How would a Patient define a medical home?

I've been hearing a lot about patient-centered medical homes again.  The topic first hit my radar screen sometime in 2006-7 when it heated up again, after what appears to be a re-introduction of it some time in the early 21st Century.  When PCMH first showed up (on my radar), it appeared to be the next big thing.

I took a sniff at what it espoused back then in order to figure out what its impact would be on my day job.  As I looked deeper into it, the technology, standards, and information requirements of a PCMH were just what I'd have expected, and so, it being more about physician business models, it passed through my consciousness pretty much without impact.  (The same could be said for Accountable Care Organizations).

Any information worker understands that you need data to do your job, and that the better and quicker it flows, the more able and effective you can be.  Physicians are information workers, whether they realize it or not.  They are containers (silos even?) and distributors of highly specialized knowledge and services.

Given that the topic has blipped three different times this week on my radar, I thought I'd take a crack at really looking at it with my patient perspective.  You know, that viewpoint from behind spring-green colored glasses.

1. A patient centered medical home is about me, after all, I'm the patient.
2. It's where I prefer to go for medical care, including information, diagnosis and treatment.
3. When I go there, they have to take me (isn't that the definition of home).  And that means not just 9-5, Monday to Friday, but all hours and all times of day that I (or a family member) could get sick.
4. At home, I know where to find stuff.  A PCMH makes it easy for me to get information, about my conditions, my treatments, my appointments, and my diagnostic studies and tests.
5. At my PCMH, they can care for me for MOST of the problems that I have to deal with.  If it's obscure, or requires specialty care, they know where to go.
6. When I call, someone I know answers the phone.
7. At home, they know who I am.  I don't have to reintroduce myself every time.
8. Finally, staying at home is cheaper for me that going elsewhere.

Most of what I've stated above is simply a patient centered restatement of many of the principles espoused by organizations such as NCQA, ACP, AAP, AAFP and others.  None of how I describe it has to do with technology directly, although all of it can be assisted by technology.  One of the most interesting disparities between my idea of "patient centered" and the one in the link above is when you compare my statement #8 above with this one from the 2007 Principles Document: 

Payment appropriately recognizes the added value provided to patients who have a patient-centered medical home. 

Note that what I have to say is not incompatible with the previous statement, but it certainly doesn't belong in a "patient-centric" document as stated above.  What I think patients want is stated quite clearly and objectively.  This will cost less (and if you can do it and make more money, that's fine, but do make sure we're spending less on healthcare). At least that's one of my values.

Half of ACO Quality Measures are in MeaningfulUse

I was doing a review of the ACO Quality Measures yesterday.  One thing I noted was that at least half of them are also in Meaningful Use.  The cool thing about that is that this team has already reported that most MU measures can be computed from the HITSP C32 with the addition of procedures section, and that nearly all can be addressed by adding smoking status and vitals (see pages 4-6 of their paper).

What about the other half?  Well, six of them come from what will now be a CMS supported survey, three of them come from claims data, and another one comes from Meaningful Use attestation reports.  So, of the remainder, what isn't in Meaningful Use Stage 1, and can it be computed from the HITSP C32?

These are the remaining measures:

1. Medication Reconciliation at Discharge (NQF #97)
2. Fall Risk Screening (NQF #101)
3. Depression Screening (NQF #418)
4. Proportion of Adults 18+ who had their Blood Pressure Measured within the preceding 2 years (CMS)
5. Diabetes Measures (NQF #729
6. Ischemic Vascular Disease (IVD): Complete Lipid Profile and LDL Control (NQF #75)
7. Treatment for CAD w/ Diabetes/LVSD (NQF #66)

Looking at each of these:

Fall Risk (#2) and Depression (#3) screening assessment scores can be recorded in the HITSP C32 Results section.  So, if you find an assessment result, you can tell that these have been done.

The diabetes measures (#5) are from the MN Community Measurement instrument.  These account for five separate measures in the ACO rule and are very simple to compute from CCD medications, results, vital signs or social history (for tobacco use) sections:

1. HgA1C < 8
2. LDL < 100
3. BP < 140/90
4. Tobacco Non-Use
5. Aspirin Use

The IVD (#6) and CAD (#7) measures can also be readily computed, as they are very similar to other computable results in Meaningful Use stage 1.

