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Contents
Executive Summary ....................................................................................................................................................3
I. Accountable Care Organizations .............................................................................................................................3
What and Who They Are ........................................................................................................................................3
Medicare Shared Savings Program: Obtaining Accountable Care Incentives .......................................................4
II. HIT: The Opportunities and Challenges of Accountable Care ...............................................................................5
Health Information Infrastructure: Amassing “Reimbursable” Data .......................................................................5
Key HIT Initiatives of the MSSP Final Rule ............................................................................................................5
III. The ACO Initiative Affects All Healthcare Stakeholders ........................................................................................7
Physicians and Other Healthcare Professionals ....................................................................................................7
Medicare Beneficiaries ...........................................................................................................................................8
Payers ....................................................................................................................................................................9
Pharmaceutical Companies ...................................................................................................................................9
IV. ACO Implementation .......................................................................................................................................... 10
Distinguishing ACOs from Other Healthcare Provider Models ........................................................................... 10
Recommendations for Successful ACO Implementation .................................................................................... 10
Candidates for ACO Implementation .................................................................................................................. 11
Challenges for ACO Implementation ................................................................................................................... 11
Table 1. ACA Guidelines for ACO Formation .......................................................................................................... 13
Table 2. CMS-Approved ACOs ............................................................................................................................... 14
Table 3. Healthcare Quality Measures for Shared Savings .................................................................................... 16
Table 4. Supplemental Information .......................................................................................................................... 17
Table 5. Comparison of the Brookings - Dartmouth ACO Pilot Sites ...................................................................... 18
Figure 1. HIT Integrates the MSSP Initiatives and the Logistical Challenges of ACO Adoption ............................. 19
References: ............................................................................................................................................................. 20
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While the United States has the most costly healthcare system in the world, this does not translate into world- class care for all Americans.
1 The Patient Protection and Affordable Care Act and the Healthcare and Education
Reconciliation Act of 2010, known collectively as the Affordable Care Act (ACA), address the divergence between value and expenditure, and the need to create a coordinated system supporting disease prevention.
2 The question remains: is the healthcare industry prepared for the movement’s impact on all stakeholders – beneficiaries, physicians, payers, and pharmaceutical companies?
The Medicare Shared Savings Program (MSSP), which is the accountable care initiative of the ACA, has advanced the Accountable Care Organization (ACO) model. This model extends beyond the ACOs approved by the Centers for Medicare and Medicaid Services (CMS) – which we term “MSSP-ACOs” for clarity – to include
ACOs formed by private health insurance providers. These private ACOs are not constrained by the ACA and have fewer restrictions. Nonetheless, all ACOs will have similar challenges: collecting, chronicling, and reporting massive quantities of beneficiary data and using innovative ways to provide coordinated and preventive care. All
ACOs will need to identify gaps and maintain profitability as quickly as possible to stay ahead of the growing population of Americans who are elderly and/or chronically ill.
This evolution in healthcare is a substantial opportunity for industries that can provide innovative ways of addressing the ACA’s goals. In the following paper, we describe the CMS ACO mandate, and how ACOs are developing in the private sector. We detail their impact on healthcare stakeholders and how ACO adoption represents a significant opportunity for the healthcare, pharmaceutical, and health information technology (HIT) industries. We identify ways in which healthcare and pharmaceutical companies may collaborate with the HIT industry to leverage current technologies and create fundamental tools to meet the needs of the evolving ACO initiative. We elaborate on why the pharmaceutical industry stands to benefit from ACO adoption, and focus on how to keep all stakeholders engaged in the process. Poised to offer solutions, the HIT industry has the resources to meet the needs of burgeoning ACOs.
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To obtain MSSP incentives, healthcare providers must participate in MSSP-ACOs, and show evidence of improved patient outcomes, while reducing healthcare costs
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The first ACOs accepted for participation in the MSSP were announced in December 2011
The ACA includes a number of initiatives aimed at reducing costs and improving care. Among them the MSSP incentivizes healthcare providers to achieve the triple aim of better care for individuals, better health for populations, and lower growth in expenditures. Medicare Shared Savings incentives can be obtained only by participating in an MSSP-ACO 1 : an organization of individuals, groups and/or institutions who provide healthcare services to Medicare beneficiaries and are accountable for both the overall quality and cost of the care provided
(Table 1).
2 The structure of every MSSP-ACO will be different, irrespective of state, region and population. When outcome standards are met, a portion of the money saved by the government is shared with the ACO. The
Congressional Budget Office estimates that the MSSP will save Medicare about $5 billion through 2019, most of which will likely be paid to the MSSP-ACOs.
3,4
The ACA mandates that ACOs meet strict requirements to be accepted into the MSSP (Table 1).
2 Each ACO must include enough primary care physicians (PCPs) to serve a minimum of 5,000 Medicare beneficiaries, which is understood to be a sufficient number of patients to achieve the volume of outcomes necessary to gain incentives. The ACO must also meet quality and reporting standards, as well as receive and distribute shared savings payments among its providers who have entered into legally binding contracts defining their participation.
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This process entails substantial preparation and a thorough understanding of the benefits and risks; however, it provides significant opportunities to healthcare management strategic partners in the HIT arena and individuals positioned to offer guidance to healthcare professionals/organizations seeking to form ACOs.
On December 19, 2011, the CMS released a list of 20 health systems and 12 physician groups that applied for and were approve to receive accountable care incentives, as members of the Pioneer ACO model (Table 2).
5 This track is consistent with, but separate from, the MSSP, because these groups were already organized in “ACO-like arrangements.” On April 1, 2012, 27 ACOs became the first to be accepted into the MSSP.
6 All of these ACOs represent the first wave of organizations that would benefit from strategic partnerships with the HIT industry.
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Although the ACA was enacted in March 2010, its MSSP was implemented on January 3, 2012
