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    The good news, bad news of recent ACO results

    August 27th, 2015

    This week, the Centers for Medicare & Medicaid Services announced 2014 results for 333 Medicare Accountable Care Organizations (ACOs). It’s pretty exciting news; 56% of ACOs reduced costs and improved quality measures and reporting, which is up from 40% in previous years.

    The downside of the report is that only 29% of ACOs participated in shared savings, which is simply not enough. The ACOs are saving money, but they’re not earning revenue at the same rate. It’s clear that we, as in industry, have to do more to facilitate success.

    Think like a payer

    To earn shared savings, ACOs need to think more like payers. Unlike traditional fee-for-service models, new value-based-care models require providers to balance risk scores and quality measures for better patient care. They have to manage patient coding to account for risk, which is what payers do all the time.

    As an industry, we need to improve care coordination tools for multi-provider networks, especially when it comes to engaging patients. Here are a few scenarios where having the right tools can make a difference to an ACO:

    Do we need to order that test?

    Sharing real-time information and test results can help avoid unnecessary costs. Collaboration tools can, for example, alert primary care physicians when one of their patients shows up in the emergency room. If she’s had a recent lab test in one place, those results can be shared instead of duplicated.

    Are we doing enough to motivate the patient with chronic disease?

    Patient portals are a great start, and we’ve only scratched the surface by engaging patients in a proactive way. Maybe it’s helping a patient who is overwhelmed with medications learn how to manage them. Or building skills through cooking and exercise classes. It’s incredibly important to help patients find new and different ways to improve their quality of life. It opens the door to new opportunities for reimbursement too, such as through the CMS Chronic Care Management program.

    Where are the unmanaged illnesses in our patient population?

    Some patients avoid the doctor. If they have heart disease and are not actively participating in their care, it’s only going to get worse. Finding unmanaged disease – tomorrow’s high-cost patients – can be as simple as an empathetic phone call to ask a patient, “How are you?”

    Taking steps like these will help improve ACO savings rates. Similar care collaboration efforts have enabled all of Allscripts-managed ACOs achieve savings in their second-year. They recognize it’s not just about quality reporting and not just about reducing cost with better patient outcomes, but achieving all three with coordinated care to earn shared savings. It’s the Triple Aim.

    To find out more about how Allscripts can help with value-based-care efforts, contact us.

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    Unlocking the mysteries within your CMS claim file

    May 12th, 2015

    In a healthcare industry that is shifting from fee-for-service to value-based-care models, it’s increasingly important for practices to understand everything about their costs. To that end, Centers for Medicare and Medicaid Services (CMS) delivers a claim file to Accountable Care Organizations (ACOs).

    Unfortunately, ACOs often don’t take full advantage of the intelligence available within the CMS claim file. But if ACOs can unlock these “mysteries” held within the file, they can reduce costs more quickly. Here are just a few examples:

    Where do all my patients receive care?

    Your CMS claim file can show you where your patients are actually receiving care. The answer may surprise you.

    For example, we helped one of our ACO clients in the rural Midwest plot on a map where its patients were receiving care. As expected, patients received a lot of care in the surrounding counties. But unbeknownst to the physicians, patients received care in scattered locations all over the country.

    To truly coordinate care, ACOs need to know when “snowbirds” are visiting specialists in Florida, for example. All of these episodes help give a more complete picture of a patient’s health risks.

    Because CMS attributes these patients to us, we own their chronic care management, right?

    Not necessarily. A recent blog post discussed the importance of accurately calculating the number of attributed lives.

    But there is nothing that prevents another physician office from inviting your patient to be part of its Chronic Care Management program. Practices that are proactive in reaching out to patients could earn them as attributed lives over time.

    So it’s important for practices to continue to engage their patients, to maintain that relationship and to better coordinate that patient’s care.

    Are we coding our high-risk patients properly?

    Proper diagnosis coding becomes increasingly important in a value-based-care model. CMS uses these codes to set its benchmark on how much it expects patients to cost over time. CMS actuaries will set a lower financial payment for a bunch of healthy patients than they will for a group of really sick patients with comorbidities.

    Let’s say a physician examines a 70-year-old man with a sore throat. Turns out it’s a strep infection, and that’s how he codes the encounter. Now, let’s say that same patient also has hypertension, diabetes and is obese. If the physician fails to note these diagnoses, then CMS regards this patient as healthy, instead of the higher-risk (higher-cost) patient he actually is.

    Coding practices can significantly alter the CMS perception – and therefore target benchmark – of how healthy or high-risk your patient population is. It’s important to get that right for an ACO to be successful clinically and financially.

    The ultimate goal is coordinated care

    Unlocking the mysteries of the CMS claim file can be frustrating if you don’t know how to use the guideposts. But the effort is worth it.

    Looking at several CMS initiatives – whether it’s ACO, Comprehensive Primary Care Initiative (CPCI), Patient-Centered Medical Home (PCMH), or others – and they all point to one thing: coordinated care. Participating in these programs is all about stopping duplication of services, improving lives and outcomes.

    We have healthcare economists and care managers that can help your practice uncover intelligence in your CMS file. To learn more, contact us .