That just leaves #1, Medication Reconciliation on discharge.  Because the CCD is not a discharge summary, you'd really want to look at a different document to compute that measure.  But if you did open up a discharge summary, and found one of the required entries of the IHE RECON profile, you could be assured that medication reconciliation was performed at discharge.

So, half of ACO measures are meaningful use measures, and you should be able to compute nearly all of the the other half from the standards already required for Meaningful Use stage 1.  And it could even get better under stage 2 when we have other documents supported for Transitions of Care.

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

The focus is changing in HealthIT

Why do EMR systems come with ICD-9-CM codes installed instead of SNOMED CT?  It may very well be that it's because that's what providers get paid for.  It used to be common wisdom that biggest reason for installing an EHR was to improve upon payment.  With meaningful use, the focus is shifting from that to exchange of clinical data.

If you look at the ACO rules, the shift is also towards exchanging clinical data.

If you look at some of the work happening in Health Information Exchanges that payers are setting up, there also is a move towards clinical data exchange.

If you look at the recent work of the HIT Standards committee, you see the focus on quality measures has shifted to clinical vocabularies.

I welcome this shift, and see it as the start of a Healthcare Revolution.

This sort of revolution won't be without its challenges.  We definitely need established mappings from ICD-9-CM and ICD-10-CM to SNOMED CT to support them.  As HIMSS mentions in their post, it could take some time to implement.

A sumary of a summary: What is an ACO and how does HealthIT matter?

This is in response to a request from a colleague that I simplify my summary of the proposed ACO rule from Friday. This summary is based on that post, and vastly simplifies the 427-page rule. Read the post from Friday, or better yet, the rule and various commentary on it for full details (see the Friday post for links).

What is an ACO?
An ACO is an organization that contracts with CMS to take responsibility for care of patients, agreeing to terms that include providing high quality, patient-centered, evidenced-based care.  In so doing, the ACO hopes to reduce costs of care incurred by those patients. When those patients are Medicare eligible, and the ACO provides most of the primary care for that patient, the ACO can receive incentive payments from Medicare. If it fails to reduce costs, it would share (eventually) in the increased expense by paying Medicare back. In order to receive incentive payments, an ACO must report quality measures, exceed certain thresholds in quality and patient experience, and generate a savings over baseline costs as established by Medicare. If it "wins" (meets all quality and cost goals set by CMS), it can get a significant chunk (more than half) of that savings back.

An ACO can be formed by doctors, nurse practitioners, clinical nurse specialists and physician assistants, and hospitals that employ them. It can also include Federally qualified Health Centers and Rural Health Centers. CMS has some additional incentives for an ACO if they do. It can also include Skilled Nursing Facilities, Nursing Homes, Long Term Care Hospitals and Critical Access Hospitals.

An ACO must be a legal entity, and might be an existing legal entity if appropriately structured and governed. Governance requirements include a certain percentage of physician control, existence of physician directed quality programs, and patient involvement.

As a patient, if your primary care provider becomes part of an ACO, your rights don't change. You still have the option to get care anywhere you want, just as you have today. However, a couple of things will be different. CMS and your provider will tell you about the ACO. You will be given the option to opt-out of sharing certain data that CMS has on you with the ACO. The ACO will communicate with you clearly about your care options, and will make it easy to get access to your records, and transfer them to other care providers.

If you aren't a Medicare patient, how could this rule effect you? Well, CMS seems to be encouraging other payers to take advantage of the rule. I presume payers other than CMS could make agreements with the ACO for their own members as well.

How does all of this effect Health IT?
There are several requirements in the rules regarding support for Meaningful Use (e.g., 50% of providers would have to be meaningful users), the quality reporting requirements are rather detailed and require health IT support, and the need to exchange summary data on patients, and to utilize individually and aggregated data from CMS on patient populations will all require Health information technology to support these capabilities. There are a lot of other opportunities for Health IT to make ACOs better able to support their mission.

A Patient and HealthIT Centric summary of the ACO Rule

Yesterday, HHS published the long awaited regulation on Accountable Care Organizations (pdf).  If you want the bookmarked version, get it here. At the same time, the Office of the Inspector General released a notice on waiver designs (pdf) regarding Anti-trust, physician self-referral and certain other penalties with regard to the formation of ACOs.  Also, the FTC and DOJ released a separate notice on a proposed Antitrust Enforcement Policy (pdf) regarding ACOs.  HHS also released a FAQ sheet (pdf)  for providers, and the New England Journal of Medicine published a perspective article written by Don Berwick on the NPRM.  There's plenty of chat about the ACO NRPM on twitter, as well as blog commentary by the usual suspects.  Today, there's apparently even a leaked memo (pdf) providing some key answers to questions critical of the rule.