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Criteria have been established for determining incentives earned (Table 3)
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Skeptical stakeholders must be assured that the incentives are worth the risks, particularly the financial risk
Although the ACA was enacted in March 2010, throughout the course of 2011 the CMS received 1,200 formal comments from various stakeholders and held several informal feedback sessions.
7 As a result, the CMS made several substantial changes to the MSSP, which were addressed in the “Final Rule” − herein referred to as the
“MSSP Final Rule” − which became effective on January 3, 2012.
2
Eligibility to receive a share of the savings requires that the organization be structured as an ACO, and report on the quality of care through performance assessments. The assessment domains are patient/caregiver experience, care coordination/patient safety, preventive health, and at-risk populations (Table 3).
2 Each of the 4 domains is weighted at 25%, despite comments from stakeholders that some domains should be weighted more than others because not all are under provider control.
2 These domains suggest ways in which HIT may assist
ACOs in providing improved care and obtaining incentives (Table 3).
Patient/caregiver experience will be determined by the Clinician & Group Consumer Assessment of Healthcare
Providers and Systems (CG-CAHPS ® ) survey.
8 The at-risk-populations domain includes: diabetes, hypertension, ischemic vascular disease, heart failure, and coronary artery disease. Against the recommendations of some critics, the MSSP Final Rule mandates that the diabe tes component be scored as “all or none,” requiring that
ACOs receive either all of the points associated with the diabetes at-risk patient assessment or none of them
(Table 3).
2 To receive shared savings, MSSP-ACOs must be ‘patient-centered’ in their approach and address the needs of all Medicare patients, including those at high risk, who may be particularly exposed to adverse healthcare experiences such as hospital-acquired conditions.
There are financial risks associated with participation in the MSSP. If an ACO does not save the government money, it may pay penalty fees. Additionally, stakeholders have voiced their concerns that the financial risks involved in ACO formation and implementation do not outweigh the potential incentives, and that some providers may be excluded from the MSSP due to a lack of up-front funding resources.
9 The Center for Medicare and
Medicaid Innovation launched an advanced payment initiative to provide small practices and rural community hospitals the capital to offset the expense of purchasing systems needed to become an ACO and facilitate acceptance into the MSSP.
7 CMS has also presented alternative options for practices that are not ready to form
ACOs.
7 Strategic partnerships between modest medical centers and community physicians can potentially disperse risk and keep smaller stakeholders at the table; HIT can play a large role in facilitating these relationships.
Although the government requires that each MSSP-ACO include at least 5,000 patients for adequate performance reporting, this number may be too small. Larger-sized populations will facilitate outcome measurements and
ACOs with more patients will be less likely to experience fluctuations in expenditures, which could lead to stronger penalties. HIT can facilitate ACO growth by reducing unnecessary prescriptions, procedures, tests, and hospital
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visits. ACO providers will be more attractive to beneficiaries if they can offer better care and “customer service.”
Thus, ACOs could enlarge their sample size, and potentially receive more incentives.
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The use of electronic health records is not mandated by the MSSP Final Rule, but remains the logical solution to healthcare data reporting
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Electronic health records are not synonymous with electronic medical records (Table 4)
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With increased use of HIT, the industry must convince patients that their personal information remains safe
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Evidence-Based Medicine may be supported through HIT improving access to relevant health quality information which may not have been as accessible in the past and which can improve quality health outcomes and patient management
Seamless healthcare delivery requires an integrated setting – physically and electronically − so that all providers share patient information and resources such as records; surgical, imaging and laboratory resources; and more.
By design, the integrated services provided by all ACOs lead to shared savings that are assessed through improved clinical outcome, and for ACOs, through performance reporting. The CMS has provided financial incentives to reward the utilization of electronic health records (EHRs) through the EHR Incentive Program (which has become somewhat synonymous with the phrase “meaningful use”). This program gives financial incentives to healthcare providers who incorporate HIT into their practices (Table 4).
10
When proposed initially, the use of EHRs was required for an ACO to become eligible for the MSSP. However, in response to numerous concerns from broader stakeholders, the MSSP Final Rule no longer mandates the use of
EHRs in ACOs.
2 The MSSP will reward ACOs based upon the percent of physicians who have adopted, implemented, upgraded, or demonstrated meaningful use of certified EHR technology.
2,11 This measure will be double weighted because CMS regards the use of EHRs as tantamount to the provision of coordinated care and actionable information in real time at the fingertips of the healthcare provider.
This demands the question: how can ‘reimbursable’ data be amassed without EHRs? Given that ACOs will have at least 5,000 Medicare beneficiaries for eligibility – in addition to their patients who are insured through private healthcare companies – it is nearly impossible to imagine a means by which any ACO could amass beneficiary data for the purposes of incentive reporting without EHRs. Yet, there are still some who may remain unconvinced about the benefits of EHRs. This may be due to the fear of clunky user interfaces, intractable medical errors, and large inefficiencies accompanying great expenditures. Meaningful Use does provide some incentive, but it is the mandate of the HIT industry to dispel the fears and provide logical, useable and sophisticated solutions.
The ways in which personal data is disseminated and the growth of EHR use have not escaped consumer attention. One survey concluded that the majority of patients wanted their physicians to adopt EHRs. However, many were concerned that EHR use may lead to greater incidences of lost or stolen personal information.
12 This survey underscores the important role of HIT in the protection of patient information. Consumers want access to their records, the government is prepared to incentivize access, and the HIT industry must accept this challenge.
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Health information technology is uniquely poised to offer value in key components of the Final Rule (Figure 1).
Among its initiatives, the MSSP Final Rule promotes the use of HIT as a means by which the promise of the triple aim may be achieved (the triple aim is defined as improving the experience of and access to care, improving the health of populations, and reducing health care costs). As such the ACOs are encouraged to include methods within their structure to promote 2 :
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Evidence-based medicine
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Patient engagement
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Processes of reporting quality and cost measures
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Coordination of care
Every ACO, whether approved for MSSP participation or private, will be taking advantage of these opportunities.
The ACO initiative supports the use of evidence-based medicine (EBM) in its decision-making process, supporting the importance of integrating research evidence, pertinent clinical expertise, and a patient-centric approach to treatment. The best way to utilize EHRs to inform the practice of EBM may not yet have been fully realized. Traditionally, EBM is a self-directed process undertaken by physicians to formulate their own best practices; HIT may offer solutions to physicians who would prefer to employ the most efficient means possible of identifying best evidence. This is a role many have envisioned could be filled by EHRs; however, the most ideal way of executing this is still in its infancy.
The smartphone and tablet trends indicate how intrinsically technology has been incorporated into everyday life.
