Can MACRA and MIPS Move the Needle for Healthcare Analytics?


Post by Corinne Stroum (Pascale)


Sr. Program Manager for Healthcare Analytics, Caradigm

The Medicare and CHIP Reauthorization Act (MACRA) draft has become a novel I can’t put down. Its 962 digital pages tell a compelling story on the future of healthcare metrics. One narrative I follow in particular, is the next generation of quality measurement that shifts the focus of healthcare analytics to the reporting of patient outcomes.

In MACRA’s first year, most Medicare Part B clinicians will be eligible for the Merit-based Incentive Payment System (MIPS). MIPS will unify existing process-based quality measurement systems into one that promotes diversity of measure types and encourages providers to report on measures which it deems to have more impact.

Here are some examples of measure types that form the performance standards in MIPS:

    • Process measures – These are the most simple measures to report on such as whether a provider successfully completed something, such as an evidence-based best practice. This might take the form of an annual influenza vaccination for an at-risk patient. While process measures formed the meat of early healthcare quality metrics, they don’t tell the whole story.
    • Outcome measures – These measures get to the heart of clinical care by measuring how providers have influenced patient’s health. For example, has the patient’s depression index score gone down over a six-month period? Did an intervention prevent complications? Did a patient attain cancer remission?
    • Intermediate outcome measures – Some outcome measures look at the long term, which may take years to measure performance. Intermediate outcome measures are an important part of the story because they identify other clinical markers to indicate progress along the way. One example is the reduction of fasting blood glucose as part of a larger diabetes management plan.
    • Patient-reported outcome measures (PROs or PROMs) – Championed by organizations like PCORI, these measures are the window into the perspective of the patient: how does the patient feel about his/her health (such as the PROMIS survey) or how does the patient report the outcome of treatment?
    • Patient experience measures Cousins to PROMs, patient experience measures ask patients and caregivers about their perception of their care. The Consumer Assessment of Healthcare Providers and Systems (CAHPS) and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) are well known experience measures.

The MIPS quality performance category offers opportunities to achieve bonus payments as well as prevent penalties. CMS will allocate points for quality measure performance depending on a “benchmark decile” – assigning providers level of achievement based on thresholds set during a baseline period. These deciles determine the points that the provider will receive. For measures already with overall high performance – those which CMS deems to be “topped-out” – it will be more difficult to obtain full points, incentivizing providers to explore new healthcare quality measures in which they can demonstrate excellence.

MIPS will require one outcome and high-priority measure as part of a standard submission. CMS deems high-priority quality measures as those which track appropriate use, efficiency, care coordination, or patient safety.   Additionally, CMS will score two bonus points for each additional outcome and patient experience measure and one point for each extra high-priority measure that a physician or group elects to report on.

In the first two years of MIPS, the Quality Performance score makes up about half of the performance score. In the following years, the Quality Performance score will balance out with the Resource Use score and clinicians should move from MIPS to advanced APMs. For the next two to three years, however, MIPS will move the needle on quality measurement. It will incentivize providers to report on impactful measures and measures that have not already “topped out”, and to store and transmit quality performance data electronically. This electronic data sets the stage for future victories in healthcare analytics: more data to work with, and more meaningful data.

I highly recommend beginning the process now to develop your MIPS strategy before the performance period begins in 2017. You shouldn’t underestimate the time needed to implement MIPS data and reporting requirements, identify the measures you can be successful in, and plan for how you will drive improved performance in those measures. If you’d like to talk about how Caradigm can help you with your MIPS Quality Measurement strategy, then please leave us a note here.

What are Bundled Payments Really About?


Post by Neal Singh


Chief Executive Officer, Caradigm

It wasn’t that long ago that the healthcare industry was trying to agree upon a definition of population health and you’d see articles like this one that tried to explain it. It’s actually pretty remarkable how in a short period of time, provider organizations have made great strides in adopting strategies and building technology infrastructure to adapt to value-based reimbursement models. We’re now entering the next phase of population health where the industry can apply learnings and iterate to hone in on the strategies that will actually yield better value for patients – improved outcomes at a lower cost. One of the most important programs that many providers are adopting is the Bundled Payment for Care Improvement (BPCI) program. Let’s explore the topic further.

