Measuring quality in ACOs


How organizations can overcome challenges of reporting, capturing patient data.

One of the core goals of accountable care organizations (ACOs) is improving the quality of patient care. ACOs are subject to 33 quality measures, which present challenges when it comes to managing workflows, reporting and overall patient care.

Earlier this year, several Medicare Pioneer ACOs dropped out of the program. However, experts say financial pressures are likely to have played a much more prominent role than quality measures.

“The issue was maybe one of focus and return on investment, more than a difficulty with the quality measures,” says Bill Fera, MD, principal and chief medical officer with Ernst & Young’s healthcare advisory services practice in Pittsburgh.

Even though 60% of the Pioneers earned financial gain from the program in the first year, he predicts that as commercial health plans become more focused on risk sharing and ACO-like structures, Medicare’s ACO structure becomes less appealing.

“The Medicare ACO concept is harder to move forward because of its fee-for-service basis, so there is more focus on the commercial ACO that can be more of a true partnership,” he says.

Moving quality forward

The 33 ACO quality metrics represent a more narrow set than the 65 that Medicare leadership had initially been proposed. The measures are divided into four broad categories: patient/caregiver experience, care coordination/patient safety, preventive care, and at-risk populations for specific conditions (diabetes, hypertension, ischemic vascular disease, heart failure and coronary artery disease).

“These are cornerstone questions about quality,” says Dennis R. Horrigan, president and CEO of Catholic Medical Partners in Buffalo, N.Y.

Most of these measures build upon quality programs that are in existence already, with nationally accepted metrics, according to Fera. These measures build on existing programs, and hospitals that have been participating in quality programs-whether on the commercial side or through Medicare-have already been reporting on a lot of them.

Still, reporting quality can be a challenge for even the most well-prepared ACO. Boston-based Atrius Health, with six community-based medical groups and a home healthcare and hospice agency, was one of the first Pioneer ACOs and leaders to consider quality measures and reporting to be a core competency.

“We view the quality measurements as an opportunity to identify gaps in care. However, some of the 33 are completely new measures we have never reported before,” says Emily Brower, executive director of accountable care programs. “We relied on past experience in developing new measures to build some workflows, documentation and reporting tools. When we interpreted the measures where there was leeway, we created most definitions so that they required a pretty high bar.”

For example, risk assessments to determine if patients are in danger of being injured in a fall is a brand new measure, and a clinically important one as falls are a major reason for hospital readmissions. To set up the measure, Atrius Health evaluated available assessment tools and chose the one with the greatest clinical validity. Then, it determined the best areas to focus on from a clinical perspective. The ACO developed workflows to conduct the assessment and also document it in medical records and plans for following up on high-risk patients. With monthly tracking, Atrius Health can report to its medical groups on their performance and send out reminder alerts to conduct the fall-risk assessment.

Another reporting challenge results from the lack of clear guidance on what is required to meet the numerator and denominator.

“In most cases, we have the data, but Pioneer ACOs have had to make judgment calls around meeting numerator or denominator tests because there is a lot of variability,” says Brower. “We also had to build out a new IT piece to pull data from electronic health records and import it into the tool.”

“We already have the systems in place to pull information out of electronic medical records [EMRs],” says Catholic Medical Partners’ Horrigan. “We’ve been doing this for years, so it is not as difficult.”

However, the organization still dedicates two full-time employees to work on it. “When you have to do the measurement, it takes six to eight weeks at full court press,” he says.

Even with those resources, there can be issues, often related to underreporting.

Building systems

One of the key challenges associated with ACO quality measures involves capturing and reporting the data effectively and efficiently. ACOs work with many different providers and practices with many different IT systems, reporting habits and clinical processes, making data collection difficult.

Dan Marino, president and CEO of Health Directions, LLC, Oakbrook Terrace, Ill., who has worked with three Pioneer ACOs, suggests that ACOs collaborate proactively with associated practices to ensure appropriate data collection at each site. “Not all EMRs are set up to support the capture of local data,” he says.

For example, an ACO can capture the smoking status of a patient. However, the measure also requires tracking how the provider is helping the patient to stop smoking and any plans in place to achieve that goal-information that is not necessarily included in EMRs.

