2. CONTENT
Pillars for Accountable Care
Patient attribution
PCMH versus ACOs
Five modes of Accountable
Care
Core competencies
Six core structural
components of successful
ACO deployment
Pioneer ACO burn and learn
lessons
Barriers & root cause analysis
Early value-based adopters
Value discovery assessment
Modified Triple Aim
GPRO
Breakdown by 33 Measures

3. PILLARS OF ACCOUNTABLE CARE
Provider-led
Providers and payers co-own responsibility for the cost and quality of care provided to a
defined population; shifts both rewards and risks to aligned, integrated care systems
Population attribution to ACOs, with opt-outs and choice
Health engagement/wellness initiatives that are tailored to the individual
Diverse group of providers, including hospitals, specialists, primary care, and post-acute
care, that can coordinate across settings
Robust health information technology infrastructure and performance measurement
capacity
Providers and payers share population-based data on a timely basis
Long-term partnerships with a range of payment options

4. DIFFERENTIATING PCMH FROM AN ACO
PAT IENT C ENTER ED
MEDICAL HOME
AC C OUNTABLE C A R E
O RG A N IZ AT IO N
Created in 2007 to better
access, care
coordination to build
strong relationship
between the PCP and
patient.
Payers provide a per
member per month
bonus for PCP
services
Strong PCP core also,
but comprised of
many medical
homes.
ACOs are accountable
for cost/quality
within and outside
the PCP relationship

5. ACO CORE COMPETENCIES

6. SIX CORE STRUCTURAL COMPONENTS OF SUCCESSFUL ACO DEPLOYMENT
A commitment to providing care that puts people at the center of all clinical decision-making
A health home that provides primary and preventive care
Population health and data management capabilities
A provider network that delivers top outcomes at a reduced cost
An established ACO governance structure
Payer partnership arrangements

7. PIONEER ACO BURN AND LEARN LESSONS
Mortality rate was high. One-third dropped.
Of that one-third, seven re-organized and entered the MSSP.
One of the key challenges for hospitals and physicians is that the incentives are to
reduce hospital stays, emergency room visits and expensive specialist and testing
services — all the ways that hospitals and physicians make money in the current feefor-service system.
All 32 Pioneers succeeded in improving quality and performed better than fee-for-service
Medicare in 15 quality measures

8. CURRENT BARRIERS & ROOT CAUSE ANALYSIS
Multispecialty group formation, umbrella alignment is difficult with income dispersion
Size of the patient population, with a 5,000 as minimum ante to play
Cultural: human centered, physician-led, continuous improvement, flexibility
Resources, PCPs drive-but specialists operate the pedals
Staffing, PCP shortage
Lack of measure continuity, different payouts with different models at once
Market-based, disease specificity and prevalence will never allow for a one size fits all
Legal: anti-trust, anti-kickback, and self-referral Stark Law

9. PATIENT ATTRIBUTION IN ACOS
Patient-based vs. Episode Based
Patient-based holds the provider accountable for the entire spectrum
Episode assigns provider (s) from symptoms onset to completed treatment
Single attribution vs. Multiple attribution
SA assigns to provider with highest percentage of patient’s cost, minimum
threshold 25-35%, while MA is assigned when threshold is not met typically
Prospective (historical claims) vs. Retrospective (actual utilization)
Blend

10. RISK STRATIFICATION IN POPULATION HEALTH MANAGEMENT
Wellness scores answers the question of who are my ACO patients that could
benefit clinically and financially from an engagement campaign. Over 100
variables affect this score, but here are a few examples:
Patient's health risks as identified by a health risk appraisal form or other
questionnaire
Clinical diagnoses
Utilization data from insurer or other source (lab, pharma, PACS, claims,
mHealth or remote monitoring)
Clinician’s personal knowledge related to a patient’s social, financial,
mental, or physical condition

11. FIVE MODES OF ACCOUNTABLE CARE

12. ACO READINESS ASSESSMENT
Questions designed for your initiative and readiness around:
Organizational structure and commitment
Proposed network
Value-based experience
Open component technologies
Quality and care management
Retention strategy and growth plan

13. DATA SHARING
Q UA R T E R LY AG G R E G AT E
REPORTS
MONTHLY CLAIMS DATA
 Will be based on previous 12
months of data and include:
 Can request a standardized
dataset:
• Financial performance
• Quality performance scores
• Aggregated metrics on the
assigned beneficiary
population
• Utilization by Subpopulation
•
•
•
•
•
Procedure codes
Diagnosis codes
Dates of service
Provider/supplier ID
Part D data

14. ACTIVATING ACCOUNTABLE PATIENTS
Patients need to share in their own accountability, and some tips reside here. Much can be
achieved through a comprehensive Patient Portal with these ACO quality metrics satisfied:
CAHPS: Getting Timely Care, Appointments, and information
CAHPS: How Well Your Doctors Communicate
CAHPS: Patients’ Rating of Doctor
CAHPS: Access to Specialists
CAHPS: Health Promotion and Education
CAHPS: Shared Decision Making
CAHPS: Health Status/Functional Status

