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VISIT US AT BOOTH 4043 ACCOUNTABLE CARE ORGANIZATION Reference Guide POPULATION HEALTH

ACCOUNTABLE CARE ORGANIZATION - Greenway Health€¦ · Accountable care organizations (ACOs) seek to improve care, increase the health of populations and reduce medical costs. In

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Page 1: ACCOUNTABLE CARE ORGANIZATION - Greenway Health€¦ · Accountable care organizations (ACOs) seek to improve care, increase the health of populations and reduce medical costs. In

VISIT US AT BOOTH 4043

ACCOUNTABLE CARE ORGANIZATION Reference Guide

POPULATION HEALTH

Page 2: ACCOUNTABLE CARE ORGANIZATION - Greenway Health€¦ · Accountable care organizations (ACOs) seek to improve care, increase the health of populations and reduce medical costs. In

2 | Population Health

Accountable care organizations make value-based care their businessAccountable care organizations (ACOs) seek to improve care, increase the health of populations and reduce medical costs. In this guide, you’ll learn how ACOs can earn extra revenue by participating in value-based programs and how connecting multiple types of electronic health records (EHRs) helps organizations achieve their mission to improve the healthcare industry as a whole.

Save money, make moneyACOs can earn a percentage of the savings accumulated from reducing costs by participating in value-based programs such as:

1) The Medicare Shared Savings Program (MSSP): ACO providers are reimbursed by traditional fee-for-service as well as shared savings but are not incentivized for creating “savings” by cutting back on necessary facilities or personnel. There are three tracks of the MSSP, and as your organization takes on more risk, the reward grows accordingly.

2) The Advanced Payment ACO: Participants receive a $250,000 advance, a $36 per beneficiary variable payment and an $8 per beneficiary monthly payment, which must all be repaid as the ACO creates savings.

3) The Pioneer ACO: Designed for experienced coordinators of care, the Pioneer ACO enables providers to move quickly from a shared savings payment model to a population-based payment model separate from the MSSP.

Most ACOs can receive up to 50 percent of the savings generated by reduced overall costs to the Centers for Medicare and Medicaid Services (CMS). But when you take on additional financial risk, your potential shared savings grow as well.

GREENWAY COMMUNITY ADVANTAGE Greenway Community gives your organization visualized and actionable insight into quality and cost performance at each level of the ACO. With this view, providers can maximize their share of captured savings by reacting to factors causing underperformance. Patients who are hindering quality performance because of their health or noncompliance can be easily identified and managed using Greenway Community Manager for follow-up.

Success beyond measureNo matter the program an ACO chooses, the formula is the same: improve quality of care and reduce costs, then get paid. Performance is based on

Takeaways

Greenway Community, our population health management tool, includes analytics, risk stratification, care management and data exchange solutions that enable providers to make more informed decisions and delivery more efficient, effective care.

$853,693

estimated earned shared

savings

50%

Most ACOs can receive up to

of savings

$2million

projected savings

Greenway Community’s ACO Advantage

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Population Health | 3

33 quality measures within four domains:

• Patient experience of care (seven measures)

• Care coordination and patient safety (six measures)

• Preventative health (eight measures)

• At-risk population management (12 measures across five chronic diseases)

CMS has also established national benchmarks based on participant data and measure attainment. To be eligible to share in savings, ACOs must meet cost savings criteria and cross a minimum attainment level of 30 percent on at least one measure in each of the four domains.

GREENWAY COMMUNITY ADVANTAGE Based on a study of a 45-provider multispecialty ACO with 6,800 attributed Medicare patients, Greenway Community helped increase the organization’s quality score by 20% and earn $2 million in total projected sav-ings and $853,693 in estimated earned shared savings.

Between a rock and a benchmarkWhile the ACO model can be very profitable, it presents unique challenges that must be considered before entering into an ACO agreement.

• Benchmarking and tracking measures are not one-size-fits-all, with many measures being comprised of several individual measures and some that are strictly pass-fail.

• Domains are difficult to manage. For example, many measures in the patient and caregiver domain are based upon patient survey feedback, which is subjective and requires a high response rate to be accepted.

• The measures themselves can be complicated. More than 15 unique denominators are present, each tracking a different patient type. Organizations without sophisticated reporting tools may miss important informational nuances.

Sharing and caringWith all of the challenges presented to ACOs, connectivity between the EHRs that allied providers use should not be one of them. When the systems within an ACO network do not talk to each other, practices risk making mistakes caused by manual work, such as paper note-taking, multiple phone calls, and unreliable receipt and response times through snail mail.

Similarly, when your in-network EHRs don’t connect with the practices your ACO sends numerous referrals to, efficiency suffers and accurate, timely patient data is at risk. In order to improve the health of entire populations, ACOs must operate with the complete picture of patients’ health.

GREENWAY COMMUNITY ADVANTAGE Greenway Community pulls both claims and clinical data from a variety of resources, such as other EHRs, HIEs, hospital systems and payers, so you have a complete picture of a patient’s health.

The complete picture of healthAccurate data is everything in healthcare, but gaining the complete picture of a patient’s health requires multiple types of data from multiple sources. If an ACO relies solely on claims data to gain insight, there’s a high chance it will miss surgical history, medication allergies and other clinical information that claims data cannot provide.

Relying on a combination of claims data and clinical data will help providers see the clearest picture of a patient’s medical history, but data is only as good as its source. To avoid missing critical information, an organization needs a well-integrated IT system and shared information across and outside the ACO.

• Ambulatory practices should be able to exchange clinical care summaries to give providers the most up-to-date patient information and ensure patients are assigned appropriate clinical risk levels.

• Hospitals and other providers of acute care should be connected to the data, so that critical information is available on ED visits.

