Learn more about Accountable Care Organizations (ACOs) and strategies for better value-based care contract reporting.
What is an Accountable Care Organization (ACO)?
According to the Centers for Medicare and Medicaid Services (CMS), an Accountable Care Organization (ACO) is a group of doctors, hospitals, and other health care providers who come together voluntarily to give coordinated, high-quality care to the Medicare patients they serve. Care coordination between providers ensures patients get the appropriate care at the right time. One of the overall goals is avoiding the unnecessary duplication of services, which results in cost savings for CMS and providers. Coordination also aids in preventing medical errors.
ACOs and Healthcare Payment Models
As explained in the Pioneer ACO Final Report, the ACO model was designed to provide financial incentives for fee-for-service (FFS) Medicare providers to reduce inefficiencies in care delivery. ACOs are meant to increase communication and coordination between providers. This affords organizations an opportunity to share in financial rewards and avoid penalties. ACOs seek to improve care for their patients by focusing on value, innovation, care management, and clinical integration. Many providers viewed the Pioneer ACO model as a chance to continue their care improvement efforts while reaping financial rewards.
Care Improvement Reporting Categories
Providers were able to pursue quality improvements through their own strategies when the Pioneer ACO model launched in 2012. The four Medicare Shared Savings Plan (MSSP) categories were initially Provider Engagement, Care Management, Health Information Technology, Beneficiary Engagement. The four categories are similar today but have had some adjustments made since their initial inception. The four categories for 2019 are:
- Quality Measures: The Quality Measures performance category measures health care processes, outcomes, and patient experiences of their care. This category requires reporting on electronic Clinical Quality Measures (eCQMs), MIPS CQMs, Qualified Clinical Data Registry (QCDR) Measures, and Medicare Part B claims measures. (Medicare Part B claims measures are only available to small practices.)
- Promoting Interoperability: The Promoting Interoperability (PI) performance category promotes patient engagement and electronic exchange of information through certified electronic health record technology (CEHRT). This category requires clinicians submit reporting data through a certified EHR system that complies with 2015 Edition certification regulations.
- Improvement Activities: The Improvement Activities performance category measures participation in activities that improve clinical practice.
- Cost Measures: The Cost Measures performance category measures the resources clinicians use to care for patients. It also measures the Medicare payments made for care (items and services) provided to beneficiaries.
There are over 250 MIPS measures to report on for 2019 across these four measures categories. Understanding the measures for each category is key to accurate and efficient reporting. It’s important to know your patient population when selecting measures to report on. Each measure has a different set of qualifications and benchmarks that need to be reported on for maximum reimbursement. This also ensures you avoid potential penalties.
EMRs and Value-Based Healthcare Reporting
Electronic Medical Records (EMRs) are digital versions of the paper charts in clinician offices, clinics, and hospitals. These records contain notes and information collected by clinicians in that office, clinic, or hospital. They are primarily used by providers for diagnosis and treatment. These digital files are incredibly valuable for providers, allowing them to easily collect data and track patient health over time.
EMRs play an important role in value-based healthcare reporting. Providers can engage in federal and commercial value-based contracts, which rewards them for hitting certain measures benchmarks. Each measure has a different set of benchmarks and requirements that require reporting. Collecting patient data that’s relevant to the measures you’re pursuing is crucial. Meeting measures benchmarks and closing gaps are the only way to maximize reimbursements and avoid potential penalties. These incentive payments are one of the main drivers of the value-based healthcare evolution.
Better Reporting for ACOs
CMS has set additional, ACO-specific measures to report on across four categories: Patient/Caregiver Experience (10 measures), Care Coordination/Patient Safety (4 measures), Preventative Health (6 measures), and At-Risk Populations (3 measures, one each for Mental Health, Diabetes, and Hypertension). An ACO’s success depends on prompt analysis and reporting. On-time and accurate reporting through the CMS web interface on attributed lives requires prospectively managing gaps in care related to preventative measures.
One overall tip is to engage in prospective reporting. Prospective reporting requires actively reviewing gaps in care on a frequent, regular basis. This allows providers to effectively monitor patient progress. Prospective reporting is the ideal alternative to waiting for CMS to release their sample sizes. In that case, retrospectively following up with patients could reveal unaddressed gaps in care.
Here are some examples of how ACOs can do better with their reporting and improve their scores across some ACO-specific measures. While these tackle some MSSP-specific measures, the strategies employed can be used for similar federal or commercial contracts.
At-Risk Population Measures
ACO-27 - Diabetes: Hemoglobin A1c Poor Control - ACO-27 is an inverse measure, and can be difficult to improve. CMS now permits physicians to bill for activities that keep them in communication with patients who have a chronic disease. Implementing a Remote Patient Monitoring (RPM) program may improve this measure. As this measure requires intervention and time, prospective reporting on it would be beneficial and could lead to a higher score. ACO-28 - Controlling High Blood Pressure is another measure that can be improved using this strategy, though not an inverse measure. Frequent RPM also enables providers to see trends in a patient’s health. Monitoring these trends helps to determine whether or not a patient needs an office visit for a more thorough examination or follow up.
Preventative Health Measures
Prospective reporting can help with preventative health measures as well.
ACO-19 - Colorectal Cancer Screening and ACO-20 Breast Cancer Screening - These two measures require enough time for the patient to schedule and receive their screenings. Knowing the ACO’s performance on these measures in advance of the CMS sample will offer enough time for patients to meet the measure. It’s important to keep in mind that each patient’s needs are unique based on their age, health, and other factors. These needs should be of the utmost importance when addressing these screenings.
ACO-17 - Preventative Care and Screening: Tobacco Use: Screening and Cessation Intervention and ACO-18 Preventative Care and Screening: Screening for Clinical Depression and Follow-up Plan - Both of these measures can be addressed once a year during a patient’s annual checkup as long as a provider is billing for an annual wellness visit. Tobacco use affects health and can develop into a chronic illness down the line. The Clinical Depression screening uses a standardized tool to understand the effects of potential depression. This also guides a patient’s care plan and may segue into an at-risk population measure, ACO-40 - Depression Remission at Twelve Months.
Patient/Caregiver Experience and Care Coordination/Patient Safety Measures
Both of these categories are handled through claims and the use of a CMS-certified patient satisfaction tool. A measure such as ACO-2 - How Well Your Providers Communicate can be easily improved when a physician knows when to communicate. RPM dashboards that highlight quality performance can alert a physician to which patients need attention. Patients who openly communicate with their doctors often see fewer trips to the office, fewer trips to the emergency room, and fewer bills. These patients also tend to be happier and less litigious.
Measures such as ACO-1 - Getting Timely Care, Appointments, and Information and ACO-45 - Courteous & Helpful Office Staff may require very little in terms of workflows or cost. A monthly staff meeting on ways to improve patient satisfaction and customer service can go a long way in succeeding on measures such as these.
Monitoring and Managing Measures Gaps
Improving the health of patient populations through ACOs is a key driver of CMS. Monitoring systems, dashboards, and multiple EHRs can be a complex and time-consuming affair. Employing the use of a tool such as Measures Manager™ can ease the burden.
Measures Manager™ aggregates your data from disparate EHR systems into one streamlined dashboard. Simple charts, graphs, and totals allow you to see exactly how you’re performing on your contract measures. This enables you to proactively identify gaps in care and address those gaps with different populations of patients. With a simple overview, you can see exactly where you are on each measure.
Measures Manager™ offers an opportunity to see how each provider is performing on specific measures. It also allows you to group patients together, enabling you to formulate care plans to close measures gaps. Prospectively reporting on measures can make or break your value-based contract reimbursements.