Why do we fundamentally need bundled payments? Patient outcomes and costs have to be viewed holistically. The care of patients and payment of services for a single course of treatment often requires multiple providers in multiple care settings, but has historically been siloed. For example, a patient needing a hip replacement requires care from a host of clinicians including a surgeon, anesthesiologist, radiologist, care manager, physical therapist, home health aide, pharmacist, etc. In a fragmented health system, care is not coordinated between providers, which leads to inefficiencies and variability. In order to incentivize coordinated and standardized care, The Centers for Medicare and Medicaid Services (CMS) will now pay a single payment for all of the services performed to treat a specific episode of care in the BPCI program in four models, as well as will hold providers more accountable for patient outcomes such as readmissions. Bundled healthcare services are also making waves globally as they are being applied successfully in multiple countries including Germany and the Netherlands.[1]

I believe this is a significant step towards delivering better value to patients. Approaching the delivery of healthcare as an episode that takes place across the continuum increases visibility and accountability for both outcomes and costs. When measuring outcomes, if providers look beyond what they directly control to the full cycle of care, they will be able to identify new areas of improvement. The beauty of BPCI is that improving outcomes (e.g. speeding up time to begin treatment, reducing complications such as infections that lead to readmissions), often leads to lower costs. Likewise, by looking holistically at costs, providers will be able to determine new areas of improvement such as how quality care can be delivered by the appropriate and most cost-efficient clinician in the appropriate and most cost-efficient facility.

In the short-term, there could be shared savings opportunities as waste and inefficiency are removed. In the long term, repeatability and continuous refinement will lead to excellence in specific episodes of care that can help secure additional contracts. Providers will also be able to apply the improvements in care outside of the Medicare population so that other populations can benefit. As providers become domain experts in their areas of strength, they will set the benchmark for clinical outcomes and cost reduction for the rest of the industry. That’s healthcare transformation.

BPCI does however create some new challenges for healthcare providers. It links specialists, primary care and post-acute care services in a way that will force providers across the continuum to collaborate and change existing practices and workflows. Providers will need to integrate care and thus share data from health IT systems across sites within their health system and with external providers to improve the coordination of patients moving between different settings. These are significant barriers given that legacy health IT systems were not designed to support these types of integrated workflows. Innovation in health IT is required such as the sharing of patient data (e.g. lab results, care plans) in real-time across multi-EMR environments and streamlined workflows (e.g. automated role-based tasking, tracking of patients across the continuum, secure messaging).

I firmly believe that BPCI will expand rapidly and that it will become one of the key levers helping providers effectively transform healthcare delivery and drive better outcomes for patients. It’s a provider and patient friendly program because it is not focused on reducing utilization, but focused on improving efficiency and accountability for quality and costs. It also supports the CMS goal of interoperability and the broader direction of accountable care organizations and clinically integrated networks. Stay tuned for future blog posts where other members of the Caradigm team will explore bundled payments in more detail including how Caradigm’s award-winning care coordination solution supports BPCI workflows.

[1] Bundling Payments to Promote Integration and Efficiency. The Commonwealth Fund. Originally published: http://www.commonwealthfund.org/publications/international-innovation/apr/bundled-payments-to-promote-integration-and-efficiency

Moving Towards Automated Provisioning and Identity Management


Post by Mark Pilarski


Vice President and General Manager, Caradigm

I recently read this interesting article by Robert C. Covington on the IT security talent shortage. He cites a telling statistic that virtually all companies (92 percent) that planned to hire information security professionals expected to have trouble doing so.[1] Relief may be coming in the future as Covington believes that there’s a wave of future security professionals entering college programs that will join the workforce in a few years. However, with the amount of daily due diligence needed to combat today’s security threats, organizations need a strategy to compensate for the talent shortage in the meantime.

Covington cautions against falling into the temptation of buying security tools that require multiple IT staff to manage. His point is that rather than improve security, they can actually compound the talent shortage problem. On the other hand, he does recommend investing in tools that can automate routine processes such as log monitoring. I think he makes an interesting point about what types of security tools to invest in, which I would like to explore further.

