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In 2011, the health care industry went through some interesting changes – from Meaningful Use attestations and delays to ICD-10 – but one of the less publicized milestones was one that may have a deeper and longer lasting effect on how we care for patients and that was the CMS final rule on the Medicare Shared Savings Program (MSSP). I believe that this rule, and the types of new provider risk-bearing models it encourages, will spawn a whole new generation of health information technology. A generation that focuses not just on patients currently seeing doctors and being admitted to hospitals and appearing on a census, but on a much broader spectrum of analytics, clinical transformation tools, wellness/prevention solutions and automated care management systems for comprehensive management of patient populations.
For an MSSP ACO to succeed, it must deliver care to its attributed Medicare fee-for-service population for less than it costs CMS. Comparing an ACO’s actual cost of care to CMS’ pre-determined value of what it is expected to cost them ─ or the ACO’s “hurdle rate” ─ determines if an MSSP ACO will be able to participate in gain. But as of now, CMS hasn’t released these hurdle rates ─ making it very difficult for an MSSP ACO to ascertain whether success is possible under these parameters, and therefore to decide with any confidence whether or not to proceed to contract with CMS.
Evaluating and managing population risk has traditionally been the payer’s role in the health care system. But as providers become increasingly accountable for populations, they will need to be equipped with many of the same competencies that payers have been relying on for years. This includes the right technology to capture both clinical and claims data, but also the ability to analyze and transform these data into actionable information that affords the delivery of high quality, efficient health care and ultimately real population health — that’s where actuarial services come in.
Like many folks in the healthcare industry, the “light reading” that has graced my nightstand over this past week or two has consisted of 700 pages of the Department of Health and Human Services’ Final Rule on Medicare Accountable Care Organizations (ACOs). Overall, the changes from the draft proposal, aimed at nudging providers away from a fee-for-service model and into one of shared savings and risk, are both substantial and encouraging, with a number of key improvements in three key areas:
While many things remain undefined when it comes to the industry’s move to pay for performance, one thing is certain – one size does not fit all. Encouraged by the regulations around Medicare’s CMS-based ACO, providers, physicians and payers are teaming up in a variety of ways to create new models of collaborative care. Although the CMS-defined ACO model has the lowest downside and many health systems will need to adopt it due to competitive pressures, the following models allow for the ability to scale to various-sized populations and design customized shared savings arrangements tailored to the needs and demographics of each community:
This week’s guest post comes from Justin Chang, M.D., chief of emergency services, Kaiser Permanente, Colorado, and medical director, Exempla St. Joseph Hospital Emergency Department. A proponent of collaboration and enhanced coordination of care, Dr. Chang makes the case for a new model of healthcare delivery as defined March 31 by the Centers for Medicare & Medicaid Services (CMS) in its proposed ruling on Accountable Care Organizations (ACOs).
I think we can all agree — physician, payer, provider, patient, etc. — that the ultimate goal of regulations and reform should be to improve the delivery of healthcare, lowering costs and ultimately, making patients healthier and more satisfied. Coupled with driving toward the results defined by CMS, this requires some fairly significant changes in how healthcare providers operate — changes which may rightfully make some providers uneasy. But what many of us may not realize is that hospitals, physicians and payers across the country are already becoming advocates for the types of changes ACOs will require, supporting a shift away from the fee-for-service and silo-type models, even before the regulations go into effect.
I commented several months ago about how the hurried healthcare reform bill became so imperfect that there was no way it would not add to already escalating costs. But in accordance with the rule of unintended consequences, all the debate around the bill, along with the fear that some of its most onerous provisions like large cuts in Medicare for hospitals, has spurned a tidal wave in thinking and planning about new models of care that will be more efficient. We now hear the words “accountable care organization,” or ACO, more often than you heard “web strategy” during the dot.com boom. ACO is a technical term originated by the Brookings think-tank and adopted by CMS to cover the rules around ACO eligibility and qualification. However, the term “Sustainable Health Communities” (SHC) is a more descriptive term with the obvious connotation that left to our present course, the current system is unsustainable, and the addition of “community” extends all the way into all the pre- and post-acute care entities.
While the meaningful use debate rages on, the Centers for Medicare & Medicaid Services (CMS) have opened the proposed rule on the EHR incentive programs – which includes the definition of meaningful use and other requirements for qualifying for incentive payments – for public comments. The deadline for comments is Monday, March 15th, and we’re encouraging folks to weigh in on the good, the bad and the ugly. The more industry can shape how this rule should be shaped, the closer we come to putting the real “meaning” behind meaningful use.
For more information and to submit a comment on the proposed rule, visit the Regulations.gov website. For additional information on the proposed rule, visit http://www.cms.hhs.gov/Recovery/11_HealthIT.asp.
- Mark Crockett, M.D.
Standing in the Interoperability Showcase at HIMSS10 is frankly amazing. We are participating in the Emergency Department interoperability scenarios, passing clinical documentation to and from other systems, using IHE standards for information exchange. I was standing with a friend and CMIO who is a practicing physician, and when he saw how easy it was to get information regardless of source, his comment was, ”This is how it is supposed to work, how it was always supposed to work.” I agree. And more vendors than ever are participating.
Talking with the HIMSS folks that orchestrated the impressive setup, I come to find that the numbers of folks “interoperating” in this display have more than doubled in the past two years, now demoing nearly 60 use cases and 28 clinical scenarios. Similar to the IHE show in January, the interest in interoperability and move to embrace standards at HIMSS is palpable. And it’s not just on the show floor – I have been talking to vendors all over that are now delivering or planning to deliver shortly to their customers this type of technology.
Welcome to the inaugural post of Healthcare-Exchange, a forum designed to offer fresh perspective, encourage the exchange of ideas and drive discussion — no matter how controversial — all in the name of healthcare.
A term that’s come to encompass so much more than a doctor’s visit, healthcare in the US has seen more changes over the past few years than in the 20 years before it. From the electronic health record to patient safety to universal coverage, we invite you to weigh in on the issues that will make the biggest impact on the healthcare world in the year ahead. Below, I’ve included my Top Five Predictions for 2010 and want to hear if you’re on the same page:
