Developing a Blueprint for Accountable Care
Lawmakers, payers, and providers have touted accountable care as one of the most promising strategies to transform healthcare payment and delivery. Today, healthcare organizations around the country are putting the people, tools, and technology In place to take on greater responsibility for clinical and financial outcomes-and prepare for future competition based on value.
Living in Two Worlds
Hospital and health system leaders face an enormous challenge as they move toward accountable care: They must maintain adequate revenue to keep their doors open while investing in the infrastructure to build their value proposition. "For the next 10 years, we need to be comfortable living in both the fee-for-service and accountable care worlds," says
Failure to fully commit to accountable care may be why many organizations have stumbled in their early ACO efforts, says
Still, most healthcare organizations do not have Montefiore's experience with taking on risk to manage a patient population. This has led to some innovative approaches, Including ACO collaborations between competitive health systems. For example, in 2010,
Making the transition from fee-for-service to value requires an intentional commitment and a focused strategy. Whether an organization is looking to launch a population health program, participate in an ACO, pilot new payment models, or forge community partnerships, effectively pursuing an accountable care strategy requires a robust plan. With this in mind, this HFMA Educational Report, sponsored by
Acquiring and Aggregating Data
Those at the forefront of accountable care recognize that good clinical and financial data underpin any value-based care effort. Claims data in particular can be essential to these types of arrangements. Until recently, however, payers have been reluctant to share claims data with providers, but that attitude may be changing, says
A number of provider organizations are making timely, accurate claims data part of their negotiations with payers. "One of our mantras when exploring partnerships of all shapes and sizes is 'no data, no deal,"' says
Regardless of the kind of data on which a value-focused organization relies, it should take a well-considered approach to how to use and communicate the information. Following are a few strategies to keep in mind.
Create an infrastructure to support data analytics. Nebraska Health Network uses a third-party analytics tool to identify opportunities from claims data and measure progress toward the entity's goals. The ACO also plans to build an enterprise data warehouse to merge clinical, claims, lab, and pharmacy data to get a more complete picture of the populations it manages. "Our two sponsoring systems use different electronic health records, and we have several other EHRs within our independent clinics, so merging the data is not overly straightforward," says Handke. "But it can be done, and it must be done, to drive forward the value proposition to our customer."
The ACO recently hired a new vice president of operations, who has experience working with analytics tools in the financial and insurance industries. Part of this executive's new role will be building a larger team of analysts and IT experts to support the ACO's strategy.
Work with what you have. One of the biggest mistakes that healthcare leaders make is waiting for "perfect" data before taking action, says
Do not overwhelm providers with too much data. In the case of data, more information is not necessarily better. Organizations should commit to delivering essential information to the people who need it in a timely manner. Montefiore, for instance, creates simple dashboards that allow providers to quickly see trends in their patient populations. "Physicians don't have time to wade through data on their 1,000 patients," says Rosenthal. "But if we can show them the 15 diabetes patients with critical changes in their health status, we can focus clinician attention, ultimately improving the quality of patient care and generating savings."
Marry data with real-world assessments. Data analysis is only the first step in effective care management. Organizations must go beyond the data and consider the patient's life situation and other external factors. "When a delivery system is involved in care management, it must be engaged in dealing with its population's social challenges as well," Rosenthal says. "You can have three individuals who are the same sex and same age, and who have the same clinical diagnosis and blood work, yet they can have three different life circumstances that require a different intervention. You wouldn't identify those circumstances until you actually do an assessment of the individual to understand what his or her life challenges are, such as poor housing or lack of transportation."
Partner with payers on data-driven care management. Historically, payers have been more successful at leveraging data to drive outcomes. Providers should consider reaching out to their larger payers to join forces in this area. For example, while at BCBS of
Reducing Variation
Until the past decade or so, physicians have relied primarily on their own training and experience to guide treatment. With the advent of evidence-based guidelines, many healthcare organizations began to measure their own performance against established standards in an effort to improve quality and reduce unnecessary costs. Now, ACOs are using the same approach to show medical groups how they perform against one another, says Ludwig of
Physicians can be a driving force in adopting best practice and reducing variation. An effective method for bringing physicians together and encouraging collaboration is to create physician-led committees. 'The group practices that we put into our Boeing network never really talked to each other before, but we created an infrastructure through the ACO, so these groups are getting together for the first time," Ludwig says. "Not only are they looking at each other's data, but they are able to share best practices." They do this through a formal committee structure. "The committee infrastructure is critical, particularly when you have groups outside your own employed group in the network. You have to engage them and get them excited about the work," he says.
