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Effective care management is the answer to ACO success

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Mike Hoxter, Chief Technology Officer, Lightbeam Health Solutions

In August, the Centers for Medicare and Medicare Services (CMS) reported that the Accountable Care Organizations (ACOs) participating in the  generated more than $411 million in total savings in 2014, which includes all ACOs’ savings and losses. Of those, 97 ACOs qualified for shared savings payments of more than $422 million by meeting quality standards and their savings threshold.[1]

Leaders from these ACOs attribute their organization’s ability to reduce costs and share savings while improving care quality to better care management, particularly involving transitions from the hospital to home or a post-acute care setting, according to a study commissioned by CMS.[2]

However, survey results show effective care management was not shared by all the ACOs. Many ACOs were unable to effectively access and share timely data to help monitor and report on patients. A key differentiator among the experienced ACOs in this study, as well as other provider organizations proficient at care management, is that their care coordinators are supported with information technology tools that are able to capture data from around the care continuum, stratify patient risk and deliver actionable insight to help engage patients, avoid readmissions and prevent adverse events.

As many ACOs and other healthcare organizations have found, this holistic view of patient populations not only improves care management efficacy, but also can decrease unnecessary spending and improve revenue for both value-based and fee-for-service payment models.

Multiple data sources are critical

The “Pioneer” ACO program — which included 32 early entrants that joined the program before other MSSP organizations — saved a total of $384 million in 2012 and 2013.[3] The CMS-sponsored ACO study points out many of these Pioneer and other MSSP ACOs had mature information technology systems and more than half of Pioneers were able to analyze claims and clinical data to assist with care management.

As demonstrated in the study, the ability to capture and analyze claims as well as clinical data from across the ACO is essential, especially during crucial care transitions where community-based primary care physicians may not receive prompt discharge reports from area hospitals or post-acute facilities. Many population health management (PHM) platforms, however, only utilize claims data, which can be up to 120 days old, to monitor patients’ care utilization. While claims data are vital, other data sources, such as clinical, pharmacy and lab information are also crucial for accurate risk stratification and timely interventions.

Data normalization and automated analysis

Capturing multiple continuum-wide data sources is only one facet of effective care management. Once aggregated, data must be standardized to a common format for accurate and reliable analysis.

In fact, according to the study, the top challenge facing Pioneer, risk-bearing and non-risk bearing MSSP ACOs was combining non-standardized data from different electronic health record (EHR) systems. This is where an enterprise data warehouse is integral to normalize data from these disparate sources. Once normalized, data should be presented visually through easily interpreted charts and graphs that help physicians and care managers identify where they and their patients are using unnecessary resources and missing opportunities to improve outcomes.

Automated analysis of normalized data can also generate prioritized lists of high-risk patients in need of clinical interventions. While organizations have some risk-stratification capabilities now through their EHRs, more sophisticated tools are needed to stratify patients with multiple comorbid conditions. For example, through existing EHR tools, care coordinators may be able to filter lists of diabetic patients who have uncontrolled HbA1c levels, but combining multiple other uncontrolled chronic conditions may not be possible, although essential for stratifying risk and controlling costs. This leads to patients being contacted by care managers too frequently and leads to potentially too many physician appointments, which can contribute to cost overages and reduced shared savings. A more holistic view of high-risk patients with multiple chronic conditions available through advanced PHM tools can make outreach and re-engagement efforts much more efficient.

Continuous quality and cost improvement

Improving financial performance is essential for sustaining ACOs, but providers must also achieve 33 MSSP care-quality requirements to earn the shared savings. Attaining these metrics is also positively associated with achieving desired clinical outcomes, which is the ultimate goal for any provider organization. Improving quality metrics is again where population health data analytics presents an advantage to providers.

With these tools, patient outreach and interventions can be more targeted and efficient, but also care coordinators and providers at the point-of-care have the ability to view, report, and electronically submit all measures required by CMS and other quality reporting programs. Reliable quality reports based on providers’ own charts and claims also helps encourage behavior change among providers so they are focused on achieving metrics.

Given all the clinical quality and financial gains associated with advanced, integrated PHM tools, it is perhaps no surprise that the CMS study discovered: “ACOs with established systems in place discussed its importance and the work they continue to do to more efficiently utilize system capabilities to merge and manipulate data.”

Following the example of these top-performing ACOs is advisable for not only other MSSP participants, but any provider organization interested in improving patient outcomes while succeeding in the value-based payment environment.

[1] The Centers for Medicare & Medicaid Services. “Medicare ACOs Provide Improved Care While Slowing Cost Growth in 2014.” Press release. August 25, 2015. https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-08-25.html

[2] L&M Policy Research, LLC. “Pioneer ACO Evaluation Findings from Performance Years One and Two.” Report. March 10, 2015. http://innovation.cms.gov/Files/reports/PioneerACOEvalRpt2.pdf

[3] L&M Policy Research, LLC, et al.

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