The complexity of the ACO rule leads to an interesting structure in the explanatory material preceding the actual proposed regulation.  There's a lot of discussion of various options that were considered, as well as the identification of the option proposed in the NPRM.  In this, you can treat these options as a sort of multiple-choice question in your responses.  If you don't like what was proposed, look at the other options discussed to see what might be better, or combine features of two or more options.

My particular specialty is in the exchange of clinical data.  I don't usually deal with administrative data, payments, claims or Medicare.  So, I'm looking at these rules from two different viewpoints:  As a consumer of healthcare, how do these rules affect me and my family, and as an IT expert, what Health IT changes will be needed to support these new organizations with regard to clinical data.

Let's start off with a quick review of the rule from a consumer perspective:

1. First off, I want to address the "Morality of budgeted care" issue brought up on the HHS ACO call yesterday by a physician as the first issue.  Under the proposed rule, an ACO has to meet stringent guidelines to receive additional incentives, including quality, coordination, used of evidence based medicine, and support for at-risk populations.  See the second response on page 2 of the leaked memo for some more details on that topic.  And to that provider I have to say: "Remember your own oath", as the NRPM does (page 14).
2. This is a program that affects Medicare beneficiaries (page 15 and §425.2(a) on page 372).
   If you aren't a beneficiary under Medicare, this rule does not directly affect you (yet -- you will be beneficary someday), but it may do so indirectly as ACOs are formed and payers discover how to take advantage of them also (see page 277).
3. ACO may be formed by your group or individual physician practice, or a hospital in your neighborhood (page 40) including some critical access hospitals (page 48 and §425.2(b) on page 372). According to the rule, doctors and healthcare practioners (which includes physician assistants, nurse practitioners, and clinical nurse specialists), and hospitals employing them can form ACOs. (see §425.5(b) on page 377)
4. Other suppliers of healthcare may participate in the ACO (but may not form one on their own), including Federally qualified health centers (FQHCs), rural health centers (RHCs), skilled nursing facilities (SNFs), nursing homes, long-term care hospitals (LTCHs) and all critical access hospitals (CAHs) (page 48).  And in fact, ACOs are encouraged to include FQHCs and RHCs by an increased incentive (page 273).  
5. Existing legal entities performing similar functions for patients may be qualified if they have appropriate governance structures, so if you are getting care from a similar entity today, it could become your ACO.  (page 49 and §425.5(d)(8) on page 383)
6. Your health plan, even though not a Medicare-enrolled entity could partner with an ACO and help administer it, but ACO participants would need to have 75% control of the ACO. (Page 57)
7. An ACO will contract with the Federal government to be an ACO for a minimum 3 year period initially, so if your HCP becomes a member of an ACO, you can be assured a commitment to the program. (page 62 and §425.5(d)(1 and 3) starting on page 378)
8. The Clinical management of the ACO will be overseen by "a senior-level medical director who is also a board certified physician", so you can be assured that a physician, and not claims administrator will be setting ACO policy. (page 63 and §425.5(d)(9)(iii) on page 385)
9. Included also are physician directed quality assurance and process improvement program requirements, and implementation of evidence based guidelines by all members of the ACO (page 63 and §425.5(d)(9)(v-vi) on page 385) 
10. There are several provisions suggested that are being used to prevent behaviors by the ACO to avoid high-risk beneficiaries -- with significant and escalating penalties for non-compliance. (page 64, 115, 312, 316-318 and §425.12(b) on page 405)
11. ACOs will agree to certify their accountability to CMS for the quality, cost and overall care of Medicare beneficiaries. These organizations will be making a commitment to CMS regarding how they treat you. (page 67).
12. CMS will pay cost savings benefits to the ACO directly, rather than the participants, and the ACO will share those savings with its participants (the healthcare providers). [Sorry, patients don't get any payments back]. (Page 69)
13. The ACO will have a large enough population of patients (minimum of 5000) to provide appropriate care for you, and will have enough primary care physicians to support you and/or your family members (page 71 and §425.5(d)(13) on page 389). 
14. The ACO will actively promote engagement of you and your family in your care (page 79 and §425.5(d)(15)(i)(B) on page 390).
15. Even though your primary healthcare provider may be a member of an ACO, they are not allowed to restrict the care you get.  You may go outside the ACO for care, and your benefits will not be affected by doing so (page 81).
16. Care will be patient-centric (last paragraph of page 81 - page 86 and all of §425.5(d)(15) starting on page 390)
17. There will be a mechanism for patient involvement in ACO governance!  (page 84 second bullet, and page 90-92, §425.5(d)(8)(ii)(b) on page 383 and  §425.5(d)(15)(ii)(B)(2) on page 391)
18. There will be processes to communicate with you that are understandable (page 85 first bullet and  §425.5(d)(15)(ii)(B)(6) on page 392 )
19. ... and to get your medical records (page 85 second bullet and §425.5(d)(15)(ii)(B)(8) on page 392)
20. You get to "grade" your providers by completing a survey about your experience (page 87).  The suggested grading tool is the CAHPS Clinician and Group Survey. (see §425.5(d)(15)(ii)(B)(1) on page 391)
21. As a member of an at-risk group or minority, be sure that ACOs must develop plans to address needs of diverse populations (page 92), population disparities (page 93) and individualized care.  (See §425.5(d)(15)(ii)(B)(3) on page 391)
22. Because of concerns about misleading or confusing consumers, CMS proposes that all marketing materials be approved by CMS prior to use (page 96 and 97 and §425.5(d)(4) on page 381).  This is one provision that seems a bit overboard to me.  I'd rather see strong guidelines provided, with strong penalties for misuse rather than this level of oversight.  Note that this provision does not apply to normal clinical (e.g., reminders or referrals) or administrative communications (e.g. billing and claims issues).
23. The ACO will have a compliance officer responsible for ensuring compliance of the ACO to requirements under the rule (page 99 and §425.5(d)(10) on page 388).
24. Your "ACO" will be determined based on what physician provides (they use the word "plurality") of your primary care during the prior year. (page 102, 139, 153-161).  If you decide to change primary care physicians during the year, the ACO primary care physician providing you with the most care will receive the benefit.  Don't like your ACO provider?  Change them, there is no penalty for you as a patient. (See §425.6 on page 392)
25. Primary care (see #24 above) includes outpatient evaluation and management (History and Physicals, Consultations) provided by a physician in internal medicine, general practice, family practice, or geriatric medicine.  Do you see your specialist as an outpatient more than your PCP as many patients with chronic conditions?  They would NOT be your primary care provider under the rule (page 147-153).  If this is a concern to you, comment.  Other options were considered that would include specialists. 
26. ACOs will be able to request your claims data (including procedure code, diagnosis code, beneficiary ID; date of birth; gender; and, if applicable, date of death; claim ID; the from and thru dates of service; the provider or supplier ID, and the claim payment type; prescriber ID, drug service date, drug product service ID, and indication if the drug is on the formulary) to have a better idea what care you have recieved (page 108).  You may opt-out of such sharing (page 128).  You must opt-in to share any data regarding alcohol and substance abuse treatment. (page 125).  See §425.19 starting on page 418
27. You will be communicated to by CMS and ACO affiliated providers you receive care from regarding your ACO options (page 162-165 and §425.5(d)(5) on page 381).
28. ACOs will be measured on 65 quality measures (page 166 - 195)
29. At least 50% of the providers in your ACO will use an EHR (page 200 and and §425.11(b) on page 40).
30. The amount of quality improvement required by your providers will ramp up year over year (page 211 and §425.8 on page 401).  I'm not sure about all of the scoring details (see all of §425.7 starting on page 394), but in reading through them I'm reminded Garrison Keillor's home town, Lake Wobegone, where all children are above average...
31. You will be able to find out: "information regarding: (1) providers and suppliers participating in the ACO; (2) parties sharing in the governance of the ACO; (3) quality performance standard scores; and (4) general information on how an ACO shares savings with its members." (page 226, §425.5(d)(1) on page 378 and §425.23 on page 426) 
32. The rule notes that: The standards for Accountable Care Organizations proposed in this rule are among the first quality standards for doctors and health care organizations established under the Affordable Care Act (page 228).
33. There is a stick with the ACO carrot of shared savings, which is shared losses.  In year 3 for all ACOs and in year 1 and 2 for those that opt-in, expenditures over the benchmark set by CMS would be shared with the ACO. (page 233).  I'm in favor of the carrot and stick approach, because it provides additional incentives to succeed.  I'll pass on commenting about where the benchmark is set because I'm not an actuary.
34. Your geography and whether or not you are served by a hospital that serves a disproportionate share of low-income payments may affect the performance of the ACO that you are in.  While geographic and income-level adjustments are made to Medicare, these are not accounted for in the rule given limitations under the law. (Page 253, and 259-261).
35. However, ACO participation in other Incentive programs will not impact the ACO, as these are meant to be complimentary, not competing (page 256-257).
36. I'll cover one and only one statement in the Impact Analysis:  This program does not affect the beneficiary's freedom of choice regarding providers or care. (page 360).

And a review of Health IT related provisions:

1. Deemed critical is "Health information technology that facilitates the aggregation and analysis of data, allows patient-level feedback, and provides alerts and reminders at the point of care." (page 59)
2. In addressing Anti-trust issues, the rule notes that clinical integration is required and: "To demonstrate clinical integration, participants must show a degree of interaction and interdependence among providers in their provision of medical services that enables them to jointly achieve cost efficiencies and quality improvements." (page 60).  Some of the clinical integration can be addressed through Health IT.
3.  "The ACO would have an infrastructure, such as information technology, that enables the ACO to collect and evaluate data and provide feedback to the ACO providers/suppliers across the entire organization, including providing information to influence care at the point of care via, for example, shared clinical decision support, feedback from patient experience of care surveys or other internal or external quality and utilization assessments." (page 64 and §425.5(d)(9)(vii) on page 386).
4. "Measures for promoting patient engagement may include, but are not limited to, the use of decision support tools and shared decision making methods with which the patient can assess the merits of various treatment options in the context of his or her values and convictions." (page 79) Health IT may help here in assessing cost, quality and potential outcomes.
5. "developing a population health data management capability, or implementing practice and physician level data capabilities with point-of-service (POS) reminder systems to drive improvement in quality and cost outcomes." (page 79-80 §425.5(d)(15)(ii)(B)(4) on page 391)
6. "define processes to… coordinate care, such as through the use of telehealth, remote patient monitoring, and other such enabling technologies. ... Compliance with this requirement may include ... A capability to use predictive modeling to anticipate likely care needs." (page 80 §425.5(d)(15)(ii)(B)(5) on page 391 )
7. "... The establishment and use of health information technology, including electronic health records and an electronic health information exchange to enable the provision of a beneficiary's summary of care record during transitions of care both within and outside of the ACO." (page 81 and §425.5(d)(15) on page 390)
8. In addition, the ACO should have a process in place (or clear path to develop such a process) to electronically exchange summary of care information when patients transition to another provider or setting of care, both within and outside the ACO, consistent with meaningful use requirements under the EHR Incentive program.(page 85 and §425.5(d)(15)(ii)(B) on page 391 )
9. "...an ACO typically should have, or is moving toward having, complete information for the services it provides to or coordinates on behalf of its FFS beneficiary population, it may not have complete information on a FFS beneficiary who, for example, has chosen to receive services, medications or supplies from providers of services and suppliers outside its organization. We believe that providing ACOs with an opportunity to request CMS claims data, as described later in this proposed rule, on their potentially assigned beneficiary population would allow them to understand the totality of care provided to beneficiaries assigned to them by identifying the services and supplies that fee-for-service beneficiaries receive during the performance year both within and outside of the ACO."  (page 110 and §425.19 starting on page 418) More Health IT to request process the claims data.
10. "...where feasible, we should provide information to help ACOs improve the quality of care, improve the health of their beneficiary population, and create efficiencies within their systems. One possible approach is to provide aggregated data on beneficiary use of health care services." (page 111)
11. There will be plenty of quality reporting needing Health IT (65 measures in all): "In this portion of the proposed regulation, we propose: (1) measures to assess the quality of care furnished by an ACO; (2) requirements for data submission by ACOs; (3) quality performance standards; (4) the incorporation of reporting requirements under section 1848 of the Act for the Physician Quality Reporting System; and (5) requirements for public reporting by ACOs." (page 166-195 and §425.9-10 on page 401).
12. At least 50% of eligible providers in an ACO will use an EHR (page 200), but not necessarily hospitals (page 222 and §425.11(b) on page 404).  Furthermore, CMS may terminate the ACO agreement if the number of meaningful users falls below 50%! (same page).
13. "...eligible professionals would be required to submit data through the ACO on the quality measures proposed in Table 1 using the GPRO tool and methodology described in section II.E.3. of this proposed rule to qualify for the Physician Quality Reporting System incentive under the Shared Savings Program" (page 216 and §425.11(a) on page 404) PQRI = more Health IT requirements.
14. Note that in the above, CMS plans "to align the incorporated Physician Quality Reporting System requirements with the general Shared Savings Program reporting requirements, such that no extra reporting is actually required in order for eligible professionals or the ACO to earn the Physician Quality Reporting System incentive under the Shared Savings Program. Thus, for ACOs that meet the quality performance standard under the Shared Savings Program for the first performance period, the Physician Quality Reporting System eligible professionals within such ACOs will be considered eligible for the Physician Quality Reporting System incentive under the Shared Savings Program for that year." This is a potential two-for-one deal for ACO participating providers.  It is double or nothing for providers that fail to meet the quality and shared savings requirements, but if they only fail to meet the shared savings requirements, they can still get the PQRS benefit (page 218).

