How Accountable Care Organizations Meet Quality Benchmarks

September 19, 2016 - Accountable care organizations (ACOs) are relatively new patient care models that can operate with either public or private health payers. Initially, the Centers for Medicare & Medicaid Services (CMS) created the first accountable care organizations under the Medicare Shared Savings Program. Today, ACOs have grown in popularity and private, commercial payers are now investing in partnering with these models of care.

ACOs have a number of goals they must meet in order to be worthwhile endeavors. These goals include reducing healthcare spending and sharing in cost savings as well as meeting quality performance benchmarks aimed at improving the quality of care and patient outcomes.

Data analytics needed for meeting quality performance benchmarks

In order to succeed in meeting and improving upon quality performance benchmarks, hospitals and physician practices participating in ACOs need health IT tools and data analytics capabilities to determine their clinical performance. The first steps will also include incorporating standardized quality metrics.

However, some healthcare organizations such as the National Quality Forum have stressed the inadequacy and complexity of quality reporting programs while calling for the creation of more accurate and easier-to-use quality reporting platforms. Measuring data effectively is key toward meeting quality performance benchmarks for the nation’s ACOs.

“The core work of the National Quality Forum is to be the gold standard for measures that are used throughout the healthcare system.  Everybody needs and deserves to have consistent and accurate information about healthcare,” NQF President and CEO Christine Cassel, MD, told HealthITAnalytics.com.  “That’s easy to say, but in a world where data sources are multiplying by leaps and bounds and where there’s a growing emphasis on tying payment to performance, there’s a lot of complexity when it comes to actually implementing systematic improvements.”

“Some of those challenges have to do with understanding big data in every way it manifests itself,” Cassel added.  “We always have to ask ourselves how we can turn data into meaningful information, particularly for consumers and providers.  You do that by creating measures that are accurate and that are consistent so that you can compare apples to apples across a community, a group of providers, or across the nation as we try to achieve the Triple Aim of better population health, better healthcare, and more affordable healthcare.”

Reaching quality metrics is key for accountable care organizations in order to share in their savings. The Medicare Shared Savings Program has shown that the number of ACO participants have improved their quality performance since implementing the MSSP platform.

In an interview with HealthPayerIntelligence.com, Erin Page, President of the Accountable Care Coalition of Texas, discussed how her ACO measures success and quality of care.

“What we’re doing with CMS on the MSSP model or CMI [Center for Medicare & Medicaid Innovation], the quality component is done through GPRO [ACO Group Practice Reporting Option] scores that are done on an annual basis,” Page commented. “They’re made very similarly to how Medicare Advantage Star Ratings. There are HEDIS measures involved, there are health outcome surveys that beneficiaries will take, and there are also satisfaction surveys from patients about their experience inside their physician practices. Those three components make up the GPRO score.”

“You have to hit certain thresholds at the GPRO score in order to gain any of your earnings that you have made from CMS. If you don’t practice high-quality medicine and making sure that you’re giving preventative services, you’re managing the diabetics, and you’re managing CHF and CAD, you don’t get any of your savings,” Page continued.

Page stressed the importance of disease management and preventive medicine when it comes to reducing the costs of care and being cost-efficient.

“We look at each individual physician and we look at their quality scores. We can see where they have improved or have not improved. The sample size is fairly small but they need to treat everyone the same so the program that we put in place really encouraged physicians to have the tools necessary in order to do all the testing and be more proactive about patient care. Similar on the Medicare Advantage side, the physicians have to comply with Star Ratings. Those are all types of quality measures. We’re able to look at the star measures down to each individual physician that’s assigned a panel in the HMO.”

Marci Nielsen, CEO at the Patient-Centered Primary Care Collaborative, spoke with HealthPayerIntelligence.com about how her organization promotes and supports its members in measuring the quality of care they provide to their patients.

“When it comes to assessment of success, because we are a coalition that really is trying to push for high-performing primary care as defined by the Triple Aim and now moving toward a concept referred to as the Quadruple Aim where we’re also paying attention to clinician satisfaction, we don’t point back to our members in particular. We look to the peer-reviewed literature and we point to best practices and provide examples for what could be and should be and how these health systems and primary care practices achieve their goals,” Nielsen said.

“The AC Lan is an initiative that was launched as part of the Affordable Care Act. Everyone who signs up for the Lan is required to turn back around and explain what your organization is doing to meet the specific goals the Lan has. We’re less bureaucratic than the Lan. Anybody who wants to focus on promoting high-quality primary care can be a member of our organization. We try to show them the path to what that looks like and try to educate and advocate with policymakers what kinds of payments are necessary and what kinds of policies are necessary,” Nielsen added.

Major challenges Facing ACOs

Results from 2014 show that 20 Pioneer ACOs and as many 333 participants of the Medicare Shared Savings Program gathered a total of $411 million in savings, but in reality only half of Pioneer ACOs and one-third of MSSP participants actually shared in these cost savings with regard to the quality performance benchmarks.

This shows that there are still challenges standing in the way of accountable care organizations sharing in cost savings and reducing healthcare spending. Page discussed some of the challenges that the Accountable Care Coalition of Texas has faced.

