ACOs: The IT Challenges Within
In an effort to redesign the Medicare payment model to promote higher quality of care at a lower price, federal healthcare agencies are advocating accountable care organizations (ACOs) to promote accountability and conserve costs. Sounds like a good idea, but what does that mean for your IT department?
That’s the million-dollar, or perhaps billion-dollar, question. According to language in the Patient Protection & Affordable Care Act (PPACA), ACOs must be accountable for the quality, cost and care of Medicare fee-for-service beneficiaries, and must follow reporting requirements and quality performance standards, including e-prescribing and EHR use.
The Centers for Medicare and Medicaid Services (CMS) guidelines for ACO eligibility are expected this month, and key aspects of the model, including the regulations and criteria that must be met for facilities to be deemed accountable, remain unknown.
But even before the guidelines and governance of ACOs are fully defined, many organizations have already started strategic planning, says Richard Hodach, MD, MPh, PhD, chief medical officer of Phytel, a Dallas-based company focused on physician-driven health improvement.
That doesn’t mean your organization has missed the boat if it hasn’t started planning. “At this point, if your organization has not started thinking about ACOs, it might be best to wait for the guidelines,” Hodach says. “The CMS model will be the foundation and is a good starting point and several organizations and newly found collaboratives have been established in framing the ACO model and are engaging in detail the structural areas of the ACO.”
“There will be up-front costs because you will have to retool significant infrastructure: Health IT is the backbone of the ACO,” says Warren Skea, director of the Health Enterprise Growth Practice at Pricewaterhouse Coopers (PwC) in Dallas. With bundled payments and rewards for better care, clinical and financial data will converge.
In the long run, ACOs might make the system more transparent and provide better care to patients, but “the process will not be a walk in the park,” says Bruce Henderson, national leader of PwC’s EHR/HIE Practice. Organizations will face upfront costs associated with retooling their infrastructure, and change management.
These IT challenges will heap a significant burden onto providers during the initiation stages of ACO implementation, according to Henderson.
Without careful consideration of these challenges, ACOs also could go the way of health maintenance organization (HMOs), which were touted as a way to curb healthcare costs and deliver better care, but never lived up to those promises.
EHRs may be great tools for managing acute patient populations, but EHR systems currently aren’t capable of managing chronic disease patient populations, nor can they “look across the continuum of care,” he says.
“The biggest challenge ACOs face is managing a specific cohort or group of patients and [completely] managing their healthcare needs,” says Skea. A related challenge to adoption, at least initially, will be “keeping patients inside the network of providers,” he says.
Without effective patient education, self-monitoring tools could add layers of trouble-shooting and management headaches to the health IT workload, says Hodach. To remedy this problem, Phytel deploys “digital coaches” to help patients identify conditions and symptoms online, rather than having to make additional trips to their provider’s office.
HIEs will pull together information from disparate systems and aggregate patient data into a single patient record, says Henderson. “HIEs can help us understand certain patient populations and the processes that are being provided to patients with specific diseases or co-morbidities.”
“With the evolution of ACOs, there is a need to manage the entire continuum of disease—from inpatient to discharge and from wellness to the most complex of cases,” he adds. ACOs should do three things: improve quality, decrease costs and create a positive patient experience, Henderson says.
The transition to ACOs and the shared-savings model, which CMS has slated to begin in 2012, will offer payors and providers incentives to provide better care. Traditional fee-for-service models will still be in place; however, at the end of the year, there would be cost savings across the board that would be shared by the payor and medical group.
“Right now, there is no incentive to manage populations. We need a reimbursement mechanism so payors can share those savings with providers,” Skea notes. Hodach says that the shared-savings model would shoot for a cost savings of 2 to 3 percent, in which half would remain with the payor and half would go back in to the Medicare system and be disbursed among various stakeholders.
The incentive to participate in an ACO will trace back to reimbursements. But improving care and disease management is the model’s top priority, which can only be accomplished with proper health IT, says Hodach.
Disease management capabilities are coming online as well: “Automatically running reports that dig into patient populations and subpopulations will be very helpful to managing these patients and chronic diseases,” Hodach says. “We can put these data into reports and show the patient populations, the gaps in care, and then allow the care team at multiple levels to be able to look at and filter that data and take action.”
The challenge will be interfacing data from home health solutions with EHRs, says Henderson. Organizations like the Continua Health Alliance, which develops standards, are already working to make devices interoperable with the EHR so data can be transferred automatically, he says.
Skeptics have drawn unfavorable comparisons between ACOs and HMOs from the 1980s and 1990s. However, ACOs stand a better chance of streamlining care and reining in costs because of advances in health IT, says Skea. Amalgamating patient home monitoring data with the EMR, e-prescribing, disease management and others, will provide a higher quality care that will focus on prevention, ultimately leading to lower costs.
However, Skea adds, “this is a significant transformation and relatively difficult in a lot of ways, and I expect that there will be a lot of growing pains with this, and IT will be a significant component of that.”
That’s the million-dollar, or perhaps billion-dollar, question. According to language in the Patient Protection & Affordable Care Act (PPACA), ACOs must be accountable for the quality, cost and care of Medicare fee-for-service beneficiaries, and must follow reporting requirements and quality performance standards, including e-prescribing and EHR use.
The Centers for Medicare and Medicaid Services (CMS) guidelines for ACO eligibility are expected this month, and key aspects of the model, including the regulations and criteria that must be met for facilities to be deemed accountable, remain unknown.