As this continues, patients will come to expect technology to be integrated into the healthcare system as well.
Easy-to-use HIT solutions could enhance patient compliance and allow HCPs to assess and encourage compliance or provide patient education materials in a timely, efficient, user-friendly way that supports the choosing of health-appropriate decision-making processes by patients. These are only a few of the innumerable ways to address the opportunity presented by the MSSP Final Rule.
As we described, amassing reimbursable data for the purposes of reporting on quality and cost measures is the only way to receive incentives through the MSSP; nonetheless, this need is important to MSSP- and private
ACOs alike. This challenge belongs to HIT alone. We posit that an EHR with an interface that is both intricate and user-friendly may be the only efficient way to capture patient data and facilitate the compilation of patient data and reporting. These solutions already exist in various forms; however, the secondary challenge for HIT will be to thoroughly and efficiently educate end-users in an effective and compelling format that encourages adoption of
EHRs into full practice.
With enhanced patient engagement and the incorporation of technology into healthcare, simple ways to coordinate care will improve the efficiency of the system. The use of EHRs to find elegant ways to connect all members of the healthcare team − PCPs, specialists, NPs, PAs, social workers, physical therapists, laboratories, and pharmacists − is an opportunity for HIT. As technology facilitates communication among MSSP-ACO members, the lessons learned in efficiency and cost savings will spread to all healthcare partners.
Although not an overt initiative of the MSSP Final Rule, to meet the objectives of ACO adoption successfully, each participant of the ACO who will be developing data to be reported to the CMS will need to make evidencebased medical decisions, engage patients, coordinate care, and report data back to the ACO for dissemination to
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the CMS. Participants in the ACO model, whether MSSP-approved or private, will not operate at their full potential unless their practice management needs are met. The purpose of HIT is to offer logical solutions to create efficient office practices in patient and billing management – particularly as the new medical classification system is fully rolled out and coding medical procedures becomes obtrusive (Table 4).
As the healthcare infrastructure changes, access to care and the experience of value will be affected greatly.
Healthcare reform represents a significant shift in power for healthcare professionals (HCPs), patients, payers, and pharmaceutical companies. While it is difficult to anticipate with complete accuracy the full ramifications of sweeping healthcare reform, the following paragraphs describe some potential consequences of the legislation.
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Participation in ACOs, and the ACO healthcare delivery model as a whole, represents a substantial role change for some HCPs
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The HIT industry is a natural partner for physicians who are early adopters of technology and even those who require both convincing and training
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The ACA does not make any requirements for private ACOs who are not going to be a part of the MSSP:
Physicians who participate in private ACOs may have very different experiences
Yes, physicians who participate in ACOs are accountable for all of their patients, according to the MSSP Final
Rule. Concerns have been raised about the ramifications of being held accountable for patients who may be deemed ‘unmanageable’ or who may refuse to be treated.
2 Rather than excusing healthcare providers from responsibility for such individuals, the Final Rule insists that these individuals represent opportunities to provide superior patient engagement. Further, steps taken to avoid such Medicare beneficiaries would lead to termination of an ACO’s eligibility to participate in the MSSP. Thus, the importance of finding innovative ways to engage patients and manage chronic conditions cannot be overstated.
As members of the healthcare team, non-physician practitioners, such as nurse practitioners and physician assistants, may be utilized more extensively, attaining better patient outcomes for high-acuity or chronically ill patients.
13 Medicare beneficiaries who have visited ERs or had short hospital stays may require follow-up care to achieve the better outcomes promised by the ACO model. Registered nurses may assess treatment regimen adherence and perform patient outreach in a setting other than an office, 14 thus avoiding unnecessary office visits which contribute to the rising healthcare cost. Clinical care coordinators may assist patients with chronic conditions or be tasked with identifying and following up with patients at risk for hospital readmission.
15 For example, telemonitoring has already been used to reduce hospital admissions.
16 The success of all ACOs will likely be driven by innovative ways of improving healthcare delivery by expanding the utilization of healthcare professionals beyond the office setting, and HIT can provide the tools to make this paradigm work (Table 3).
The role of PCPs as coordinators of patient health is moved firmly to the forefront, and the business of healthcare is a significant component of the physician workload. Physicians, already heavily encumbered by regulations, may see an even greater increase in their practice management workload, while changing their current business practices to align with participation in either an ACO. If they choose to do so, incorporating an EHR into their
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practice (discussed in Part III below) is only one facet of the additional responsibilities PCPs may take on. Further, the expense of hiring additional personnel or purchasing practice management equipment may affect a physician’s income substantially.
9
The answer is complex. The formation and implementation of ACOs are driven by financial resources – typically, hospitals and larger physician organizations will have sufficient capital to form ACOs. However, if the ACO is a nonprofit organization, physicians may be required to pay an initiation fee and/or annual dues.
9 Many physicians will be part of organizations in which ACO participation is a logical step, and the choice will be made for them.
Participation in an ACO requires a legally binding participation agreement; therefore, it is crucial that the participant understands the financial risk involved in joining an ACO.
Participation in a private ACO that is not seeking MSSP approval may be very different; they are held financially accountable by the payer, not the federal government. Indeed, some physicians who are a part of the early private ACOs may experience few changes if any at all, as these ACOs have already implemented many of the policies and procedures required of MSSP-ACOs.
Some have argued that physicians who have a choice can be stratified by those who are reluctant to join, and those who will actively (and proactively) participate in the ACO evolution. Physicians who are early adopters of technology – who have already incorporated smartphones and tablets into their practice of medicine − are likely to embrace the HIT industry as a natural partner.
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Can see any Medicare provider they choose
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Poised to experience better service than ever before
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Use of personal information can be a drawback for some
Among all of the stakeholders affected by a shift to the ACO model of healthcare delivery, patients stand to receive the greatest benefit. Medicare beneficiaries are poised to experience better service by healthcare providers, due to improved coordination of care, and better management of chronic illnesses and co-morbidities.
Arguably, ACOs are under pressure to perform well – or at least be perceived by their Medicare beneficiaries as performing well – as 25% of their score with respect to outcome reporting is dependent upon their patients’ responses on the CG-CAHPS (Table 4).
2
One of the goals of the ACA is to address the healthcare needs of low-income Americans, racial and ethnic minorities and other underserved populations, 15 such as geographically isolated or disabled persons. By bridging healthcare gaps experienced by Medicare patients and increasing access for these patients, the ACO movement by CMS will improve the healthcare service and experience for the patients of ACO providers who are not necessarily Medicare beneficiaries or not beneficiaries yet.
Medicare beneficiaries will be able to seek care from a Medicare provider of their choice, and the provider does not need to be a member of an ACO.
