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

#	Domain	Measure Title	NQF Measure #/ Measure Steward	Method of Data Submission	Pay for performance R = Reporting P=Performance
					Year 1	Year 2	Year 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