15. ACO MEASURES: CARE COORDINATION/ PATIENT SAFETY
Measure
Care Coordination/ Patient
Safety
Physician Description & Objectives
8
All Condition Readmission
Avoid readmissions by seeing your patients within 7 days following
inpatient discharge
9, 10
COPD, Asthma & CHF
Avoid unnecessary admission of COPD, Asthma and CHF patients by
seeing them on a monthly basis
11
EMR Incentive Program
Payment in 2014
Attest for Meaningful Use in 2014 (either Medicaid or Medicare)
12
Medication Reconciliation
Physician must perform med rec and document that he/she is aware of
inpatient facility discharge meds and will either keep or change meds
13
Screening for Fall Risk
Screen patient for falls risk in office

16. ACO MEASURES: PREVENTIVE HEALTH
Measure
Physician Description & Objectives
14
Care Coordination/ Patient
Safety
Influenza Immunization
15
Pneumococcal Vaccination
Provide or document that patient received pneu vac
16
Adult Weight Screening
AND Follow-up
Calculate BMI – If abnormal, document follow-up plan (education, Rx
intervention, diet & exercise, etc.)
17
Tobacco Use Assessment
AND Tobacco Cessation
Intervention
Depression Screening AND
Follow-up
Screen for tobacco use – If user, provide & document cessation counseling
(includes counseling & pharmacotherapy
19
Colorectal Cancer Screening
20
Mammography Screening
FOBT – last 12 months, Flex Sig – Last 4 years and Colonoscopy – last 9
years
Mammogram performed within the last 24 months
21
Pressure Measurement AND
Recommended Follow-Up
Plan is Documented
Screen for high blood pressure – If patient has BP greater than 120/80,
rescreen and provide lifestyle modifications (i.e. NA intake, diet and
exercise, etc.)
18
Provide or document that patient received infu imm
Screen for Depression – If patient is depressed, document and provide
follow-up (additional evaluation, Rx intervention, suicide risk assessment)

17. ACO MEASURES: AT RISK POPULATION
Measure
At Risk Population
Physician Description & Objectives
22
Hemoglobin A1c Control
(<8 percent)
Control DM patient’s HbA1c - below 8%. Follow ACO’s HbA1c goal
attainment protocols
23
Low Density Lipoprotein
(<100)
Control DM patient’s LDL - below 100. Follow ACO’s LDL goal attainment
protocols
24
Blood Pressure (<140/90)
Refer to measure 21
25
Tobacco Non Use
Advise patient to quit tobacco use
26
Aspirin Use
27
Hemoglobin A1c Poor
Control
(>9 percent)
Blood Pressure Control
(<140/90)
Complete Lipid Profile AND
LDL
Control (<100 mg/dl)
Provide patients with DM and IVD a daily aspirin or
antiplatelet medication
Control DM patient’s HbA1c with goal of below 8%.
Follow ACO’s HbA1c goal attainment protocols
28
29
Control HTN patient’s BP with goal of <140/90
Document and complete lipid profile AND control LDLC
(<100 mg/dl)

18. ACO MEASURES: AT RISK POPULATION
Measure
At Risk Population
Physician Description & Objectives
30
Use of Aspirin or Another
Antithrombotic
Provide patients with IVD a daily aspirin or
antithrombotic medication
Heart Failure
31
Beta-Blocker Therapy for
LVSD
(EF <40%)
Coronary Artery Disease
Patients with Dx of HF and w/ a LVEF <40% should be
on beta blocker therapy (bisoprolol, carevdilol, or
sustained release metoprolol succinate)
32
Drug Therapy for Lowering
LDLCholesterol
Patients with CAD need documented plan for LDL
control
33
MediACE Inhibitor or ARB
Therapy
for Patient with CAD and
DM
and/or LVSDcation
Reconciliation
ACE Inhibitor or ARB Therapy for Patient with CAD and
DM and/or LVSD (LVSD - patients with EF <40%)

19. GPRO
The majority of measurements require submission through the CMS GPRO web
interface tool, and you will need architecture to map data and populates the
GPRO for reporting of measurements. There are a few recommendations for
vendors I will make, but all accomplish the following:
Prepares and sends the report to the CMS GPRO web interface
Provides a flexible reporting tool
Assembles EMR data with Primary Care Physician data behind the scenes
Displays CMS feedback from the GPRO

20. MODIFIED TRIPLE AIM
Satisfaction of the patient
and provider is paramount
with ACO final rule
Care Experience
Patient/Provider
Satisfaction
Per capita cost
Population
Health

21. For a free copy of this deck, ROI
spreadsheet, or the Discovery
Assessment, please contact:
CJ Fulton
618-579-9192
healthideation@gmail.com