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    4 essential steps to forming an ACO

    April 28th, 2015

    January 2016 may seem like a long ways off. But if you’re thinking about forming an Accountable Care Organization (ACO) for next year, the clock is already ticking.

    The fee-for-service reimbursement model is shifting to value-based-care financial models, such as an ACO. The U.S. Health and Human Services (HHS) set a goal of tying 30% of its payments to these types of arrangements by the end of 2016, and 50% by the end of 2018.

    Now is the time to start planning. Here’s a checklist of the essential steps organizations should take in 2015 to be ready to start an ACO in January:

    1. April & May 2015 – Decide if the ACO model is the right one for you.

    Assess your current situation with questions like these:

    • Are physician incomes going up or down?
    • Are your physicians properly aligned with a value-based-care mindset?
    • Does your schedule have room for more patients with complicated health issues?
    • What percentage of your income comes from Medicare/Medicaid?
    • How well are you engaging your current patient population?
    • How do specialists coordinate with primary care colleagues?
    • Do your private insurance payers have value-based plans in the works?

    If your practice wants to coordinate all care for your patients and is willing to engage with the community beyond your four walls, then the ACO model is probably right for you.

    2. April & May 2015 – Assess your Medicare population to determine if you have enough attributed lives.

    This step is often an ACO rookie’s most common mistake. But you need perspective on what percentage of your practice will qualify.

    If you do not meet the minimum of 5,000 patients, then you need to establish a network of specialties and primary care that can help build that number. Ideally, the number of patients is small enough to maintain control, but large enough to protect against cost variability. CMS has a special program to help smaller practices with ACO populations of 5,000 to 10,000, which is perhaps especially helpful in rural areas.

    When Allscripts helps clients with this piece, we’ve found that there is a financial benefit to building the attribution base. For every dollar they invest to bring existing patients back to their practice, it generates as much as four dollars in return.

    3. May 29, 2015 – File notice of intent with Centers for Medicare and Medicaid Services (CMS).

    This may be the easiest step, but it sets the stage for your application process. You don’t want to miss this deadline, because your next opportunity will be a year away and will postpone your ACO start date until January 2017.

    4. July 31, 2015 – Submit your application to CMS.

    The application is a series of documents. CMS may have follow-up questions that a practice needs to address. The whole application process can take several months from start to finish.

    Contact us if you’d like to learn more about how Allscripts can help you with any of these steps.

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    How small practices can earn Chronic Care Management revenue

    April 14th, 2015

    One third of the U.S. population has at least one chronic disease, such as cancer, asthma, diabetes or heart disease. Chances are good that we, or people we love, have experienced the challenges of coordinating care for these complex conditions.

    Clinicians recognize the importance of staying connected to their patients. But teams at small practices may not have enough volume – or stability of volume – to justify hiring additional clinical staff to coordinate care for complex patients.

    Taking full advantage of the new reimbursement opportunity

    In 2013, Centers for Medicare and Medicaid (CMS) launched a program to begin reimbursing for non-face-to-face care coordination services. It’s called the Chronic Care Management program, and its goal is to improve care for patients with two or more chronic diseases.

    CMS has a list of about 22 things the practice needs to do to comply, including engaging with each patient over the phone for 20 minutes each month to coordinate care. It doesn’t have to be one phone call, but could be a five-minute phone call each week, for example.

    On these calls, clinicians find out what’s going on with patients and help them figure out what care they need and where they can get it. In return, CMS will pay about $40 per member, per month.

    Decision: Invest in staff or outsource?

    For a practice that has a high, steady volume of chronic disease patients, it might make most sense to hire additional staff to manage it. Let’s say the practice has 480 CMS member patients who have two or more chronic diseases. One five-minute phone call to each of these patients would require 40 hours every week, or one full-time employee.

    Assuming this practice meets all criteria for the program, it would earn about $19,000 per month in revenue for these 480 patients, or $230,000 per year. Subtract the total cost of the full-time employee, and the practice can see its net revenue for this program.

    But what if you don’t have that many patients? Or what if you don’t want your staff to take on this responsibility? Allscripts has partnered with Citra to help practices outsource this work. You just have to identify the patients who are willing to participate, and our care coordinators will engage them every month on the phone. (A recent news release highlights one of these partnerships.)

    Bottom line is better population health management

    No matter which model you chose, better care coordination is a win for everyone. The complex patient receives better care, the clinician knows they are providing higher-quality care, CMS reduces its overall costs and rewards the practice financially.

    To find out more about how Allscripts can help you with chronic care management or other value-based care projects, contact us.

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    An ACO rookie’s most common mistake

    February 26th, 2015

    To stay competitive in an evolving healthcare landscape, independent small physician practices are creating their own Accountable Care Organizations (ACO). It’s important for them to have accurate expectations before applying to Center for Medicare & Medicaid Services (CMS) and its Shared Savings Program.

    Unfortunately, new ACO applicants often miscalculate the number of CMS patients, or “attributed lives,” they are responsible for, putting their entire cost structure at risk.

    Whose patient is it?

    CMS assigns each patient to a provider who will be responsible for that patient’s cost and quality of care. A sophisticated algorithm determines where this patient belongs, based on claims data.