While the profile of security within healthcare is rapidly rising, the ability to secure budgetary funding is very competitive with other health system initiatives. This is why a compelling business case is typically needed to get approval to purchase new security applications. One of the strongest rationales for a new security tool is if it brings broader value to your IT organization on top of reducing your vulnerability profile. Security solutions that can increase the overall productivity of your team and free them up to take on other projects are worth a closer look. Automated log monitoring is one example of this, but there are others.

For example, some larger organizations are spending thousands of IT hours annually on manual provisioning and deprovisioning processes. Consolidations in the healthcare industry will continue to occur, and if your organization has gone through a merger or acquisition, you know what an enormous commitment of IT resources that provisioning related processes entail given the quantity of applications in your portfolio. Manual provisioning and deprovisioning processes should also be a red flag for your security team because there’s too many moving targets (i.e. shifting roles, new employees, non-employed clinicians) and too many applications to effectively manage through manual processes.

That’s just one example. Consider manual entitlement attestation processes. Do you think that inefficiencies in those processes could cause your organization some serious challenges in the event of an audit? It definitely can. Consider the investigation of potential threats related to improper access and the remediation of those threats. Do you think your organization would be better off being able to automate as much of those processes as possible to remediate threats faster? The answer is obviously yes. Did you know you could have those benefits while also freeing up chunks of IT and Security resource hours for other projects?

There’s a growing awareness that automating provisioning and identity management processes is a strong investment because it brings high value from both a security and IT efficiency point of view. It also supports broader security governance programs and has synergies with existing investments in single-sign on solutions, which integrate into provisioning and identity management solutions. To learn more about how you can automate provisioning and identity management processes, you can download our whitepaper on the topic here.

[1] 2015 Global Cybersecurity Status Report. ISACA. Published http://www.isaca.org/cyber/Documents/2015-Global-Cybersecurity-Status-Report-Data-Sheet_mkt_Eng_0115.pdf

MACRA: Reporting for Quality’s Sake


Post by Brad Miller


Vice-President of Clinical Solutions, Caradigm

Now that we’ve had some time to think about the Medicare Access and CHIP Reauthorization Act (MACRA) and digest the details, a few high-level points stick out. First, it does away with Medicare’s Sustainable Growth Rate (SGR), which few physicians were in favor of due to the detrimental impact on services fees. Second, it consolidates and simplifies current reporting programs that were viewed by some as reporting for reporting’s sake– Physician Quality Reporting System (PQRS), Value-based Purchasing (VBP) and Meaningful Use (MU). For example, in the Merit-Based Incentive Payment System (MIPS) track of MACRA, providers only have to report on six measures, instead of the nine required in PQRS, and they also have greater flexibility in choosing what those six measures are. Third, and most importantly, CMS’ ultimate goal with MACRA is to move healthcare further to a system based on quality, and to accelerate the shift in how providers use technology to improve patient care and outcomes. CMS believes that based on its conversations with thousands of clinicians and patients, most providers have yet to acquire the right set of technology tools to make care and reporting more effective and coordinated.

Andy Slavitt, Acting Administrator for the CMS describes one the main drivers of MACRA:

“With many hours of observations, what became clear was that the combination of technology, regulation and measurement took time away from patients and provided nothing or little back in return. Among other things, physicians are baffled by what feels like the ‘physician data paradox.’ They are overloaded on data entry and yet rampantly under-informed. And physicians don’t understand why their computer at work doesn’t allow them to track what happens when they refer a patient to a specialist when their computer at home connects them everywhere.”[1]

So, how should providers start preparing for MACRA? The first thing they need to determine is whether they will qualify for the MIPS or Alternative Payment Model (APM) track. It can be a complicated determination because some organizations could be considering entering into programs (e.g. NextGen ACO) that would impact which track they will qualify for in the future. Next, they should assess their current ability to succeed in all of their value-based programs, including how they will meet the MIPS or APM reporting requirements in order to qualify for bonus payments. Although it feels like the proposed rule was just announced, providers should begin strategizing for MACRA now because the performance period scoring for MACRA begins in 2017.