Those entities that are more advanced from an information technology standpoint are better positioned to generate the necessary reporting and to have automated reporting, making it less of a strain on the ACO’s resources. However, ACOs that do not have an advanced data warehousing environment or an enterprise intelligence environment may be struggling more. If an ACO has to do manual extractions from records, compilation and assignment of numerators and denominators, it becomes extremely onerous, says Fera.

Improving care

If information technology is the backbone of a successful ACO, patient care is the lifeblood. With multiple facilities, providers and practices often geographically scattered, it can be difficult to ensure that providers are doing and documenting what is necessary to measure and improve quality.

Marino notes that the more successful ACOs are putting in place care coaches and navigators to help providers modify clinical workflows.

Providers’ priorities are not always aligned with those of the ACO. For example, some providers might be volume-driven in their practices. With quality metrics having a longer-term impact that might not be realized for 18 months or more, “this is not something that is top of mind,” he says.

Care coaches can also help providers understand who is a high-risk patient and which patients are costing the ACO the most money. These coaches can emphasize different care protocols for different patients based on their risk cohorts. For example, a high-risk diabetic could have an out-of-control condition, be overweight and also have high blood pressure. The care coach can work with providers to improve or exceed certain clinical quality metrics.

Other innovations can also help. For example, an ACO can program its systems to send electronic alerts to providers about additional services and clinical activities the patient might require to get better care. Catholic Medical Partners gives all of its doctors an electronic account record that creates prompts for patient care, such as a mammogram for female patients over age 40.

Managing transitions in care is crucial to ensuring proper handoffs between primary care physicians and specialists when a patient is discharged. “Not only does that help support measures, but it can help manage costs significantly,” Marino says.

Providers also need feedback. “It is important to provide information and data back to providers so that they can begin to understand how they can change their clinical workflows in order to support each measure and, more importantly, provide  better quality of care,” Marino says.


Long-term improvements

How much progress ACOs make on these metrics will depend on a number of factors, including the percentages of patients in different risk cohorts. In other words, if an ACO has more high-risk patients, there is more of an opportunity to realize cost savings. With healthier patients, it is more difficult to see improvement.

“It is pretty hard to improve once you are getting up to, say, the 90th percentile,” says Brower. “It is harder to squeak out that last little bit.”

In addition, eking out all possible quality improvements may not always be clinically appropriate.

Once Atrius Health receives the performance benchmarks for all 33 measures, it can better plan where to drive its improvement plan in the future.

Fera notes that all of the Pioneer ACOs have achieved improvements in quality and about 60% of them achieved some financial benefit from those improvements in the first year.

“That is pretty surprising because you would expect it to take three or four years to manifest savings,” says Fera. For example, enforcing a very stringent diabetic control program could yield benefits faster than expected by leading to patients being less sick, having fewer admissions to the hospital and less dependency on medication. “What will be interesting is how much those ACOs that stay in the program are able to save over the next two or three years,” he says.

No matter what cost savings they realize, ACOs need to determine how much of that is due to better care coordination and more follow-up versus actual medical improvement in patients.

“Having care coordinators to remind people about screenings and to follow up and help with post-care issues, such as medication compliance, could lead to ACOs picking low-hanging fruit in reducing hospitalizations and so on,” says Fera.

However, moving forward, it could be harder for ACOs to continue to lower costs. Those that perform well at the outset have less room for showing improvement on already-high scores.

“Over time, we will see that it is better healthcare and control of chronic conditions that will yield savings, rather than the process-oriented changes like better care coordination, but those savings will be harder to realize,” says Fera.

As these quality metrics become embedded in ACO operations and reporting, it seems natural that this information will be shared with healthcare consumers. This is especially true now that the Centers for Medicare and Medicaid Services is releasing pricing information. After all, to determine value, consumers need access to both sides of the care equation.

The metrics themselves may also evolve. Fera notes that many of today’s quality metrics are only process-based. “Ideally, all of the metrics will start to move toward true outcomes,” he says.  MHE“Ideally, all of the metrics will start to move toward true outcomes,” he says.  

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