    A smaller primary practice may assume that every History and Physical (H&P) it performs for Medicare patients will count toward its attributed lives total, when in fact that is not the case.

    For example, if that patient sees a specialist who also conducts an H&P (potentially unnecessary duplication) then provides additional services and fees, that specialist will likely earn the attributed life from CMS.

    So it’s not always the primary care provider that earns the attributed life, and it’s very hard for practices to determine ahead of time.

    The risk of getting it wrong

    One of two things can happen if the practice overestimates the number of attributed lives:

    1. CMS rejects the ACO application. At that point, if the CMS window is open to do so, they can join another ACO group. Otherwise, the practice will not be part of an ACO.

    2. Maybe the practice still qualifies to be an ACO, but CMS assigns a substantially lower number of patients. This outcome is particularly dangerous to practices that have built their cost structure around the expectation of a certain number of patients. If a practice expects 15,000 lives, but earns only 8,000 lives from CMS, its shared savings income would be much lower than expected.

    Neither option is desirable; it’s important to go into the ACO application process with appropriate expectations. Allscripts is now offering a service to help small practices estimate attributed lives. Download a white paper or contact us if you’d like to learn more.


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    Finding tomorrow’s high-risk patients

    February 4th, 2015

    As the healthcare industry offers more ways to earn risk-based or value-based revenue, providers are more proactively coordinating care, engaging patients and managing population health. Analytics are fundamental to all of these strategies, even in small practices.

    To be successful, physician practices need analytics that are predictive across multiple populations. They need to know who the high-risk patients are today, but they also need to identify the “rising-risk” patients. With intervention, these patients can have a healthier future.

    The cost of unmanaged cardiac conditions

    One healthcare organization evaluated its Accountable Care Organization (ACO) population with Johns Hopkins Adjusted Clinical Groups (ACG®), an industry standard to adjust risk and predict future healthcare usage.

    With analytics, this ACO found that more than half of its patients were either high risk (30%) or very high risk (27%). Furthermore, it found that the average total costs were astronomically higher for these patients:

    Finding tomorrow's high-risk patients today

    Next, the ACO looked at probabilities for hospitalization within high-risk patient profiles. It found that two out of three patients have a cardiac condition. Analytics revealed that cardiac patients who had not seen their primary care provider within the last three months had 21% more emergency room use and 51% more hospitalizations.

    While the primary concern is making sure these patients receive the best care possible, there is also a financial component: overall costs for these patients is 48% higher than patients who regularly see their primary care providers.

    This data represents an opportunity to better manage care for cardiac patients. If the ACO can get these patients to more consistently visit their primary care providers through care coordination and patient engagement efforts, it could potentially save as much as $12.7 million per year. Even if the ACO could only affect change with one out of every ten patients, it would save more than $1 million.

    We can help you find unmanaged opportunities within your own healthcare community. Contact us for more information.


    Why small physician practices are missing out on analytics

    January 14th, 2015

    Small, independent physician practices have the best of healthcare IT worlds, and the worst.

    On the plus side, they can control everything that happens inside their walls. They have access to their clinical and financial data. They can be more nimble with Healthcare IT decisions than larger organizations, from selection to implementation to governance.

    But if small practices don’t have analytics, they could be losing money. And they may not even realize it.

    Most practices don’t have the right tools

    Small practices likely have reporting tools in their electronic health record (EHR) and practice management solutions. “Canned” reports can help track and monitor certain aspects of a practice, which is essential to having a healthy core.

    But it takes more sophisticated analytics tools to really understand things like referral patterns, clinical pathways, care coordination – especially in context with cost data. Analytics tools for value-based care enable practices to build dashboards, slice and dice data, and review a patient’s progress in real time. They should also have ad-hoc capabilities to drill down into details about disease management, service locations and more.

    What are other barriers between practices and the right analytics tools? Some practices lack software that is Open. Others lack awareness that these tools even exist. One of the biggest barriers, however, is limited time.

    Who has time for analytics?

    Many small practices feel that they simply don’t have the time to do more with their data. Physicians and administers aspire to what they might do, such as improve outcomes, become more efficient, retrieve maximum revenue. Then reality sets in: They don’t have the time.

    With all the demands placed on small practices today, physicians are understandably reluctant to invest more resources into analytics. If they are making payroll on fee-for-service payment models, it’s easy to assume that all is well. But unless they use analytics, they won’t see opportunities to follow up with patients, catch missing revenue from payers or identify other inefficiencies. They’ll continue to make the same revenue mistakes and not even realize it.

    Preparing for more complex business models

    As small practices face increased complexity and reduced reimbursements, they’ll need to be ready for value-based financial models. Physicians recognize that these models require either 1) employees with expertise in this area (often beyond the reach of small practices), or 2) an outsourcing partner they can trust*.

    Once the right analytics resources are in place, physicians can better focus on medicine, and practices can create more efficient mechanisms to earn revenue – in both fee-for-service and value-based-care models.  Which, in turn, is the best of both worlds.

    * For an assessment or more information about Allscripts analytics services for small practices, please contact us.

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