At Caradigm, we are already working to stay ahead of MACRA. This includes evaluating and prioritizing the proposed measures in advance of the final rule. We are also collaborating with customers to understand their specific requirements and to determine if there are any synergies with their other initiatives and applications. Our overall approach is to build a data aggregation and analytic foundation that can be used to support multiple initiatives and reporting requirements. That foundation has to be robust yet nimble and efficient so organizations can scale programs and evolve rapidly to meet future iterations of requirements. We have architected our technical solutions to help technology support, rather than be a burden, on the progress of providers.

MACRA is a broad topic with lots of areas to explore and many implications for providers, so we will be discussing different parts of it regularly on this blog. If you’re interested in speaking about your quality reporting and MACRA needs further, then please send us a note here.

[1] Slavitt, Andy. “Datapalooza: MACRA, HER Reform and Working with Doctors – Not Against Them.” The Health Care Blog. May 12, 2016. Originally published: http://thehealthcareblog.com/blog/2016/05/12/datapalooza-macra-reforming-meaningful-use-and-working-with-doctors-not-against-them/

Filling The Care Management Tool Box


Post by Vicki Harter


Vice President, Care Transformation

As I talk to many providers across the country about how to transform to value-based care, the conversation inevitably turns to the need for care coordination and care management. With many Centers for Medicare and Medicaid Services (CMS) initiatives including the recently announced Comprehensive Primary Care Plus program emphasizing the need for better care coordination, many providers have concluded that they need to evolve how they deliver care for high risk or at risk patients. This is both exciting and a little bit scary. The hard part is figuring out the right way to go about it given that there is no single blueprint that works for all providers.

One of the best written articles on care coordination that I’ve seen was this one written by Patti Oliver, RN, BSN and Susan Bacheller, BA.[1] I could not agree more with Oliver and Bacheller when they say there is a growing movement toward greater care coordination, as more health systems realize there are better ways to deliver care:

“From our combined experience, we both know how critically important it is to have good care coordination in any healthcare system or arrangement, including ACOs. Care coordination helps providers to form a complete picture of a patient’s overall heath and it also allows them to be able to better communicate with the patient, their family, and with each other. Care coordination also requires constant prioritization and re-prioritization of patients for effective panel management; it means applying art and science to split attention between patients with immediate needs and those ripe for preventive measures or patients we regard as healthy working adults”

Oliver and Bacheller then explored the essential functionality that care coordination software should deliver naming the following five features:

  1. Care coordination tools should be tailored to your patient population.
  2. Care coordination tools should have a single place the care coordinator can visit to get the full picture at the panel and patient levels.
  3. Care coordination tools must allow for convenient use of clinical pathways and be flexible for the care coordinator.
  4. Care coordination tools need to have strong communication features among providers to facilitate care hand-offs and to involve family/caregivers when appropriate.
  5. Care coordination tools should integrate with other systems—or at least be straightforward about their ability to do so.

These five items are solid foundational features to seek when it comes to care coordination and care management tools. Having worked closely with providers to identify their requirements for success in coordinating care across the continuum, I would also respectfully highlight a few other key areas.

Workflow automation – as most organizations are looking to scale their population health initiatives, one of the biggest challenges is how to manage large populations given constrained resources. One of the key components to look for in software is the ability to automate time-consuming manual workflows so that the care team can work more efficiently and also at top-of-license. Care management software should be able to auto-generate care plans and assign tasks based on patient answers to assessments.

Evidence-based guidelines – While flexible clinical pathways are important, so is the need to ensure consistency of care. This is especially true for more complex, co-morbid patients who often require care from a larger care team. Care management solutions should help reduce variation of care by embedding evidenced-based guidelines directly into care workflows to guide action. Tools should also be able to help identify best practices so that they can be shared throughout the care team.

Support for multiple programs – Care management technology requirements vary by program. For example, in the CMS Chronic Care Management program, providers must be able to track and report on time spent per month on core care management processes. For the Bundled Payments For Care Improvement (BPCI) program, providers need to be able to transition and track patients to post-acute care. Look for flexible care management solutions designed to support multiple programs so that you can maximize your return on investment.

