Accountable Assessments for your ACO

Date: 05.15.2013 | Zach Urbina">Zach Urbina

aco tech assessmentsGuest blogger CJ Fulton

No matter what side of the aisle you’re on, all parties agree, the means by which providers are paid and incented needed a disruptive transition. Fee-for-service was a payment system with pernicious incentives.  Quantity trumped quality, and providers’ efficiency was penalized with reduced revenues. And yet the shift to risk sharing arrangements comes with tremendous challenges for even the most sophisticated health systems.

Providers that engaged in risk-adjusted capitation and thrived will champion your ACOs success in payment reform. For the FFS machines that crank through 30+ patients a day, the ACO stakeholders need to create tools to enable the care-team to think like a health plan while achieving the Triple Aim2 (Berwick’s three plus provider-patient-payer satisfaction). As I’ve written here before, technology and many other factors play an important role.

So, if you’re a Medicare ACO, you will need to baseline your patient panel during the rate calculation period.  Make certain to submit the most accurate and specific codes to CMS to represent your patients’ true clinical severity thus creating the most appropriate and exact HCC score.

To clinically and technically address this need, include pervasive deployment tools that capture this data in the form of a comprehensive visit with insurance company guidance. For accountable care, I dub thee an “accountable assessment”.

The assessment’s clinical design will capture missed diagnosis, dropped diagnosis, establish a risk profile for new patients, and allow for accurate resource planning as a result of personalized care plan recommendations.

The technical design must be pervasive, open component and designed for data capture. This live data will provide the most real-time data that your patient can offer and should be a part of the lifetime health record along with claims, pharma, labs, and any other data you can pull into your care architecture. This data will prove valuable for analytics and aid in the automating workflows of proactive care management.

Should you be at the starting line of the ACO race:

  • Run some quick analytics around persistent chronic conditions & interfered disease states. Generate a list of those patients who may not be specifically coded or comprehensively evaluated to-date.
  • Create an accountable assessment and completely assess those members that will be assigned to your ACO (think about the 33 quality metrics as a starting point). Submit claims directly to CMS to ensure they have accurate codes to compile the rates for the ACO payments.

And if you’ve already started the ACO race:

  • Get all your members in for their annual physical ASAP and utilize your accountable assessment template. Work with CMS to ensure they have recognized the members’ conditions and calculated premiums accurately.
  • Ensure all your members are completely assessed by their PCP each year because CMS can adjust your HCC score down.

In my opinion these tools need to be tablet-based intuitive, and available online and offline that can be synchronized because these assessments should be designed to be completed at the provider office or the patient home-web access is not always available.

In addition to vendor tools, work with your internal IT resources to help you develop your own, by translating regulations into business rules and rules into code.  Whichever route you go, be sure that that your care-team are the facilitators of the accountable assessments when possible, it’s the greatest opportunity to establish a meaningful patient-ACO relationship.

Lastly, as a seven time marathon finisher: Boston Strong!

CJ Fulton is the Director of ACO and Government Consulting for ZeOmega.  He brings over 17 years of diversified international experience in HIT, population health design, and innovating new health care models for payers, providers and value-based care organizations. More information about Accountable Assessment Configuration Engines (ACE) available here.

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