“I think a big challenge when you get into ACOs is the availability of data,” Page explained. “Making sure hospitals let you know when patients are admitted. That has been a real challenge where the hospitals don’t want to be as open with their data. There are many hospitals who we work with that we get information on a daily basis so we do know who’s in the hospital. But we have many other hospitals that basically say, ‘Unless your doctors are going to act as hospitalists, we’re not going to let you know who’s in the hospital.”

“[The challenges include] consistent availability of data [and] making sure we know where the patients are,” Page added. “Part of the way we solve for that is making sure we engage directly with the physicians on EMRs and even sending clinical folks into the physician practices so that we can get data and also help them coordinate care. This is still a fragmented healthcare system but as data comes together more and we’re able to analyze it and be more proactive versus reactive, it will make us always deliver a higher quality of life to patients.”

When it comes to meeting the challenge of getting data from hospitals head-on, some accountable care organizations have ensured that hospitals are part of their overall network. According to a study from The Commonwealth Fund, patients who receive treatment at hospitals that belong to ACOs are more clinically complicated and tend to stay longer.

Additionally, ACOs that include hospitals have twice as many primary care physicians and three times as many specialty doctors. The study also found that 63 percent of ACOs with participating hospitals have provide more comprehensive services.

How ACOs strengthen their payer partnership

In order to keep the revenue cycle stable and overcome obstacles associated with cost reduction, accountable care organizations will also need an effective partnership with their health payer. Page described how ACOs can create a beneficial partnership.

“The way that we’ve done that historically is by engaging in a risk relationship with the payer,” Page added. “The physicians have consistent revenue for the work that’s going to be done outside of exam room. When you’re managing risk, there’s a lot of administrative work that has to be done by the staff. The other piece is being able to negotiate capitation rate for the physicians. They have a consistent revenue stream coming in every month, but the real key point is being able to have transparency with the payer and receive data from the payer.”

“When you’re asking a primary care physician to manage holistically the patient even if they really don’t know what happens to the patient when they leave the clinic, we need the payers and the MSSP program to provide the claims data,” she continued. “Even though the claims data is out of date, it gives us the trend in the areas clinically that we need to focus on for disease management. It really becomes an open line of communication between the payer and the physician. At the end of the day, payers don’t process medicine and physicians don’t write health plans, so the partnership works well.”

Nielsen also described how the Patient-Centered Primary Care Collaborative assists participating payers in supporting their partnership with accountable care organizations.

“One [way we support payer partnerships] that often comes to mind relates directly to ACOs,” Nielsen started. “When you look at the most recent data and whether ACOs are, in fact, achieving their policy goals, we are often tempted as part of our eternal quest for achieving the Triple Aim, we often find ourselves measuring just one component of the Triple Aim. That’s the cost component. That’s certainly important to payers in government and certainly in the commercial sector.”

“When you dive down into the data and you look at the quality measures that ACOs are reporting back to CMS, what you see is that quality measures in terms of patient experience don’t necessarily correlate with the cost measures,” she continued. “Everybody agrees that we don’t want to just cut the cost of care if we’re not also improving it. We also don’t want to improve the quality of care at any price.”

“If we’re using the power of primary care, we’re better coordinating care and we are focused on care that patients need and want and we’re pulling out the overuse and misuse of healthcare. That’s where everyone is in total agreement. Thirty percent of our healthcare dollars are wasted. Patients don’t want that. Payers don’t want that. And healthcare providers don’t want their time wasted. The policy to pull us back into primary care that’s done right is team-based and patient-centered. Payers want value and healthcare providers want to deliver value,” Nielsen said.

The revenue cycle of accountable care organizations

The Accountable Care Coalition of Texas works with the Centers for Medicare & Medicaid Services (CMS) as their main health payer. This particular accountable care organization is a participant of the Medicare Shared Savings Program, explained Page. Their original funding comes from Collaborative Health Systems (CHS).

“The funding came from the partnership that’s been established with CHS,” she stated. “It functions as the MSO for the ACO. The MSO took on the burden of the administrative cost structure. When it comes to IT, clinical systems, analytics, and financial reporting - it was all funded by the MSO. There is also a split between the physician and the MSO earning from the group. Basically, the ACO itself contracted with CHS to be the MSO as organization. CHS was taking the risk on the administrative services. If there were no earnings, CHS would absorb those administrative losses.”

“We actually began in April of 2012 when the MSSP first launched. We contracted with CMS,” Page said. “This is a group of physicians who have been involved with risk for many years. They have taken some form of risk or gain share from Medicare Advantage plans. Some of them have done this for 15+ years. Because they understood how to manage risk and our organization has had a very long-standing relationship with the physicians, when we saw the ACA come out, we thought that this is a great opportunity for them to expand what they did with Medicare Advantage from a clinical and quality perspective.”

The revenue cycle of the Patient-Centered Primary Care Collaborative rests mostly on member dues, explained Nielsen.

“All of the member organizations pay dues,” she said. “We’ve got our executive member dues. We’ve got about 72 organizations that pay dues. They comprise almost 90% of the funding for our organization. We also have conferences and we do some other technical assistance for organizations that want to know more about primary care transformation. Also, last year, we were one of CMS grant recipients for the transforming clinical practices initiative. So we are now a federal grantee. As part of this, we run one of the support and alignment networks that’s specifically focused on patients, families and caregivers.”