As Oliver and Bacheller noted in their article, many new technology solutions for care managers are starting to appear. It can certainly be confusing given the broad range of features and different classes available (i.e. enterprise to basic). Ultimately, identifying the right solution will depend on your organization’s specific goals and the scope of what you are trying to achieve with population health. I look forward to having more conversations with providers this year about how they want to transform care.

 

 

[1] Patti Oliver, RN, BSN; and Susan Bacheller, BA. ACOs: What Every Care Coordinator Needs in Their Tool Box. American Journal of Managed Care. 9.24.15.

 

Where to Focus on Improving Chronic Disease Care


Post by Deb Leyva


Account Executive, Caradigm

Strategies for chronic disease management have to evolve because of the enormous increase in patient volume that’s expected. CMS statistics cited in this article project that the number of total people covered by Medicare will jump from 55.3 million in 2015 to 80 million by 2030.[1] Today, about 69 percent of Medicare patients have two or more chronic conditions.[2] Faced with an aging and co-morbid population, health practitioners are being pressed to identify the right strategies to prevent chronic disease and lower costs.

The challenge is knowing where to focus initial efforts. Many organizations are continuing to experiment in accountable care, however the overwhelming majority have found it difficult to lower the cost of care for a defined population. To explore this topic further, I thought it would be helpful to revisit this article by the Centers for Disease Control and Prevention (CDC) that listed four domains that providers should think about when seeking to improve chronic disease care.

Domain 1: Epidemiology and Surveillance: Gather, analyze, and disseminate data and information and conduct evaluation to inform, prioritize, deliver, and monitor programs and population health.

Domain 2: Environmental approaches that promote health and support and reinforce healthful behaviors (statewide in schools and childcare, worksites, and communities).

Domain 3: Health system interventions to improve the effective delivery and use of clinical and other preventive services in order to prevent disease, detect diseases early, and reduce or eliminate risk factors and mitigate or manage complications.

Domain 4: Strategies to improve community-clinical linkages ensuring that communities support and clinics refer patients to programs that improve management of chronic conditions. Such interventions ensure those with or at high risk for chronic diseases have access to quality community resources to best manage their conditions or disease risk.

To encapsulate these domains, the CDC is recommending care that is preventive, coordinated and engages patients. Also heavily implied in the domains is the idea that new health IT infrastructure is needed to support these changes. While I believe that these recommendations are fundamentally sound, they are broad and don’t specify where providers should focus.

Many of Caradigm’s customers choose to start with improving care coordination because of its central importance to driving population health. The importance is highlighted further because care coordination impacts all of the CDC Domains. For example, the ability to aggregate and share data (Domain 1) should be part and parcel of care coordination improvement efforts. So should increasing the use of preventive care (Domain 3) as well as the linkage with community-based organizations (Domain 4). Improving patient engagement (Domain 2) for co-morbid patients typically needs to be led by care managers through high-touch efforts involving a team of clinicians, family members and friends.

In my role with Caradigm as a customer account manager, I can tell you that it’s amazing to be in the room with a customer that has reached a consensus on their top population health priorities. For example, they may lay out the four or five specific care management workflows they want to improve first. Defining clear goals and a path to achieve them is a huge achievement in of itself. There’s no question that changing how an organization cares for the chronically ill is a long-term and highly iterative pursuit. No one has all the answers today, but focusing your efforts gives you a better chance to drive initial results and build momentum for your overall population health strategy.

[1] Sullivan, Tom. Chronic care management: Is the $50 billion market more hype than reality? HealthcareIT News. April 26, 2016.

[2] Lochner, Kimberly A ScD and Cox, Christine S, MA. Prevalence of Multiple Chronic Conditions Among Medicare Beneficiaries, United States, 2010. Originally published: http://www.cdc.gov/pcd/issues/2013/12_0137.htm

Time to Value in Population Health


Post by Vicki Harter


Vice President, Care Transformation

The stakes are high when it comes to population health as improved patient outcomes and long-term financial success are on the table. By now, most providers recognize the need to evolve. They must participate in new value-based programs, collaborate with other providers, and tailor workflows to support the changes. Implementing these changes is not easy! It takes significant amounts of time and resources from across the organization. When it comes to acquiring health IT tools to support population health, it often takes providers 9-12 months to evaluate the myriad of available solutions. I don’t blame providers for wanting immediate results after spending so much time investigating population health tools.