• Ensure you receive frequent claims data from payers. By doing so, even if a patient goes outside of your clinical network, you will still have their most complete medical history — no matter where they’ve received care.

When an entire ACO is connected, medication reconciliations, post-discharge instructions and identifying where high and avoidable expenditures take place all become easier. This improved efficiency leads to more accurate, timely care and healthier populations.

ACO measuresTo ensure your organization is on track to meet ACO measures, consult the following useful charts and measures index.

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4 | Population Health

USEFUL CHARTS AND MEASURESACO MEASURES

BETTER CARE FOR INDIVIDUALSPatient/Caregiver Experience

Getting timely care, appointments, and information Health promotion and education

How well your doctors communicate Shared decision-making

Patient’s rating of doctor Health status/functional status

Access to specialists

Care Coordination/Patient Safety

Risk-standardized, all condition readmission

Ambulatory sensitive conditions admissions: COPD Discharges for patients over 40 with COPD, asthma or acute bronchitis (ICD-9 codes)/Patients 40 and over

Ambulatory sensitive conditions admissions: Congestive heart failureDischarges for patients over 18 with heart failure/patients over 18

Percent of PCPs who successfully qualify for an EHR incentive program payment (double weight)

Medication reconciliation: Reconciliation after discharge from inpatient facility (documenting reconciled drugs) Patients who had reconciliation of discharge meds with current medical list in outpatient record/all patients over 18 (two rates, 18–64 and 65+)

Screening for fall risk. Three aggregate rates: A. Patients screened for future fall risk at least once in 12 monthsB. Patients who had a risk assessment for falls completed within 12 monthsC. Plan of Care for Falls: Patients with a plan of care for falls document within 12 monthsA. All patients over 65. B/C. All patients over 65 with a history of falls.

BETTER HEALTH FOR POPULATIONSPreventative Health

Influenza immunization Patients who received immunization or reported receipt of immunization/All points over 6 months of age

Adult weight screening and follow up (when BMI goes out of normal parameters, follow-up plan documented during encounter) Patients with documented BMI, and when outside normal parameter, documented follow-up/all patients over 18

Pneumococcal vaccination Number of patients who say that have had a PNU shot/CAHPS respondents 65+ responding

Tobacco use assessment and cessation intervention (if IDd as user, cessation counseling) Patients screened for tobacco use during 2-yr period and received cessation counseling if IDd as user/all patients over 18 seen for at least two visits or one preventive visit

Depression screening (screen 12 and up + follow up) patients screened for depression using age-appropriate tool and follow-up plan/all patients over 12

Mammography screening One mammogram per year/Women 42–68

Colorectal Cancer screening Screening for CC/patients 51–75 Blood pressure measured within preceding 2 years

want to connect to a national HIE

want to connect to a city HIE

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Population Health | 5

ACO MEASURES

At-Risk Population

Diabetes composite A1C (less than 8.0) Blood pressure control BP adequately controlled, must be less than 140/90 (upper limit)/patients 18-85

Diabetes composite LDL (less than 100) Ischemic vascular disease Lipid profile and lipid controlPatients with completed lipid profile with result <100mg/dl/patients 18+ discharged for AMI, CABG, or PCI or had diagnosis of IVD

Diabetes composite blood pressure (less than 140/90) Ischemic vascular disease use of aspirinPatients who used aspirin/patients discharged for AMI, CABG, PCI, or IVD

Diabetes composite tobacco non-use Y/N Heart failure: Beta-blocker therapy for left ventricular systolic dysfunctionPatients given beta-block therapy in outpatient. Setting or at hospital discharge/Patients 18+ with diagnosis of heart failure or with a current or prior LVEF < 40%

Diabetes composite aspirin (on aspirin with diagnosis of ischemic vascular disease unless contraindicated)

CAD composite: LDL cholesterolPatients LDL-C < 100 mg/dl, or patients with a higher level and documented plan to et a lower one/patients 18+ with CAD

Diabetes mellitus: A1C (less than 9.0). Not risk adjusted. CAD composite: ACE, ARB, treatments Patients with ACE or ARB therapy/Patients with CAD

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6 | Population Health

ADMINISTRATIVE CLAIMS OUTCOMES MEASURES Used for quality tiering if a practice does not meet the reporting criteria of the PQRS incentive

Number of admissions for bacterial pneumonia (AHRQ) Number of discharges for UTI (AHRQ)Number of dehydration admissions (AHRQ)Number of discharges for uncontrolled diabetesNumber of discharges for short term diabetes complicationsNumber of discharges for long term diabetes complicationsNumber of discharges for lower extremity amputation for diabetesNumber of admissions for COPDPercent of population with admissions for heart failureRate of provider visits within 30 days of discharge

Follow-up after hospitalization for mental illness (NCQA, Care coordination)Use of right-risk meds in the elderly (NCQA, Patient Safety)Lack of monthly INR monitoring for warafarin users (CMS, patient safety)Use of spirometry to diagnose COPD (NCQA, clinical care)Statin therapy for patients with coronary artery disease (CMS, clinical care)Lipid profile for beneficiaries who are on lipid lowering medications (resolution health, clinical care)Osteoperosis management in women over 67 who had a fracture (NCQA, clinical care)

Dialated eye exam for patients under 75 with diabetes (NCQA, clinical care) HbA1c testing for patients under 75 with diabetes (NCQA, clinical care)Urine protein screening for patients under 75 with diabetes (NCQA, clinical care) Lipid profile for patients under 75 with diabetes (NCQA, clinical care) Lipid profile for patients with ischemic vascular disease (NCQA, clinical care)Antidepressant treatment for depression (NCQA, clinical care) Best cancer for women under 69 (NCQA, clinical care)

ADMINISTRATIVE CLAIMS PROCESS MEASURES