Each month, Ludwig leads a model of care committee where the medical groups discuss key initiatives like improving care transitions. As a result of the committee's efforts, the ACO developed a residential care team composed of physicians and nurse practitioners who visit ACO patients in skilled nursing facilities. The ACO has also reduced the 30-day all-cause readmission rate for patients in the skilled nursing facilities from 13.3 percent to 7.5 percent and shaved nine days off the average length of stay from 29 days to 20 days.
Nebraska Health Network also uses physician-led committees to engage providers in reducing practice variation and improving quality. It currently has 13 care redesign workgroups on topics like primary care, emergency department utilization, and oncology. Their purpose is to review best practices and determine which evidence-based guidelines should be issued to the network. "As part of our clinical integration strategy, we will actually measure compliance with those guidelines," Handke says.
Demonstrating Value
To be successful with risk-based payment models, healthcare organizations need to consistently demonstrate that they can be good partners with various stakeholders and deliver value, namely high-quality care that keeps costs in check. To that end, organizations can consider the following strategies.
Think like a payer. Health systems tend to focus on government-mandated quality metrics and patient satisfaction, but from a payer finance perspective, these endpoints do not add a lot of value, says Carmouche, the former BCBS of
Have a "compass." Organizations must do more than give lip service to delivering value: They should establish guiding principles for the work. Consider Nebraska Health Network, which is resting its value strategy squarely on the healthcare consumer. "Everything we do must be adding value to the end customer," Handke says. 'This means focusing on better outcomes, a more customer-friendly experience, and lower overall costs." To stay attuned to the right goals, Nebraska Health Network outlined several guiding principles for its work:
* Create a clinically integrated network of providers
* Become experts in population health management
* Build the IT infrastructure to make data-driven decisions and measure outcomes
* Engage consumers in new ways, such as telemedicine
* Develop products that leverage the ACO's value
Be open to payer-driven approaches. Many payers are experimenting with different payment models, finding that some are more successful than others. At BCBS of
Other programs, however, have been more successful. Carmouche created another program that gave providers with BCBS patients who had at least one chronic disease a
Engage employers. These companies can be willing and eager participants in ACO models. "Employers are benefiting from provider networks beginning to assume more care management capabilities and quality management services," Montefiore's Rosenthal says. Many large employers, including Montefiore, have moved to a self-insured model in which they use the insurance company for its provider network and administrative capabilities but are largely self-funded. Montefiore has entered a unique shared-savings program with the
Team up with the competition to meet gaps in care. In some areas, organizations are looking to their peers for assistance in delivering value and closing care gaps. "In one part of
* 11 percent decrease in 30-day, all-cause réadmissions from 2013 to 2014, which avoided an estimated
* Medical cost increases that were 31 percent lower than the average for
* 2 percent reduction in medical costs for
Improving Cost of Care
One of the most challenging aspects of developing an accountable care strategy is quantifying cost and ensuring patients receive care in the locations that deliver the highest quality at the lowest cost. "For many healthcare organizations, this may be new measurement territory," says
In simple terms, McClure defines the total cost of care as price plus use across an attributed population, risk-adjusted to account for severity. "It is not just what you provide but where attributed patients get care outside the system as well, so you need claims data from a major payer in your market to do that," she says. "If you want to understand how what you do affects the premium down the road, the total-cost-of-care view is the most holistic way to look at that.
"Ourtotal cost index allows us to get a relative view of total care cost compared with others in our market. It also lets us drill down and understand where there is variation, which gives us opportunity to improve," McClure says.
