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The ACO model and shared savings: Can IT get you there?

The success of accountable care organizations seems possible. Association leaders aren't quite convinced. Either way, IT departments should prepare for a new reimbursement model.

The accountable care organizations (ACO) model can lead the U.S. health care system back into solvency by reducing duplicative and unnecessary procedures through having primary care physicians manage their patients' appointments -- all this while improving quality of care and rewarding providers with a percentage of the cost savings.

At least that's the theory espoused in last year's health care reform, which authorized the Centers for Medicare & Medicaid Services (CMS) leaders to create the ACO program. CMS leaders -- glass-half-full types when it comes to the potential of the ACO model -- explained at a recent informational webinar how that could happen, backing up their theories with stats from private insurer Blue Cross Blue Shield of Massachusetts' (BCBSMA) ACO-like Alternative Quality Contract payment model. (The webinar is archived here.)

Out in the field, however, health IT leaders charged with implementing technologies to enable compliance with the complex health data tracking and reporting involved with ACOs lean toward the glass-half-empty side, at least when it comes to CMS's ACO proposed rule. They doubt the shared savings program CMS promises will be enough of a payoff to inspire a nationwide ACO movement.

Among the many associations that have registered detailed, strongly worded comments with CMS regarding the ACO proposed rule -- and the complex IT commitments to support the ACO model -- are the American Telemedicine Association, the College of Health Information Management Executives, the American College of Physicians and the American Medical Group Association (AMGA).

Furthermore, the Patient Centered Primary Care Collaborative recently published a report finding that the technology needed to support the ACO model either doesn't exist or is so misaligned with the meaningful use of electronic medical record (EMR) technology that health care providers are going to have a tough time participating in both.

"The regulations prescribe, as proposed, 65 quality measures; most of the EMRs that are out there don't capture, in a structured format, all of those measures," AMGA President and CEO Donald Fisher told

His group, which represents 390 medical groups who employ 117,000 physicians, not only criticized that "excessive" number of  ACO quality measures in its comments to CMS but also what it called an "onerously complex" application process to become an accountable care organization. If the proposed rule were to remain unchanged to its final state, Fisher believes few of his group's members would participate, he told CMS.

CMS shows how shared savings could work

In the webinar, CMS director of performance-based payment policy staff John Pilotte said the ACO proposed rule "basically builds on the existing Medicare fee-for-service program and provides an opportunity for providers to participate with Medicare in a new way that rewards them for delivering and improving the quality and efficiency of care for fee-for-service Medicare patients. This," he added, "represents a new approach to delivering care and promoting better, integrated, higher-quality, more efficient care…and proactive care coordination."

The [ACO] regulations prescribe, as proposed, 65 quality measures; most of the EHRs that are out there don't capture, in a structured format, all of those measures.

Donald Fisher, president and CEO, AMGA

His co-presenter Dana Gelb Safran, BCBSMA senior vice president for performance measurement and improvement, described her organization's Alternative Quality Contract (AQC) program and its bonus payment program, which rewards a group bonus reimbursements of up to 10% based on its performance against agreed-upon performance measures. The ACO rule includes a similar wrinkle: Organizations scoring higher get bigger financial rewards.

In 2010 -- the first year of her organization's payment model -- quality improved measurably:

  • Performance in preventive care measures such as cancer screenings and well-child visits -- as well as for important measures of chronic disease care -- was three times that of medical groups not in the program, and more than double the AQC groups' own improvement rates before joining.
  • AQC groups exhibited exceptionally high performance for all clinical outcomes, with more than half approaching or meeting maximum performance target for diabetes and cardiovascular care quality measures.
  • There were no significant changes in patient experience quality measures overall among AQC groups.

"On quality measures, the year one improvements that we saw were greater than any one-year change we've ever seen," Safran said. "I've spent my career in quality improvement and have never seen improvements of the magnitude that we saw here."

If not ACO model, then some other new way to reimburse

CMS could change the ACO proposed rule to reflect changes requested by various stakeholders such as the associations mentioned above. That would improve the chances of successfully breeding a network of patient-centered provider organizations, Fisher said.

Pilotte acknowledged the comments that came in before the period ended June 6 would be carefully considered, and that CMS viewed them as an important influence in creating the ACO final rule to be published later this year.

It's possible -- as was probably the case with meaningful use last year, Beth Israel Deaconess Medical Center CIO and federal data standards advisor Dr. John Halamka noted -- that CMS wrote a kitchen sink's worth of reporting measures and other requirements into the ACO proposed rule, fully expecting that fewer would make the final cut.

If the CMS Center for Innovation's Pioneer ACO Model and its lessened reporting requirements are any indicator, Fisher said, CMS could be leaning toward paring it back. However, even if the ACO model fails to gather steam in the U.S. health care system, he added, there will be some new reimbursement model to replace the current fee-for-service model.

Physicians, medical groups and hospitals will need to prepare for this new model. Whatever it's called or however it appears in its final form, Fisher believes will involve at least three facets of the ACO model as currently imagined by CMS: Intensive quality measures reporting, meaningful use compliance and comparative reporting between health care providers, who will use each other's patient outcomes as a yardstick to measure their own quality of care.

"90% of [AMGA members] already have implemented electronic medical records, plus they've got disease registries as well as business intelligence tools that are built on to those EMRs," said Fisher, who also said his organization has launched a comparative database for members to measure their quality initiatives against each other. "As far as having the infrastructure in place, they're ready to go."

Let us know what you think about the story; email Don Fluckinger, Features Writer.

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