One of the key reasons why Caradigm formed its Care Transformation Team is to help customers achieve fast time to value following the acquisition of solutions. Our team serves as a sounding board for our customers who are making the shift to value-based care. We find that some organizations have been engaging in population health initiatives for years and are more mature in their processes while others can benefit from additional support. We tailor our approach to each customer’s strategic vision because it’s not one size fits all. The uniqueness of each organization has to be respected as we seek to identify common best practices and turn them into consistent processes.

I believe that all organizations should seek quick wins soon after acquiring population health technology. They are critical to building positive momentum for workflow transformation. The following are a few suggestions to consider when trying to achieve fast time to value in population health.

Plan early to achieve early success – establishing metrics and what quick wins look like prior to technology implementation provides a huge leg up in achieving them. Our team often collaborates with providers before contract signing to help clarify goals and expectations, and then align technology to them.

Define top value propositions – in addition to meeting specific metrics, population health tools can also deliver other types of value to end user clinicians. For example, the reduction of inefficiency or frustrating pain points for clinicians brings tremendous value to organizations and can be realized immediately. It’s important to document what the pain points and value propositions are in order to recognize that value.

Consider starting with care management – care management tools offer one of the quickest paths to value in population health because they can help remove numerous workflow inefficiencies that are impeding providers today. These can be items like having to hunt for data from multiple sources, having to manually generate care plans, or even being unaware when a patient is admitted to the ED. Care management solutions also give providers flexibility in where to start as they can begin by improving how they manage patients in a particular program, by disease category, or by focusing on a particular area of care management such as improving transitions of care.

While the road to population health can be long, organizations can achieve significant victories along the way. In fact, achieving those smaller wins should be celebrated as care transformation takes many small steps in the right direction. If you’d like to discuss how Caradigm can help you achieve quick time to value in population health, then please reach out to us here.

Healthcare’s Cybersecurity Mandate


Post by Mike Willingham


Vice President of Quality Assurance and Regulatory Affairs, Caradigm

The mandate for healthcare information security is clear. Our industry has to raise the bar. We are reminded of this by the constant stream of breaches affecting healthcare providers such as the recent incidents impacting 21st Century Oncology and Hollywood Presbyterian Medical Center. Industry reports like this one from the Ponemon Institute state that healthcare organizations face cyberattacks every month and are still struggling to find effective strategies to keep systems secure.

One of the core vulnerabilities facing healthcare is identity and access risk as that most healthcare organizations have vulnerabilities, but don’t realize their security strategies are insufficient. With frequent industry consolidation and the emergence of population health, information security is becoming increasingly more challenging to manage. Data is now being shared from a multitude of applications with both employed and non-employed physicians. Managing this risk is further complicated because it has multiple layers. You have to consider elevated privileges, remote and mobile access, multi-factor authentication, and balance these concerns with providing efficient access. While single-sign on (SSO) tools are often looked upon as the first line of defense in controlling identity and access risk, providers need additional capabilities because the threat landscape has evolved. Providers need to assume that insiders and outsiders with malicious intent are attempting to gain unauthorized access.

In order to reduce this risk, providers need greater visibility so that they can be more diligent. This entails a major shift in philosophy to a more proactive strategy that is constantly managing credentials and access rather than just reacting. The key to succeeding with this approach is to leverage automation. With the exploding number of applications and clinicians that must be managed, security teams must use tools that can automate manual security related processes. Here are a few examples of how automation can help manage risk:

  • Provisioning and de-provisioning processes, which provides consistency in the process, saves IT many hours of work and prevents errors
  • User, entitlements and behavior data can be brought together in a single view so you have all the information you need to take action
  • A governance, risk and compliance (GRC) dashboard can be set up with analytics to monitor and proactively manage risk efficiently (e.g. an orphaned accounts report)
  • Real-time alerting can identify a potential incident as it happens to minimize damage
  • Remediation can be simplified so that access can be removed or suspended in just a couple of clicks

Given the increased threats we face, healthcare needs to change its approach to security and privacy. Ultimately, the key is greater due diligence, day in and day out. If we use tools that help us accomplish this, then we give ourselves the best chance to win this battle. For additional information security best practices, you can download FierceHealth IT’s special report: Data Security in the Information-Sharing Age. You can also reach out to us here if you would like more information about Caradigm’s solutions that can help.