7 Beneficiaries will be assigned to ACOs based on services that they receive in an ACO. Thus, a Medicare beneficiary chooses the physician, and if the physician is a member of an ACO, that patient may (or may not) be assigned to the ACO for the purposes of calculating the ACO’s share of savings.
2
Many stakeholders have voiced concerns regarding the assignment of Medicare beneficiaries to ACOs, and the sharing of beneficiary identifiable claims data. The MSSP Final Rule states that CMS will provide ACOs with the name, date of birth, gender, and health insurance claim number of the preliminary prospective assigned beneficiary population (those individuals whose outcome reports may be used for the shared savings calculations.) 2 This information would be provided in keeping with HIPAA regulations and is being included to allow ACOs the ability to develop patient care plans to better facilitate the triple aim.
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Patients with diabetes, those on dialysis, or those needing kidney transplants typically require the most costly care. Stakeholders commented on the importance of considering the needs of these patients and their impact on
ACO outcome reporting. Commenters also posited that ACOs may not want to be accountable for patients such as these, or that ACOs may limit access to this type of care. In the MSSP Final Rule, CMS refused to make any exceptions for any condition, and did not exempt any specific patient from inclusion in the determination of shared savings.
2 Moreover, the Rule insists that within the ACO model, these patients would receive the greatest benefit from well-coordinated accountable care and that the objectives of the ACO initiative would not be realized in a system that excludes these patients.
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The ACO model can extend to private insurers, facilitating coordinated care for all
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Some insurance companies have formed their own private ACOs with large provider groups
While the government’s focus is on reducing costs, the model could extend to all patients regardless of their insurance. Private insurance companies are well-positioned to act as ACO payers because they currently have the infrastructure for patient tracking and performance outcomes reporting.
3 If the incentives and methods of obtaining data are consistent among payers – the government, private insurance companies – physicians and other healthcare providers will be able to offer coordinated care at lower costs to all patients and potentially share in the savings.
1 Thus, ACO formation may represent an important new business model for all payers, not just the federal government.
Private insurers such as Humana and Aetna are planning similar programs to keep up with the government initiatives.
3 The Engelberg Center for Healthcare Reform at the Brookings Institution and The Dartmouth Institute for Health Policy & Clinical Practice have united to implement and test ACO models, and to date, have chosen five Brookings-Dartmouth ACO Pilot Sites – Norton Healthcare (Louisville, KY), Carilion Clinic (Roanoke, VA),
Tucson Medical Center and some of its affiliates (Tucson, AZ), and 2 Pioneer ACOs: Monarch HealthCare and
HealthCare Partners (Tables 2 and 5).
18 The Norton Healthcare ACO initiative will evaluate its ability to work with regional partner Humana Inc. to increase quality and efficiency, improve coordination of care, and reduce waste and misuse. The success of this ACO may be derived in part from Norton Healthcare’s commitment to integrated healthcare delivery.
19 (See Table 5 for a comparison of these ACOs.)
Certainly, the choice of partners for these insurance companies likely has much to do with the ease of implementation. All of these groups serve a more than sufficient population to develop patient outcome, quality, efficiency, and expense data. Additionally, all of them have EHRs in place, and have taken concrete steps toward transforming their clinical practice to a more coordinated system (Table 5). The HIT industry is an important strategic partner for these vested stakeholders, as it will drive the development of powerful new technologies useful for ACOs.
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Patient adherence to treatment regimens, facilitated by HIT, will keep pharmaceutical companies engaged in ACO adoption
The effect of ACO adoption on pharmaceutical manufacturers can be forecasted using multiple views. Some suggest that profitability will cause ACOs to explore step therapy as a cost-savings approach (Table 4).
20 Some may argue that the ACO initiative – and healthcare reform in general – may cause pharmaceutical companies to partner with ACOs and similar organizations, to reduce healthcare costs through price negotiation. However, there is another pertinent argument keeping stakeholders at the table: improved patient adherence.
Many patients do not take their prescriptions as directed by their physicians and, as a result, cause additional healthcare expenditure in office visits and hospital stays. One study showed that the increased drug expenditure that was associated with patients taking their medications as prescribed correlated with decreased overall healthcare spending due to reductions in overall medical costs, including hospitalizations.
21 A National Bureau of
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Economic Research study indicated that increasing the treatment adherence rates of patients with diabetes from
50% to 100% reduced hospitalization by 23% and ER visits by 46%.
22 Efficacy is a substantial driver at both ends of the prescription: physicians will prescribe drugs if they are convinced of their safety and efficacy; patients have a higher chance of adhering to treatment regimens that they feel are providing them with better outcomes.
20
The argument is engagement. Pharmaceutical companies are logical partners for the HIT industry because of the potential for keeping patients engaged in maintaining their health. These technologies are in the early stages of development and implementation; however, they represent only one aspect of the ways in which HIT may facilitate patient adherence. Novel patient education materials that the physician can share with patients and caregivers are the foundation for adherence. If patients understand the importance of taking a particular medication, they may become more invested in their health outcome, and remain adherent to their treatment regimen. HIT can provide the ability to follow up with at-risk patients in the field and/or their caregivers to ensure adherence through e-tools that will report information back to a physician. While many Medicare beneficiaries may not be technology-savvy, their children and grandchildren likely are: HIT can create bridges between patients and caregivers who are geographically distant.
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The ACO initiative is not the healthcare reform movement of the 1990s, but without technology and innovation, it can become just that
The ACA requirement for the formation of ACOs is not the first example of sweeping consolidation in the healthcare industry. During the 1990s, anticipated healthcare reform legislation prompted the formation of innumerable hospital-to-hospital and physician-to-hospital unions, meant to integrate healthcare providers. Their success hinged upon, and in many instances was unhinged by, their operational, organizational, structural, and strategic design.
23 ACOs are different from independent physician associations (IPAs), physician-hospital organizations (PHOs), and the health maintenance organizations (HMOs) in the following ways 9 :
1. Providers, rather than health insurers, are accountable for patient care
2. The MSSP-ACOs are contracting directly with Medicare; third-party intermediaries are not required
3. The provider composition of ACOs are very flexible
4. MSSP-ACOs can receive payment under a fee-for-service arrangement, in addition to the incentives they may receive
Each of these differences has operational, organizational, structural, and strategic components; however, every
ACO that is created will face its own opportunities and challenges. A significant distinction between ACOs and the failed HMOs that were developed in the 1990s is that patients will not enroll in ACOs and will not be restricted to seeing doctors or hospitals within a certain ACO network.
3 Additionally, ACOs will be responsible for their own data collection − and will have to invest in this accordingly. Moreover, the ACO initiative is also distinct from the patient-centered medical home model (Table 4). Both models have a similar value offering; however, ACOs are structured to deliver value to a larger population, and receive financial benefits from lowering costs.