OK, that's enough for the day.  I have to say that I am impressed by this rule.  I find it to be pretty understandable (except for the actuarial stuff), but it's still a lot to deal with.  I would say that overall I have a positive response, but there is definate room for improvement.

As always, the opinions expressed in this blog are my own, and not that of my employer or any of the organizations that I represent as a volunteer.  As these are my opinions, they also do not constitute legal advice either, since I am not a legal professional either.

Leveraging Standards for ACO Development

One of the things I didn't get to do at HIMSS was connect up with someone who wanted a brain dump from me on leveraging healthcare standards to support Accountable Care Organizations.  One of my recent tweeps asked if EHR was required to support ACOs, and another responded that EHR is not, but that an HIE is.  To add to the alphabet soup, I'd like to throw in CDS.

What I'm hearing about most often from Accountable Care Organizations is that they are focused on cases where they can quickly realize savings.  The low hanging fruit seems to be in the area of chronic disease management, care planning and follow-up.

The top chronic diseases appear to be Diabetes [all seem to agree this is a top priority], Chronic Obstructive Pulmonary Disease (COPD), Congenstive Heart Failure (CHF) [these next two are very common], Coronary Arterty Disease (CAD), and Hypertension.

Other areas of attention are on care-planning and follow-up for post-surgical and post-ED visits.

From a standards perspective, the key areas of focus is on sharing data from various settings where the ACO has access to it.  The standard that most are already adopting is the HITSP C32/HL7 Continuity of Care Docuement as it is already contained within the Meaningful Use Regulation.  Another area of attention is on accessing laboratory results.

From a vocabulary perspective:
While many are still using ICD-9-CM codes for diagnoses, some are pushing for SNOMED CT codes.  For medications, the push it towards RxNORM, and for labs to LOINC.

So far, motherhood and apple-pie, and consistent with national directions.

Where their seems to be some struggle is on data elements needed for managing care for each of these cases.  I expect there there are still quite a number of spreadsheets being tossed around.

The next step for standardization in this area would be to apply codes to the various guidelines for treating these diseases.  The hard part is deciding on which guidelines to apply for care.  The easy part is selecting the codes for the important components.  Let's take an example of what I mean, by looking at the International Diabetes Federation's Global Guideline for Type 2 Diabetes.  I picked this guideline arbitrarily, you could use any other guideline for this effort.

Having chosen the guideline, let's take a couple of its recommendations and apply codes to them:
Guideline SD2 (see Page 9 of the PDF above) recommends a fasting oral glucose tollerance test for screening.  So, now we need to code the tests.  Out comes RELMA and we find that the most common test in LOINC^® is: 1504-0 Glucose^1H post 50 g glucose PO mg/dL.  There are some 92 other result codes that we could also look for, but I won't bother listing them.