To fully appreciate costs of care, organizations may want to turn to technology. For example, Nebraska Health Network plans to implement a comprehensive cost-accounting system. "It is on our road map," Handke says. "We need to be able to look at the total resources of our system and identify areas of highest quality and lowest cost so we can build centers of excellence within the system."
Enabling Sustainability
Healthcare leaders say one of the greatest challenges ahead is sustaining their accountable care efforts so they may realize the return on their investment. To deliver the greatest value over time, organizations are employing several approaches.
Gain sustainability through scale. Today, Montefiore manages 400,000 lives, with plans to expand to 1 million lives by 2018. "Managing a population of 5,000 lives is often as costly as managing 1 million, relative to the proportion of the population," Montefiore's Rosenthal says. "With 1 million lives, we will have
Compensate physicians for their work. "If providers live in a world based purely on relative value units, there is little chance that they will prioritize many of the activities that are needed for ACO success," the former BCBS of
Show, do not tell. "You can't just tell medical groups that they need to reduce costs and improve quality-you have to show them what to do," says Ludwig, who created a list of five "musts" for groups participating in the
Follow a protocol for care transitions.
Focus on reducing inpatient admissions. In one region, the ACO is testing dedicated phone lines in the emergency departments (EDs) that allow ED staff to request next-day appointments in the clinics rather than admitting a patient to the hospital.
Manage frequent ED utilizers. Through a weekly care management call, the ACO provides medical groups with information on high utilizers and suggestions for outreach.
Reduce unnecessary imaging. One of the medical groups in the
Engage physicians in generic prescribing and managing highcost specialty drugs.
Move beyond the mistrust. Carmouche believes that collaboration between providers, payers, and lawmakers is vital for the success of accountable care. "Providers need to reframe those historical relationships because there are many opportunities for collaboration on value," he says. "If we can do it in
In the end, a robust accountable care effort depends on engaged leadership that consistently communicate their commitment. If a CEO is ready to move toward value, but the CFO and COO remain focused on maximizing revenue, then the organization will not be able to move forward. "The degree to which the C-suite does not send mixed signals is critical," Carmouche says. "Otherwise, there is an ambivalence that permeates the health system and undermines these efforts. You have to pay attention to revenue in the short run, but there is no doubt that in most markets, future success will be based on value."
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ADDRESSING PROVIDER FAQs
QHow can my health system begin to "think more like a payer"?
Payers care about cost containment, quality, and access to care. Healthcare providers should demonstrate how efficiently they meet these metrics. One way is to target waste-avoidable or unnecessary care-such as preventable réadmissions, complications, ED visits, and high-cost imaging services.
More and more, payers measure quality by results, not by adherence to clinical guidelines or care processes. Providers need to become as familiar with clinical and financial outcome measures (such as DRGs and riskadjusted readmissions) as they are with traditional activity measures (such as relative value units)-to the point of replacing them in financial models.
Q Should the focus be on becoming the low-cost provider?
No. Simply reducing the price of services is unlikely to result in higher quality. The focus should be to increase the value of care-high patient outcomes and better experience for the cost.
Rather than low cost, look at the total cost of care (TCC)- all of a patients' care across the spectrum from hospital stay to discharge to follow-up-as opposed to the unit price of a service. Some high-cost services, in the end, decrease TCC by improving the patient's health and avoiding extensive care.
TCC emphasizes caring for the entire person in a comprehensive way, addressing all health concerns, not one isolated disease. It can lead to discussion about socioeconomic factors and lifestyle choices that influence total cost. This might not happen with narrower metrics.
QHow do you avoid overwhelming clinicians with too much data?
First, make sure that clinicians can access data within their daily workflow with an easy-to-use interface. Second, reduce alerts and reports to only the information that requires attention. Show them the elements of care they can affect and those that are used to evaluate and compensate them. Third, explain what the data mean and what should be done with them. The data are simply a mechanism to allow all parties to collaborate in a way they haven't historically.
The ideal in value-based contracts is to help physicians succeed. Share the data, provide frequent updates, and let them monitor their progress. With the emphasis on analyzing data, it can be easy to forget the importance of helping clinicians use it effectively.
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