The California Healthcare Foundation has identified 6 key considerations for successful ACO formation and implementation based on key learnings from early efforts in their state
Critical questions may arise when trying to implement a successful ACO: how to balance the financial risk of forming an ACO with the financial incentives? Are there new understandings from previous consolidation efforts that will inform the formation of ACOs? To that end, the California Healthcare Foundation has identified the following requisites for a successful ACO 23 :
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1. ACOs must identify the long-term needs of the community of patients they serve, and align them with provider capabilities, and state and federal health policy
2. The organizational structure must include defined roles, a ‘medicine-focused’ leadership, and transparent decision making to support its goals
3. The ACO’s financial incentives must be consistent with its goals for care
4. Care and finances must be coordinated appropriately through the use of technology
5. ACOs must have sufficient financial capacity to accept the risks involved in MSSP implementation and participation
6. Members of ACOs must foster an atmosphere of trust and communication
The HIT industry addresses these recommendations in two purviews: first, technological advances in patient monitoring, education, communication, and outreach will ensure improved healthcare for patients, which translates into larger incentive payouts; second, integrated and coordinated healthcare management provides innovative tools for making ACO relationships work, addressing their operational, organizational, structural, and strategic needs.
There will not be a universal app, software program, or EHR that will address all of these needs. This underscores the immense opportunity for HIT to offer high-impact solutions and the immense responsibility of HIT to ensure that those solutions are sophisticated, creative, logical, and easily integrated with each other.
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Some physicians are more likely to benefit from joining an ACO than others
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HCPs in rural areas will need to be collaborative to participate in the MSSP
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Managed care organizations are excluded
Physicians that are part of multispecialty groups or integrated models with hospitals are more likely than specialists to join ACOs.
3 The ACA identifies primary care physicians (PCPs) as physicians whose designations are internal medicine, geriatric medicine, family practice, and general practice.
2 As PCPs, these physicians bear responsibility for patient care over a long period of time, wherea s specialists are usually engaged for an “episode” of care.
24 The MSSP Final Rule mandates that PCPs may participate in only one ACO, while specialists may participate in multiple ACOs. Based upon these considerations, and the ACO model’s focus on the continuum of care, PCPs are more likely to form or participate in ACOs than specialists. Cloud technology, useful for integrating information among healthcare providers, is an influential method of reinforcing the relationships between specialists and the other ACO providers.
25
Rural participants in ACOs may have intrinsic barriers to ACO participation that others may not, including practice design, patient volume, efficiency, cost structure, and leadership inexperience.
26 Rural leaders must work with their re gion’s providers to find ways to address these issues. Partner identification and integration are critical components to ACO participation in rural areas. ACOs located in urban areas may contain a single core medical center; whereas rural ACOs may need to include multiple hospitals to obtain sufficient data to receive incentives.
While rural providers are not excluded from participation, careful thought must be applied to how they are structured, and HIT may be able to lift some of the burden of integrating ACO participants who are geographically distant.
26
As mentioned, large physician groups, hospitals, and integrated healthcare systems are excellent candidates for
ACOs (Table 2).
3 Organizations that have a solid primary care foundation and can manage the cost and quality of services across a continuum of care are likely to be successful. However, managed care companies, experienced in most aspects that would facilitate ACO success, are not eligible to participate in the MSSP.