But even before the guidelines and governance of ACOs are fully defined, many organizations have already started strategic planning, says Richard Hodach, MD, MPh, PhD, chief medical officer of Phytel, a Dallas-based company focused on physician-driven health improvement.
That doesn’t mean your organization has missed the boat if it hasn’t started planning. “At this point, if your organization has not started thinking about ACOs, it might be best to wait for the guidelines,” Hodach says. “The CMS model will be the foundation and is a good starting point and several organizations and newly found collaboratives have been established in framing the ACO model and are engaging in detail the structural areas of the ACO.”
Change won’t come cheap
For all the unknowns surrounding ACOs, there also are some definites as well: These organizations will require EHRs, comprehensive documentation, reporting and data management capabilities. They will rely on patient home monitoring and disease management tools. So it almost goes without saying that healthcare systems transitioning to ACO status will face another familiar obstacle: cost.“There will be up-front costs because you will have to retool significant infrastructure: Health IT is the backbone of the ACO,” says Warren Skea, director of the Health Enterprise Growth Practice at Pricewaterhouse Coopers (PwC) in Dallas. With bundled payments and rewards for better care, clinical and financial data will converge.
In the long run, ACOs might make the system more transparent and provide better care to patients, but “the process will not be a walk in the park,” says Bruce Henderson, national leader of PwC’s EHR/HIE Practice. Organizations will face upfront costs associated with retooling their infrastructure, and change management.
These IT challenges will heap a significant burden onto providers during the initiation stages of ACO implementation, according to Henderson.
Without careful consideration of these challenges, ACOs also could go the way of health maintenance organization (HMOs), which were touted as a way to curb healthcare costs and deliver better care, but never lived up to those promises.
EHR challenges
EHR adoption, a cornerstone of the American Reinvestment and Recovery Act’s HITECH initiative, also is a tenet of ACOs as envisioned in the PPACA. EHR use will be vital to communicate lab results, clinical documentation, in-patient stays and ER visits, and ambulatory events across one community through a single electronic patient record, says Hodach.EHRs may be great tools for managing acute patient populations, but EHR systems currently aren’t capable of managing chronic disease patient populations, nor can they “look across the continuum of care,” he says.
“The biggest challenge ACOs face is managing a specific cohort or group of patients and [completely] managing their healthcare needs,” says Skea. A related challenge to adoption, at least initially, will be “keeping patients inside the network of providers,” he says.
Without effective patient education, self-monitoring tools could add layers of trouble-shooting and management headaches to the health IT workload, says Hodach. To remedy this problem, Phytel deploys “digital coaches” to help patients identify conditions and symptoms online, rather than having to make additional trips to their provider’s office.
Integration issues
“Even if everybody suddenly acquired an EHR tomorrow, care is rendered in a variety of settings and there must be a way to aggregate all of this patient information into a single solution to allow caregivers to understand the full process of care so they can make better, faster, more accurate decisions about a patient’s future care,” Hodach says. This is where health information exchanges (HIEs) will be beneficial.HIEs will pull together information from disparate systems and aggregate patient data into a single patient record, says Henderson. “HIEs can help us understand certain patient populations and the processes that are being provided to patients with specific diseases or co-morbidities.”
“With the evolution of ACOs, there is a need to manage the entire continuum of disease—from inpatient to discharge and from wellness to the most complex of cases,” he adds. ACOs should do three things: improve quality, decrease costs and create a positive patient experience, Henderson says.
The transition to ACOs and the shared-savings model, which CMS has slated to begin in 2012, will offer payors and providers incentives to provide better care. Traditional fee-for-service models will still be in place; however, at the end of the year, there would be cost savings across the board that would be shared by the payor and medical group.
“Right now, there is no incentive to manage populations. We need a reimbursement mechanism so payors can share those savings with providers,” Skea notes. Hodach says that the shared-savings model would shoot for a cost savings of 2 to 3 percent, in which half would remain with the payor and half would go back in to the Medicare system and be disbursed among various stakeholders.
The incentive to participate in an ACO will trace back to reimbursements. But improving care and disease management is the model’s top priority, which can only be accomplished with proper health IT, says Hodach.
Change management
Some of the building blocks for ACOs are already in place. Robust EHRs are coming online, and process automation is already saving physicians and nurses time, particularly for routine procedures associated with follow-ups such as automated phone calls to recently discharged patients, says Hodach.Disease management capabilities are coming online as well: “Automatically running reports that dig into patient populations and subpopulations will be very helpful to managing these patients and chronic diseases,” Hodach says. “We can put these data into reports and show the patient populations, the gaps in care, and then allow the care team at multiple levels to be able to look at and filter that data and take action.”
The challenge will be interfacing data from home health solutions with EHRs, says Henderson. Organizations like the Continua Health Alliance, which develops standards, are already working to make devices interoperable with the EHR so data can be transferred automatically, he says.
Skeptics have drawn unfavorable comparisons between ACOs and HMOs from the 1980s and 1990s. However, ACOs stand a better chance of streamlining care and reining in costs because of advances in health IT, says Skea. Amalgamating patient home monitoring data with the EMR, e-prescribing, disease management and others, will provide a higher quality care that will focus on prevention, ultimately leading to lower costs.
However, Skea adds, “this is a significant transformation and relatively difficult in a lot of ways, and I expect that there will be a lot of growing pains with this, and IT will be a significant component of that.”