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Starting an ACO:IT Lessons Learned

Robert Slepin, PMP, VP and CIO

John C. Lincoln Health Network

Nathan Anspach, SVP and CEO

John C. Lincoln Accountable Care Organization

John C. Lincoln Physician Network

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John C. Lincoln Health Network

Overview

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John C. Lincoln Hospitals

• North Mountain Hospital 262 Beds Trauma Center Magnet Designation

• Deer Valley Hospital 203 Beds

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Physician Network: At a Glance

• 120 primary care providers Additional planned growth

• 20 specialists• 34 locations• NCQA PCMH Accreditation In-Process• Patient Visits

2011 - 263,866 2012 - 323,144 2013 - 409,000 (projected)

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Accountable Care Organization

• Approved by CMS July 2012

• 18,000 Medicare Shared Savings Program (MSSP) and Commercial members

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JCL ACO Provider Distribution

Subspecialist70%

PCP30%

Independent65%

Employed35%

401 Providers

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Brief MSSP ACO Primer

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Organization of Health Care Providers

• Primary care and subspecialty physicians

• Hospitals Acute care Rehabilitation

• Post-acute providers

• Home health organizations

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Health Care Providers (cont.)

• Disease management

• Mental health

• Health and wellness

• Patient engagement

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Reimbursement in a Medicare ACO

• All participating providers continue to be reimbursed by Medicare on a fee-for-service basis

• Patients attributed to an ACO can continue to seek care from any Medicare participating physician, hospital or provider

• If a Medicare ACO is able to reduce the cost of caring for assigned Medicare patients and meet required quality standards, a possibility of shared savings exists

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Options for Medicare ACO Shared Savings

• Tier 1 – Limited risk

• Tier 2 – Risk-bearing

In either risk model, all providers continue to bill Medicare fee-for-service using the normal Medicare fee schedule.

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Calculate Shared SavingsStep One: Determine Base Spending Level

1. Determine the number of Medicare beneficiaries in the ACO. We will use

15,000 in our example.

2. Determine the average annual spend

per beneficiary. In Phoenix, that figure is approximately $9,000.

3. Multiply 1 times 2 and the result is a very large number - $135M.

This is the base spending level.

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Calculate Shared SavingsStep Two: Reducing Cost

1. Hypothetical: average cost is

reduced by 7.5% to $8,333 per beneficiary.

2. Multiply $8,333 times same number of members. Total

Spend is now $125M.

3. Subtract $125M from $135M and

savings are $10M. The ACO takes half,

or $5M, up to a maximum amount.

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Shared Savings Possible, Not Easy

• Requires reporting performance on 33 quality measures

• At least 50% of participating primary care physicians using an electronic health record

• Costs of care have to be reduced, but beneficiaries are not limited to ACO partners

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Four Domains of Quality Measures

• Patient/Caregiver Experience of Care 7 measures

• Patient Safety/Care Coordination 6 measures including electronic health record

• At-Risk Population 12 measures, focused on diabetes, heart failure,

hypertension and coronary artery disease

• Preventive Health 8 measures, include a variety of screenings

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ACO Start-Up

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ACO Cycle

Process Data

Identify, Attribute &

Stratify

Engage

Patients

Coordinate

Care

Report

Measures

Improve

CMS

EHRs

FAX

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IT Challenge #1

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CMS transmits attribution file to ACO

ACO locates patient demographic information

ACO sends prescribed letter to attributed patients

Patients respond/don’t respond to letter

Update to CMS with patient data sharing preferences

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CMS Data Transmission

Third Party Data Analysis Tool

Disease Registries

High cost Beneficiaries

High ER Utilizers

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IT Challenge #2

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Patient Information

PCP office visit

Create and file HCC

Disease Registry

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IT Challenge #3

Support patient outreach, care management, and data collection workflow

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IT Challenge #4

Encounter data refreshed quarterly

Disease Registries

Q1

Q2

Q3

Q4

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Clinical quality measure reporting

Data Sources

Numerator/denominatorcalculation

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IT Challenge #5

GPRO web site data entry

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Strategic IT Considerations

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Core ACO IT CapabilitiesData

• CMS files• Data acquisition• Member registry• Attribution• Stratification• Disease registries• Data warehouse• Analytics and

reporting• Predictive

modeling• Quality measures

Applications

• Beneficiary communications

• EMR• Clinical decision

support• Referrals• Formulary• ePrescribing• Care management• Disease

management• Patient portal• Physician portal• Secure

communications• Telehealth• Financial

Infrastructure

• Security• Enterprise master

patient index• HIE• Mobile/wireless

Other

• IT governance• IT leadership• IT skills• Change

management

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Technology Platform?

• Options Integrated ACO platform: Optum, Aetna or other Best-of-breed ACO platform: EHR, HIE and other pieces Enterprise EHR

• Our approach Leverage enterprise EHR to fullest extent Supplement with in-house development and third party

software-as-a-service where neededo Claims data processingo Population health analytics

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Single or Multiple EHRs?

• Ideal: One EHR

• Reality: Many EHRs and paper

• Options Require all participants to adopt single EHR Two-three preferred EHRs Any EHR, take your pick

• Our approach Single EHR for JCL hospitals and physician practices Longer term – preferred EHRs and Health

Information Exchange

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FTE, Consultants or Outsource?

• Existing IT staff likely fully committed

• Significant IT resources needed

• Options FTE hiring/ramp-up time Consultant costly, and you lose investment in know-how Outsourcing – high risk

• Our approach Dedicated consultant project manager – rapid start Leverage central IT organization for other skills

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Patient Engagement?

• Options Personal Health Record (PHR) Patient portal Monitoring devices Mobile apps or text

• Our approach Leverage EHR patient portal Promote adoption at practices and via marketing Improve value to encourage interactions and create value

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Claims or Clinical Data?

• Claims Good picture of most but not all encounters Time delay

• Clinical Richer data not available in claims Real time

• Our approach Both sources of data are necessary for success

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CMS Measure Reporting?

• Options Leverage core EHR Third party reporting tool Custom software Manual workaround

• Our approach Extract data from core and legacy EHRs Manual compilation of measures Plan for automation for Year 2

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Health Information Exchange (HIE)?

• Options Public Private Both None

• Our approach Start without HIE Next step – private HIE Future – expand to public

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IT Organization?

CEO

CEO – ACO & PN

COO CMO

CIO

PMO EMR Data & Reporting

• Options Integrated with corporate IT Separate IT

• Our approach Fully integrated – single CIO

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Questions?