Some ACOs may face obstacles if they are not part of large medical systems that has taken steps to provide coordinated care across various services
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As ACO adoption proceeds, more challenges will become transparent. Some groups, as described already, have the financial and human capital as well as the technological capacity to form an ACO. For others, there may be a significant learning curve and considerable expenditure required for ACO implementation. Smaller ACOs may have trouble with performance measurements; this is where HIT will help them implement a successful system by which patient outcomes and quality measures are accurately reported. When ACOs fall short of quality-of-care measures they may be at risk of losing their contracts with Medicare and/or private insurance companies that are participating in similar shared savings programs.
3 If HIT can offer affordable solutions for these stakeholders, they will be able to participate in shared savings programs, such as the MSSP, while mitigating their risk.
Some healthcare provider systems may be interested in implementing ACOs, but they are facing barriers preventing them from benefiting from participating in the shared saving programs. For instance, academic centers may not be structured appropriately to form an ACO.
13 In general, specialists are the focus at academic centers;
PCPs are not. Further, administrative services are typically not centralized, and forced collaboration across departments may be particularly challenging, as some may have adopted incompatible processes. While HIT can provide solutions to creating a more cohesive process, as described, the balance of PCPs and specialists is an essential component of ACO formation.
Governance is a significant consideration for ACO implementation. However, primary care physicians are best suited to direct ACOs because they are frontline to direct evidence-based medical decision-making: this is affirmed by the MSSP Final Rule, which mand ates that an ACO’s clinical management is overseen by a licensed medical professional who is a practicing member of the ACO.
2 However, hospitals may be in a far better position to actually operate an ACO because of the required up-front costs and HIT systems. Hospitals have high fixed costs to operate and thus may not be as incentivized to save money; nonetheless, pressure from insurance companies may influence hospital participation in ACOs. Some have suggested that ACO implementation may accelerate the trend towards hospital mergers.
The ACA represents an evolution in healthcare, and the ACO initiative has the potential to become the first major movement toward efficient, affordable care. The HIT industry is poised at the forefront of this movement specifically because it has the capacity to meet arguably every need of the ACO triple aim:

Better care for individuals as physicians are capable of providing coordinated care derived from evidencebased treatment decisions supported by outreach

Better health for populations as communities of healthcare practitioners are better prepared from a technological standpoint to meet the needs of a population replete with chronic conditions

Lower growth in expenditures as preventive medicine is pushed to the forefront with innovative, proactive technological solutions
As the ACO initiative evolves, additional challenges and opportunities will become evident. The HIT industry is versatile enough to keep stakeholders at the table, by mitigating risk and leveraging innovation.
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Table 1. ACA Guidelines for ACO Formation 2
Eligible Entities
Professionals in group practice arrangements, including licensed physicians, physician assistants, nurse practitioners, clinical nurse specialists
Networks of individual practices of ACO professionals
Partnerships or joint venture arrangements between hospitals and ACO professionals
Hospitals employing ACO professionals
Other healthcare provider organizations such as rural health centers, federally qualified health centers, and some critical access hospitals
Eligibility Requirements
Clinical management must be overseen by a licensed medical professional who practices medicine as a member of the ACO and is physically present on a regular basis at one of the ACO locations
Must agree to become accountable for the quality, cost and overall care of Medicare fee-for-service beneficiaries assigned to the ACO
Must be a legal entity capable of receiving and distributing savings, repaying shared losses owed to CMS, certifying compliance with healthcare quality criteria
Must use a shared governance management model and maintain an identifiable governing body
Must utilize and promote evidence-based medicine
Leadership and management must include clinical and administrative systems that support the goals of better outcome and decreased costs
Include a sufficient number of primary care physicians to serve 5,000 or more Medicare beneficiaries
Agree to participate in the program for at least 3 years
Have a well-defined legal structure and its own tax identification number
A qualified he althcare professional must be responsible for the ACO’s quality assurance and improvement program
Cannot be concurrently participating in another shared savings program
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Table 2. CMS-Approved ACOs
ACO Location
Allina Hospitals & Clinics
Atrius Health
Banner Health Network
Franciscan Alliance
Genesys PHO
JSA Medical Group,
Michigan Pioneer ACO
Monarch Healthcare
Fairview Health Systems
Heritage California ACO
Bellin-Thedacare Healthcare Partners
Pioneer ACOs 5
Beth Israel Deaconess Physician Organization
Bronx Accountable Healthcare Network (BAHN)
Brown & Toland Physicians
Dartmouth-Hitchcock ACO
Eastern Maine Healthcare System
Healthcare Partners Medical Group
Healthcare Partners of Nevada a division of HealthCare Partners
Mount Auburn Cambridge
Independent Practice Association (MACIPA)
Minnesota and Western Wisconsin
Eastern and Central Massachusetts
Phoenix, Arizona Metropolitan Area
(Maricopa and Pinal counties)
Northeast Wisconsin
Eastern Massachusetts
New York City (Bronx) and
Lower Westchester County, NY
San Francisco Bay Area, CA
New Hampshire and Eastern Vermont
Central, Eastern, and Northern Maine
Minneapolis, MN Metropolitan Area
Indianapolis and Central Indiana
Southeastern Michigan
Los Angeles and Orange counties, CA
Clark and Nye counties, NV
Southern, Central, and Coastal California
Orlando, Tampa Bay, and surrounding South Florida
Southeastern Michigan
Orange County, CA
Eastern Massachusetts
North Texas ACO
OSF Healthcare System
Park Nicollet Health Services
Partners Healthcare
Physician Health Partners
Presbyterian Healthcare Services – Central New
Mexico Pioneer Accountable Care Organization
Tarrant, Johnson and Parker counties in North Texas
Central Illinois
Minneapolis, MN Metropolitan Area
Eastern Massachusetts
Denver, CO Metropolitan Area
Central New Mexico
Primecare Medical Network
Renaissance Medical Management Company
Seton Health Alliance
Sharp Healthcare System
Steward Healthcare System
Southern California
(San Bernardino and Riverside counties)
Southeastern Pennsylvania
Central Texas (11-county area including Austin)
San Diego County
Eastern Massachusetts
TriHealth, Inc.
University of Michigan
Northwest Central Iowa
Southeastern Michigan
Medicare Shared Savings Program ACOs 6
Accountable Care Coalition of
Caldwell County, LLC
North Carolina
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Accountable Care Coalition of
Coastal Georgia, LLC
Accountable Care Coalition of
Eastern North Carolina, LLC
Accountable Care Coalition of
Greater Athens Georgia, LLC
Accountable Care Coalition of Mount Kisco, LLC
Accountable Care Coalition of
Southeast Wisconsin, LLC
Accountable Care Coalition of Texas, LLC
Accountable Care Coalition of the Mississippi Gulf Coast, LLC
Accountable Care Coalition of the North Country, LLC
AHS ACO, LLC
AppleCare Medical ACO, LLC
Arizona Connected Care, LLC
Chinese Community
Accountable Care Organization
Catholic Medical Partners
Coastal Carolina Quality Care, Inc
Crystal Run Healthcare ACO, LLC
Florida Physicians Trust, LLC
Hackensack Physician Hospital Alliance ACO, LLC
Jackson Purchase Medical Associates, PSC
Jordan Community ACO
North Country ACO
Optimus Healthcare Partners, LLC
Physicians of Cape Cod ACO, Inc
Premier ACO Physician Network
Primary Partners, LLC
RGV ACO Health Providers, LLC
West Florida ACO, LLC
15
Georgia, South Carolina
North Carolina
Georgia
New York, Connecticut
Wisconsin
Texas
Mississippi
New York
New Jersey, Pennsylvania
California
Arizona
New York
New York
North Carolina
New York, Pennsylvania
Florida
New Jersey, New York
Kentucky, Illinois
Massachusetts
New Hampshire, Vermont
New Jersey
Massachusetts
California
Florida
Texas
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Table 3. Healthcare Quality Measures for Shared Savings 2
Domain Measure Title
Patient/Caregiver
Experience
Care Coordination/
Patient Safety
Preventive Health
At-Risk
Population
Getting Timely Care, Appointments, and Information
How Well Your Doctors Communicate
Patients’ Rating of Doctor
Access to Specialists
Health Promotion and Education
Shared Decision Making
Health Status/Functional Status
Risk-Standardized, All Condition Readmission
Ambulatory Sensitive Conditions Admissions: Chronic
Obstructive Pulmonary Disease or Asthma in Older Adults
Ambulatory Sensitive Conditions Admissions:
Congestive Heart Failure
Percent of Primary Care Physicians Who Successfully
Qualify for an EHR Program Incentive Payment
Medication Reconciliation: Reconciliation After Discharge from an Inpatient Facility
Falls: Screening for Fall Risk
Influenza Immunization
Pneumococcal Vaccination
Adult Weight Screening and Follow-up
Tobacco Use Assessment and Tobacco Cessation
Intervention
Diabetes
Depression Screening
Colorectal Cancer Screening
Mammography Screening
Screening for High Blood Pressure
Diabetes Composite (All or Nothing Scoring):
Hemoglobin A1c Control (<8 percent)
Diabetes Composite (All or Nothing Scoring): Low-Density
Lipoprotein (<100)
Diabetes Composite (All or Nothing Scoring): Blood
Pressure <140/90
Diabetes Composite (All or Nothing Scoring): Tobacco Non
Use
Diabetes Composite (All or Nothing Scoring): Aspirin Use
Diabetes Mellitus: Hemoglobin A1c Poor Control (>9%)
Hypertension Controlling High Blood Pressure
Ischemic
Vascular
Complete Lipid Panel and LDL Control (<100 mg/dL)
Disease
Use of Aspirin or Another Antithrombotic
Heart Failure
Coronary
Artery
Disease
Beta-Blocker Therapy for Left Ventricular Systolic
Dysfunction (LVSD)
CAD Composite: All or Nothing Scoring:
Drug Therapy for Lowering LDL-Cholesterol
CAD Composite: All or Nothing Scoring:
16 a digitally-forward-thinking initiative brought to you by S&H
HIT Value Added
Proposition

