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Apr 19 2012   9:54AM GMT

Five things we need to do now for ACO readiness

Posted by: Jenny Laurello
Accountable Care Organizations, ACOs, Continuity of Care Document (CCD)

Guest post by: Ruby Raley, Director, Health Care Solutions, Axway

Industry discussion around accountable care organizations (ACOs) is soaring – in fact, one could argue that the main topics of HIMSS12 were analytics and ACOs. In any case, we know ACOs are coming at us head-on, with limited time to think through what needs to be done in order to be successful.

But if you are a health plan or payer, there are five tasks you can do right now to improve industry understanding of ACOs, encourage adoption of ACOs and champion improvement of health care for your members.

1. Define the data. ACOs are meant to move us away from a fee-for-service structure and toward a performance or quality-based structure. We need to define what documents to exchange, including some type of document framework between all parties involved – that is, between providers, payers, labs, clinics, long-term care facilities, etc. Continuity of Care Documents (CCDs) could be the answer, but CCDs come in many variants. Perhaps the solution is to take claims data and standardized portions of CCDs, and add other documents from our encounters with patients in order to collect enough data for us to know that we are making the appropriate decisions to provide the right care.

 As part of collecting that data, many ACOs use a multi-payer structure – which is, in fact, what the Centers for Medicare and Medicaid Services (CMS) encourages when a provider sets up an ACO. That requires that health care leaders clearly and consistently define data semantics. We cannot expect one provider to produce four different variations of a document to send to four different participants in an ACO collaboration. We must work together, on the front end, to define how we’re going to use data, and how to consistently apply standards within ACOs.

2. Define critical events. As payers, what are the patient events we want to receive from providers, and when do we want to be notified? Some examples might be: When a patient leaves the hospital, so that we can follow up with them right away; when a baby is born; when patient blood work changes (e.g. for diabetic care); or when blood pressure results change. It’s critical to make these decisions now, since not every event is necessarily well-represented in the electronic exchange of information.

3. Accelerate adoption of CMS initiatives, such as claims attachments. Claims attachments enable us to send HL7-type CCD documents containing extensive patient information along with the claim. Our health plans need a better sense of the actual doctor/patient encounter – what the doctor did, what the conditions were, any counseling the patient received, etc. – and CCDs have the potential to provide that data. Such information also adds depth and context to claims and services provided to the patient. As it stands today, payers don’t usually get claims attachments as part of an online, real-time conversation, but rather after the fact as audit support. For ACOs to be successful, we have to develop the habit of sharing clinical documents with health plans.

 And this leads to another extremely critical element of an ACO: trust. Trust is an extensive topic, so we’ll focus on two aspects:  trust in technology and trust in the organization. Trust in technology is the reliance on secure electronic exchange using certificates or other encrypted communications. ACOs, like all other health care entities, must secure data to comply with the HITECH Act and HIPAA regulations. Trust in organizations, in this case, is the confidence that all parties involved in the ACO – providers, health plans and patients – are working together for the common goal of  improving patient care while reducing cost. With trust in technology and trust in the organization established (and backed contractually), information can be successfully shared and used.

4. Find the best route for patient records and empower patients in the ACO. Are we going to route records to a patient’s personal health records system, or create a new structure for patients enrolled in an ACO? How will we ensure that the patient understands and complies with their care plan? Patients may need to provide consent, and/or want to know who has access to their health records. ACOs should consider patient rights and state regulations while working to provide a patient portal that is simple to use, understandable and consistent. Improving patient outcomes requires patients to understand how their health information will be used, and be empowered to take responsibility for their own care.

5. Health plans should expect to lead the conversation. You, the health plan, are in the best position to drive the adoption of ACOs and to make them successful. Not only do you understand what data is needed, you have the technical foundation to enable ACOs. You have an existing electronic connection to providers, and you offer member (patient) portals where information can be shared.

Just as important, health plans can offer a win-win solution to the provider through administration simplification (streamlining workflows to minimize manual processes), enabling faster eligibility confirmation, faster payment authorizations and more. Health plans can also identify cost savings to help the ACO pay for itself, instead of being yet another new initiative that adds to the cost of health care and increases the administrative burden of already overworked clinicians.

Only health plans can play this leadership role in making ACOs work. They must ensure that the right data is exchanged, develop trust between all parties and lead the conversation about how to make these activities cost effective, streamlined, efficient and, lastly, workable for everyone involved.

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