proposal     
Other adjustments   
Include other adjustment based in  Part A and B claims such as  geographic payment adjustments  and HVBP payments
Finalize proposal   
Include other adjustment  based in Part A and B  claims such as geographic  payment adjustments and HVBP payments
Finalize proposal    
Maximum Sharing Rate   
Up to 52.5 percent based on the  maximum quality score plus  incentives for FQHC/RHC  participation
Up to 50 percent based on the  maximum quality score  
Up to 65 percent based on  the maximum quality score  plus incentives for  FQHC/RHC participation
Up to 60 percent based  on the maximum  quality score 
Quality Sharing Rate 
Up to 50 percent based on quality  performance
Finalizing proposal 
Up to 60 percent based on  quality performance
Finalizing proposal 
Participation Incentives  
Up to 2.5 percentage points for  inclusion of FQHCs and RHCs 
No additional incentives  
Up to 5 percentage points  for inclusion of FQHCs and  RHCs
No additional  incentives 
Minimum Savings Rate 
2.0 percent to 3.9 percent depending  on number of assigned beneficiaries
Finalizing proposal based on  number of assigned beneficiaries
Flat 2 percent 
Finalizing proposal:  Flat 2 percent
Minimum Loss Rate 
2.0 percent 
Shared losses removed from  Track 1
2.0 percent 
Finalizing proposal 
Performance Payment Limit
7.5 percent.
10 percent
10 percent
15 percent
Performance payment withhold
25 percent
No withhold
25 percent
No withhold
Shared Savings  
Sharing above 2 percent threshold  once MSR is exceeded 
First dollar sharing once MSR is  met or exceeded. 
First dollar sharing once  MSR is exceeded. 
First dollar sharing  once MSR is met or  exceeded.
Shared Loss Rate     
One minus final sharing rate     
Shared losses removed from  Track 1    
One minus final sharing rate     
One minus final  sharing rate applied to first dollar losses once  minimum loss rate is  met or exceeded;  shared loss rate not to  exceed 60 percent
Loss Sharing Limit 
5 percent in first risk bearing year  (year 3).
Shared losses removed from  Track 1.
Limit on the amount of  losses to be shared phased in over 3 years starting at 5 percent in year 1; 7.5 percent in year 2; and 10 percent in year 3. Losses in excess of the annual limit would not be shared.
Finalizing proposal 

4 comments:

  1. Great post Keith!

    We should also push ACOs to be required to put together patient education resources ... at the very least a website for cryin out loud. More on what doctors should be prescribing: http://www.healthcaremarketingcoe.com/health20/what_should_physicians_be_prescribing.php

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  2. Nice information about health care. I like it.
    Thanks ..Medical Simulation

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  3. Well written and informative. Thanks, and we will post on Twitter & LinkedIn ...

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  4. Great work Keith! Another good reference for us. Thanks, Justin

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