 

Nine Notes from NAACOS16


Post by Scott McLeod


Director of Product Marketing, Caradigm

I was recently at the Spring Conference of the National Association of ACOs (NAACOS) in Baltimore, and attended nearly a dozen sessions. Given the continued challenges many accountable care organizations (ACOs) have had in achieving shared savings, the biannual NAACOS events are excellent opportunities to hear from leading ACOs from around the country. In listening to the speakers as well as conversing with other attendees, I came away with nine key observations.

1) Difficulty: ACOs in general, are working hard to be successful, but that success is hard to come by. Comments I heard confirmed the statistic that only about a quarter of ACOs achieved shared savings. Due to this difficulty, there appears to be an increased appetite for tools that can increase the likelihood of success.

2) Uncertainty: There remains a great deal of uncertainty about value-based care—even among the winners. I spoke with a physician from one of the most successful Medicare Shared Savings Program (MSSP) ACOs, but he admitted that to some degree, they “didn’t know how they did it.”  This uncertainty affects decisions to continue in programs or engage in new ones, and also affects IT investment decisions. Providers must weigh the size of any IT investment against the possible return.

3) Benchmarking: As any shared savings are based on the comparison of actual utilization against the Centers for Medicare and Medicaid Services (CMS) established benchmark, there is strong interest in the methodologies CMS uses to establish the benchmark, e.g. historical v. regional fees, and the process for “rebasing” those benchmarks over time.  There is also interest in analytics solutions that can help (1) determine whether or not to participate in a specific program based on the benchmark, and (2) help manage their network of providers against the benchmarks for programs in which they participate.

4) What’s Next:  Organizations are considering participation in CMS’ Next-Generation ACO (NGACO) program.  While it provides some advantages for home health, telemedicine and skilled-nursing facility (SNF) waivers, it also comes with two-sided risk (i.e. greater potential upside but the addition of downside risk). Given the difficulty and uncertainty noted above, organizations are proceeding very cautiously and trying to garner as much information as possible before deciding.

5) Bundled Antipathy:  There is a level of antipathy among ACOs for awardees in BPCI (Bundled Payment for Care Improvement).  This antipathy results from the fact that CMS does not want to double-count (and double-credit) savings realized. Any savings realized for beneficiaries that qualify for bundled-payment services are credited to the BPCI entity and deducted from the potential shared savings of the ACO.  This is true even if the beneficiary is a member of the ACO. There is some feeling of unfairness as the ACO is responsible for a beneficiary’s utilization over the entire year while the BPCI entity only has to manage utilization during the length of the episode of care.

6) Variability of PAC: Whether for bundled payments or MSSP, several presenters called out the wide range of costs in post-acute care, and cited it as a big opportunity for cost management. This recent Wall Street Journal article also discusses the same issue of variability of costs.

7) Survival of the Fittest: While providing quality care to patients is always central to a provider’s mission, competing within their market is also on their minds. Strategies and initiatives adopted are business decisions that include the goal of capturing market share from competitors.

8) Diversification: The advice to the audience from a panel of large, mostly successful ACOs was to nurture other sources of revenue until the hoped-for shared savings were realized. This includes continuation of fee-for-service (FFS) business, participation in the episode-based BPCI, etc.  There was evidence of one-off agreements with large employers for a specific bundle or set of services.  As the industry makes its shift to value-based reimbursement, I expect we’ll see lots of different activities (though headed in the same direction) rather than a unified strategy.

9) Patient Care vs. Population Health:  Although ACOs are participating in a variety of value-based initiatives, the language of presenters and participants tended to focus on the quality care of patients more than managing the health of populations.  This may be a reflection that many of the speakers were physicians, but it seems that there remains a mindset around individuals rather than populations.

