Actionable Data for an Intelligent Health Delivery System

Mark L Braunstein, MDProfessor of the Practice, School of Interactive Computing

Associate Director, Health Systems InstituteGeorgia Institute of Technology

“Every system is perfectly designed to get the results it gets.”

--Paul Batalden, Professor of Pediatrics, Community and Family MedicineThe Dartmouth Institute for Health Policy and Clinical Practice

Who or What Designed our Healthcare System?

No one … It’s a Complex Adaptive System

Agree on shared values and goals

Organize care and information around the patient

Expand the use of information technology (IT)

Enhance the quality and value of care

Reward performance

Simplify and standardize

Expand health insurance and make coverage automatic

Guarantee affordability

Share responsibility for health care financing

Encourage collaboration

• --Karen Davis, PhD, President, The Commonwealth Fund

How?

Align Incentives to Desired Results

Who?

Accountable Care Organizations

“… networks of physicians and other providers that could work together to improve the quality of health care services and reduce costs for a defined patient population.”

--Robert Wood Johnson Foundation, Health Affairs, July 2010

Key ACO Attributes

• Invisible enrollment• Performance measurement• Shared savings• Evolution toward stronger incentives• Specifics may be left to providers

Challenges

• Will shared savings offset lost provider revenue• How to share the benefits• Legal: anti-trust issues, Medicare restrictions on

provider arrangements• Reduced competition

Pilot ResultsSAN FRANCISCO – Mature electronic health record systems and health information exchange capabilities contributed to the success of five of the 10 accountable care organization (ACO) demonstration sites funded by the Centers for Medicare & Medicaid Services, according to a CMS official.

The findings are preliminary, and the project data is under review, said Anthony Rodgers, deputy administrator for CMS’s Center for Strategic Planning, on Tuesday during the National Regional Extension & Health Information Exchange Summit West in San Francisco.

Still, the common denominator of advanced health IT for the five ACOs represents validation for the technology's ROI. The five sites got the “lion’s share” of the $36 million that was the reward for meeting CMS’ goals of better care, reduced per capita costs and improved population health.

“If that’s not a business case, I don’t know what is,” Rodgers said.

CMS envisions three evolutions of the medical home, he added. Medical Home 1.0 encompasses EHRs, e-prescribing, coordination of care and patient care management, but no ROI. Medical Home 2.0 adds advanced clinical decision support and the broader application for chronic care management.

Medical Home 3.0, however, combines managing cost and population health with a fully connected office, community health strategy and new relationships and business partners, Rodgers said.

The industry, with CMS as part of the vanguard, is moving away from fee-for-service, episodic and non-integrated care to ACOs with EHRs and finally to patient-centered, integrated healthcare that aligns incentives with the three goals.

The model is organically aligned to achieve CMS’s goals, while also changing the financial incentives to global rates, shared savings and capitation, which will motivate groups to better manage their patients, Rodgers said.

Rodgers said he didn’t know when the peer review would be completed, but once the findings were complete the results would be posted on CMS’s website.

Still, the common denominator of advanced health IT for the five ACOs represents validation for the technology's ROI. The five sites got the “lion’s share” of the $36 million that was the reward for meeting CMS’ goals of better care, reduced per capita costs and improved population health.

“If that’s not a business case, I don’t know what is,” Rodgers said.

Vermont Key Recommendations– National and state sponsors should proceed with pilots and learning collaboratives in

diverse settings, including smaller communities, to learn more about success factors in developing ACOs. A critical pilot component is funding for a local provider infrastructure and community resources.

– An ACO’s success depends on committed leadership from physicians and other key stakeholders, multipayer participation, a patient-centered primary care model, and robust IT support and reporting.

– Clusters of ACOs within selected states would encourage the development of the statewide infrastructure needed by ACOs. States can also support ACOs by mandating Medicaid participation in ACO pilots through a state waiver, implementing IT tools and a health information exchange, and sponsoring patient self-management programs, among other options.

– ACO growth in Vermont and elsewhere must be coordinated with the broader payment and delivery system reforms included in the recently enacted health reform bill. Federal policy support will be critical to enabling a fair test of the ACO model, including Medicare participation in ACO pilots by 2011, federal approval of state waiver requests for Medicaid participation in ACO pilots, and implementation of Medicaid/Medicare advanced primary care model multipayer demonstrations.

-- J. Hester, J. Lewis, and A. McKethan, The Vermont Accountable Care Organization Pilot: A Community Health System to Control Total Medical Costs and Improve Population Health, The Commonwealth Fund, May 2010.

Why IT?

… while the average Medicare beneficiary sees between six and seven different physicians, beneficiaries with five or more chronic conditions see almost 14 different physicians in a year and average 37 physician visits annually. People with five or more chronic conditions fill almost 50 prescriptions in a year.

--Anderson and Horvath, The Growing Burden of Chronic Disease in America,Public Health Reports / May–June 2004 / Volume 119

The Goals

• Continuity of care• Improved decision support• Engage patients at home• Actionable management data

Open Source GAHIE: CONNECT/Direct

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