Guideline SD4 (same page) references the WHO criteria for diagnosis of Diabetes (peeling the onion as it were).  So, now I dig out my CliniClue Browser and look up the code for Diabetes Melitus (73211009 in SNOMED CT^®).  Since I'm interested at this point in all subtypes of Diabetes underneath that code, I'll deal with that as an Intentional value set.

If we wanted to address other means of screening (e.g., Urine dipstick testing), I could look up the codes for those in RELMA as well.

I'll skip the Care Delivery section and move on to the Education section since Care Delivery references content in the other sections.

Guideline ED1 talks about Diabetes Type 2, so again I find the right SNOMED CT code (44054006).

Guideline LS2 talks about a type of care provider: dieticians.  I can dig up SNOMED codes for that, or use the Healthcare Provider Taxonomy codes (a Registered Dietician is 133V00000X in that coding system).

Guideline TT1 talks about HbA1c levels, so I need LOINC codes for that.  I find two codes in LOINC using RELMA (both of which are common):

• 17856-6 Hemoglobin A1c/Hemoglobin.total % Hgb
• 4548-4 Hemoglobin A1c/Hemoglobin.total % Hgb

Diabetes can cause retinopathy, so there are guidelines around eye screening.

Guideline ES1 talks about Eye Examinations, so I can find CPT codes for that (but not display them...)

It also discusses retinopathy, so I can find SNOMED CT codes for that (399625000) and explicitely for Diabetic Retinopathy (4855003).

 

And so on and so forth until I've got codes for the entire guideline.  Picking the guideline, is, as I said, the hard part.  Coding the stuff is Clinical Informatics drudgery, and can be quickly done (I did a good bit of the IDF guide in about 6 hours).  Some of these codes will be for conditions, others for providers, encounter types, lab results and orders, vital signs, services, medications, et cetera.

 

If I'm smart, for each of these things I've got a code for, I should also have a link back to at least one (if not all) requirements for that thing in the guideline.  This can be used later!

 

The list of coded stuff tells me what I want to see in lab reports, CDA documents, and more.  Having that list makes the job much easier, because now I can make sure that information is captured in the EHR, coded in a CDA document, or imported from laboratory reports (and mapped to LOINC where needed).

 

All those linked references I talked about earlier can also be used in Infobuttons in the EHR, or in patient educational content.

 

IHE developed the Care Management (CM) (pdf) profile to support chronic disease management.  Uptake has been slow, but I'm starting to get feedback on it, and at least one organization has implemented it that I know about.  It's designed around exactly this sort of process, and the beauty of that profile, if it were implemented fully, is the automatic generation of interfaces (no more interface engineering -- imagine taking that cost out of healthcare).

 

The next big challenge for ACOs is applying clinical decision support to this information.  The guidelines supply the rules that should be invoked on the data that we've coded, and those can be written in whatever form (programming language, rules engine, et cetera) needed.  Thomson Reuters is working on an AHRQ grant to develop electronic Recommendations.  This is essentially the step before coding a guideline into Clinical decision support logic.  A necessary step prior to describing the logic is what I just described, coding the guideline.

 

Both the CM profile and the IHE Request for Clinical Guidance (RCG) (pdf) profile support mechanisms to integrate clinical decision support as a service.  The RCG profile includes an appendix to show how to map back and forth from a CDA document to a Care provision message to support the integration of CDS as a service.    The Clinical Decision Support Collaborative is currently investigating how to integrate CDS services with ERHs, and these profiles provide some support and a standards based interface that group could take advantage of.

 

CDS is the next big area where standardized interfaces are needed.  IHE was just a bit early in its development of profiles on CDS, as the current market is focused on Meaningful Use Stage 1.  But stage 2 and stage 3 are coming, and CDS will play a key role in those stages.

I'd love to see some national efforts around the selection of and coding of guidelines for chronic conditions that could be widely shared.  I think that effort would give ACOs a huge head start.  Most often, it's not the codes that change in the decision logic, but the various measure parameters (should HbA1c be managed to 6 or 7%), should medication X be applied at this point or that.  Coding national guidelines in this way would let ACOs get a head start, and if they wanted to adjust the decision logic because they have a better idea of how to manage the condition, more power to them.  At least they could skip the step of finding the codes.  It pains me to understand how much clinical informatics expertise we are wasting doing the same work repeatedly (in some cases, reinventing guidelines that others have already well established).

Oh, and this would be a process that would have quality measurement built in.