As fast as healthcare has been evolving recently, I look forward to tracking these and other trends over the course of the year. I hope to circle back to them during the Fall 2016 NAACOS event to see if they have changed.

Population Health and “The Wire”


Post by David Lee


Product Marketing Manager, Caradigm

NPR recently published this in-depth article about the challenges of healthcare for Baltimore’s lower income residents. After reading it, it’s hard for me not to think of The Wire, the HBO series that received acclaim for its authentic portrayal of Baltimore’s deep rooted social challenges. I think healthcare is another issue that David Simon, the show’s creator, could have explored as the core premise of the series is the interconnected nature of the city’s struggles – poverty, crime, policing, race relations, politics and the education system. There is a quote from a character on the show that has become emblematic of this theme that also applies to how healthcare has been recently shifting to population health:

“All the pieces matter.” — Detective Lester Freamon to Detective Roland Pryzbylewski, The Wire

Dr. Marcia Cort, chief medical officer of the non-profit Total Health Care, states in the article that “Baltimore City is in a health crisis.” The life expectancy of residents in the impoverished Sandtown neighborhood is 69.7 years old, which is the same as in poverty-stricken North Korea. Also according to the article, “residents of the ZIP code including Sandtown accounted for the city’s second-highest per-capita rate of diabetes-related hospital cases in 2011, the second-highest rate of psychiatric cases, the sixth-highest rate of heart and circulatory cases and the second-highest rate of injury and poisoning cases. Asthma, HIV infection and drug use are common.”[1]

Over the years, some residents have developed a mistrust of healthcare due to challenges in access and because of negative outcomes experienced resulting from a lack of coordinated and preventive care. A Baltimore resident, Robert Peace, described how he developed a recurring bone infection after undergoing a surgical procedure. Likely due to receiving minimal follow-up care, the infection grew worse, became extremely painful and resulted in five additional surgeries being required in 18 months. Today, Robert has permanently impaired mobility.

Dr. Jay Perman, pediatric gastroenterologist and president of the University of Maryland, Baltimore stated in the article that clinicians have to accept responsibility for patients outside the walls of the hospital. “As a profession, as an industry, we have not sufficiently appreciated, let alone done something about, the impact of social determinants. Guys like me and gals like me can easily say, ‘I made the correct diagnosis. I wrote a proper prescription. I’m done.’ What I say to my students is, if you think you’re done — if ‘done’ means the patient is going to get better — you’re fooling yourself.” To the credit of health systems in the area, they acknowledge that there have been shortcomings in how care was delivered and are implementing improvements. These efforts include a new focus on preventing readmissions, new investment in care coordinators, primary care and post-discharge management.

Although the social challenges Baltimore faces have been ingrained for many years, healthcare is the one for which there may be the clearest path to lasting improvement – via population health. Population health as an approach recognizes that health systems must care for patients outside the walls of the hospital using a multi-disciplinary team. An expanded care team can include friends, family members and social organizations (e.g. assistance with transportation, meals, paying for prescriptions, etc.). It can involve multiple health systems collaborating in the care of patients even though the health systems are in reality competitors. It also recognizes the need for innovation in technology such as a longitudinal patient record shared across all providers, analytics, and workflow tools that can help care teams manage a high volume of patients efficiently.

I would theorize that more than any other factor, it was the shortcomings of the fee-for-service model that contributed the most to the poor outcomes experienced by Sandtown residents. Population health offers a real strategy for change. More than cost efficiency, which is often the most commonly mentioned driver of population health, improved outcomes is the most compelling reason for population health. I am hopeful that health systems like those in Baltimore will continue to invest more and scale their population health initiatives with a sense of urgency. If they can successfully transform to become more patient-centric and improve the health of the people they serve, they will be able to rebuild the trust of the community. That accomplishment would be truly worthy of a television series.

[1] Hancock, Jay. In Freddie Gray’s Baltimore, The Best Medical Care Is Nearby But Elusive. NPR.org, 2.15.16. originally published at http://www.npr.org/sections/health-shots/2016/02/15/466550095/in-freddie-grays-baltimore-the-best-medical-care-is-nearby-but-elusive