Smartphone/ta blet apps

Innovative education and communication tools

Patient outreach tools for use in office and the field

Maximizing inoffice time and experience

Sophisticated
EHRs

Electronic coordination between providers outside the
ACO such as local pharmacies

Condition monitoring

Medication regimen adherence tools and education

Cloud technology

(CAD) 
Angiotensin-Converting Enzyme (ACE) Inhibitor

Angiotensin Receptor Blocker (ARB) Therapy for
Patients with CAD and Diabetes and/or LVSD)
Table 4. Grounding the Moving Parts and Programs

The Clinician & Group Consumer Assessment of Healthcare Providers and Systems (CG-
CG-CAHPS
Survey 8,27
CAHPS) survey is one of the CAHPS surveys designed by the government to gather data regarding healthcare services

Their results are databased by the Agency for Healthcare Research and Quality, which is
Electronic Health
Record
Electronic Medical
Record
28
28
Evidence-Based
Medicine 29
Hospital-Acquired
Conditions (HACs) 2 an agency of the US Department of Health and Human Services (HHS)

Combines health data from both hard copy and electronic medical records to form an integrated record of health information, for use in the improvement of quality of care

Used for communicating health information across various healthcare settings

Medical records kept in a digital format, typically for use within a single healthcare setting, such as a doctor’s office or hospital

The process of making treatment decisions based upon clinical outcome data and clinical expertise, rather than financial research

CMS received numerous comments about how reporting HACs may affect obtaining incentives:

How would this affect ACOs that do not include a hospital in their system?

How would the data be aligned with the accountable ACO?

How would the risk be adjusted for sicker patients at greater risk of experiencing HACs?

Due to the complexity of this issue, the MSSP Final Rule did not finalize any measures with
ICD-10 30
The Medicare EHR
Incentive Program
(“Meaningful Use”) 10
Patient-Centered
Medical Home
(PCMH) 1 respect to HACs, but may do so in the future.

The International Statistical Classification of Diseases and Related Health Problems, 10 th
Revision

This coding system for diagnoses is used to share and report diagnostic information among healthcare providers/payers and gather epidemiologic data

Contains over 141,000 codes covering diseases, procedures, nature of injuries, causes of death, drugs and chemicals
 This program incentivizes the ‘meaningful use’ of certified EHR technology, described by the American Recovery and Reinvestment Act of 2009

Use in a meaningful manner (e.g., e-prescribing)

Use for exchange of health information to improve overall healthcare

Use to submit clinical quality and other measurements to the government
 A ‘staged’ approach to requirements and incentives was used

Stage 2 regulations, which called for greater personal access and interoperability, were released for comment in February 2011

The commonalities between the ACO and PCMH models:

Better access to healthcare

Improved coordination of care

Prevention of disease approach

Quality and safety ensured by the primary care medical practice

Strengthened engagement between the primary care physician and the patient

The distinction between the ACO and PCMH models, is that ACOs contain numerous primary care providers, and thus may be thought of as a “medical neighborhood”
Physician Self-
Referral Law
(“Stark Law”) 31,32

Prohibits the following activities

Prohibits a physician from making referrals for certain services payable by Medicare to an entity with which the physician or an immediate family member has a financial relationship

Prohibits a physician from presenting or causing to be presented claims to Medicare for those referred services

Waived for ACO participants during the time they are enrolled in the MSSP
17 a digitally-forward-thinking initiative brought to you by S&H

Step Therapy 20

The cost-savings approach of prescribing the cost-effective and safe drug therapies initially and reserving more costly or risky interventions as a later or last resort
Table 5. Comparison of the Brookings - Dartmouth ACO Pilot Sites 33-37
ACOs
Carilion
Clinic
(Roanoke, VA)
HealthCare
Partners
(Torrance, CA)
Monarch
HealthCare
(Irvine, CA)
Norton
Healthcare
(Louisville, KY)
Tucson Medical
Center
(Tucson, AZ)
Specifications of the Parent Organization
Type
Integrated
Delivery System
IPA/Medical
Group
IPA/Medical
Group
Integrated
Delivery System
Virtual organization of nonprofit hospital system and affiliated practices
HealthCare
Partners, LLC
Professional
Corporation
501(c)3 Legal Structure 501(c)3
Patients Served
Annually
1.4 million physician visits
47,500 hospital admissions
# of Associated
Hospitals
# of Hospital
Beds
7
1,100
Over 1 million nationally
20
170,000 managed care enrollees
6
1.5 million
54
1,857
501(c)3
35,000 inpatients;
175,000 outpatients
1
EHR
Capabilities
Clinical
Transformation
Tools
Enterprise-wide
EHR, P4P, outcome reporting, aligned incentives
N/A
Allscripts,
NextGen and
EPIC
Complex care management, patient registries, pointof-care reminders, aligned incentives for providers
2,762
Practice
Connect
®
,
NextGen
Software, patient registries, clinical staff to monitor patient transitions
Meditech
PublicQuality
Report (600 measures), disease and outcome registries, eneterprise data repository
(AMALGA)
628
Allscripts,
NextGen and
EPIC
Timely data
(admission, discharges, transfers, quality performance, efficiency, and communications)
Specifications of the ACO
Governance
Structure
Clinical senior management team
Participating
Payers
ACO PCPs
ACO Medical
Specialists
ACO Surgical
Specialists
TBD
150
250
100
TBD
Anthem,
Wellpoint
1,000
1,462
240
Physician owned and governed
Anthem,
Wellpoint
497
344
210
Internal
Humana
200
29
89
Executive
Committee/Board
United
Healthcare
75
10
15
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Figure 1. HIT Integrates the MSSP Initiatives and the Logistical Challenges of ACO Adoption
19 a digitally-forward-thinking initiative brought to you by S&H

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For more information on how the Sudler eHealth Group can help you broaden and deepen your company’s impact in the eHealth market please contact:
R. Shane Kennedy
Shane.kennedy@sudlerehealthgroup.com
212-613-3972
Cassandra Sinclair
Cassandra.sinclair@sudlerehealthgroup.com
647-259-7812
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