Health care coordination under the rules of an ACO

On March 31, 2011 CMS issued its proposed rules for Accountable Care Organizations (over 400 pages).

There is now a 60-day comment period.  Shortly thereafter, the final rules will be issued.  I am sure there will be changes in the proposed rules as there were changes in the “meaningful use” rules for electronic health records (EHR’s).  Yet, much of the intent of the proposed rule will probably remain unchanged and now is a good time for healthcare providers to begin adopting the processes, tools, measures and guidance laid out in the document, as the formation of ACO’s will probably be widespread.  It is likely that CMS will begin signing agreements with ACO organizations sometime in 2012.

Given the fact that many organizations are forming ACO structures now, I believe that it is important that physician practices and other healthcare organizations start planning for their arrival, both those groups planning to become a part of an ACO and those who are not planning on becoming a part of an ACO.  Most healthcare organizations will likely be impacted.  In West Michigan, where I live, the three major hospital/physician organizations are forming ACO’s and, as a result, will have a large impact on others who are not part of the structures.  The University of Michigan is involved in ACO’s and is providing faculty representatives at the second annual National Accountable Care Organization Summit.

Since the ACO structure will have a broad impact, let me lay out a few of its salient features, especially those that are related to quality and measuring quality.  First, with what kind of organizations will CMS sign an agreement as an ACO?  The proposed rule lists four types:

  • ACO professionals in group practice arrangements
  • Networks of individual practices of ACO professionals
  • Hospitals employing ACO professionals
  • Such other groups of providers of services and suppliers as the Secretary of HHS deems necessary.

ACO professionals are defined as physicians, nurse practitioners, physician assistants and clinical nurse specialists.  From further reading, I am almost certain that CMS will not contract with an organization that does not supply primary care services to its patients.   CMS will certainly want primary care support for its beneficiaries who are in ACO organizations.

Next, what is the intent of CMS in signing agreements with an ACO organization?  It is as quoted from the proposed rules “to promote accountability for a population of Medicare beneficiaries, improve the coordination of FFS items and services, encourage investment of infrastructure and redesigned care processes for high quality and efficient care delivery, and incent higher value care.”  The provider must be patient-centered.  The rules draw upon the goals listed in the Institute of Medicine’s Crossing the Quality.  Namely, providers should supply care that is

  • Safe
  • Timely
  • Patient-centered
  • Effective
  • Efficient
  • Equitable

Based upon these goals, CMS has listed 65 indicators with accompanying descriptions of how they will measure the indicators.  CMS will grade providers on these outcomes based upon benchmarks from providers who are not in ACO organizations.  If the ACO exceeds these benchmarks significantly it will be rewarded financially for the savings that it provides CMS.  The 65 indicators will be adjusted for regional outcomes and on other factors which can impact the ACO.  Success in achieving the measures will be based upon the population level outcomes for patients of the ACO who are Medicare beneficiaries.

Some of the measures are:

  • Controlling cholesterol levels of the patients with coronary artery disease
  • Controlling blood pressure of patients with hypertension
  • Achieving patient satisfaction on a number of factors as measured by Clinical/Group CAHPS
  • Achieving A1c levels below 7% for diabetics

Providers will need to take a thorough examination of processes and population level outcomes to achieve these goals and make changes in their processes in order to reach the goals.  Advantage Health of Grand Rapids in conjunction with Saint Mary’s Health Services is becoming certified as patient-centered medical homes by NCQM in order to achieve the level of outcomes specified by CMS.  Dr. David Blair of Advantage Health and Roberta Jelinek of Saint Mary’s recently outlined this approach at the Michigan Medical Group Managers Association’s spring conference.  Another successful approach is to use a Lean Healthcare approach which is based upon the Toyota Production System and is becoming more widespread in healthcare as more individuals are being trained and certified in this area.

Let me end with a personal example of good coordination of healthcare services.  Usually after my annual physical I ask my physician to have his staff arrange an appointment with a dermatologist if he and I agree that there are some moles on me that are suspicious. Once my dermatologist is done with the exam, he verifies who my primary care physician is so that a summary of findings can be sent to him.  Also, my dermatologist calls me within two days with the results of any biopsy.  At my next annual exam, my physician reviews the dermatologist’s findings with me again.  I find it very encouraging that the dermatologist makes an extra effort to be sure my physician is up to date with the findings.  Under the rules of an ACO, such coordination will become commonplace.  Can your site achieve such outcomes?  I believe it will be necessary to do so soon.

Donald Tex Bryant is a consultant who helps healthcare providers meet their challenges. He can be reached at Bryant’s Healthcare Solutions.

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