Accountable Care Trends, Strategies
and Best Practices
Merging Health IT with Payers, Patient Engagement and Liquid Data
WHITE PAPER
Justin T. Barnes
September 2012
Accountable Care Trends, Strategies and Best Practices • WHITE PAPER
© 2012-2014 Greenway Medical Technologies, Inc. All rights reserved.
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Contents
Introduction ......................................................................................................................... 3
Adapting to New Delivery Trends........................................................................................ 4
The Value of Medicaid ACOs ............................................................................................... 5
Tracking Patient Behavior .................................................................................................... 5
Addressing Scope of Practice .............................................................................................. 6
Employers Seeking an Accountable Future ......................................................................... 7
Health IT Best Practices and User Case Study ..................................................................... 7
The Accountability of EHRs .............................................................................................. 7
Genesis OB/GYN: Focus on Interoperability, Patient Retention ..................................... 8
Putting Your Best Practices to Work ................................................................................... 9
References ......................................................................................................................... 10
About the Author ............................................................................................................... 10
About Greenway ................................................................................................................ 10
Accountable Care Trends, Strategies and Best Practices • WHITE PAPER
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Accountable Care Trends, Strategies
and Best Practices
Introduction
Movement within the nation’s healthcare system has been swift and broad-based since the October
2011 Centers for Medicare & Medicaid Services (CMS) Shared Savings Final Rule.
By the time 32 CMS Pioneer Accountable Care Organizations (ACOs) targeting Medicare patients were
named two months later, private care coordination models for multi-organizational community of care
structures and payment variables were quickly embraced by a system poised for change.
By the end of summer 2012, more than 200 accountable care communities had formed in more than 40
states as privately driven or CMS models.
Trends within this total show that private-sector ACOs began outpacing CMS programs at a four-to-one
ratio beginning in 2012. During the same time period, the number of provider-sponsored ACOs doubled
to more than 70, an evolution expected to continue to trend upward.
Given the unlimited potential for practice-led programs, the best-practice challenges for providers
seeking to join or establish a CMS or private program in conjunction with payers and other caregivers
are technological, financial, legal and simply finding the right seat at the right table.
The reality for healthcare providers is that the time is now to examine models being proposed or
forming that could impact future success. It is essential to engage peers in discussions of their
knowledge and strategies, or attend informational sessions by payer or insurance groups, industry and
community leaders, hospitals or regional CMS offices. (Hospitals remained the largest sponsors of
private ACOs through summer 2012.)
Overall, the original targeting of preventive care and improved outcomes for America’s nearly 50 million
Medicare recipients (a number growing in eligibility by the rate of 10,000 per day) has been recognized
as an equally strategic and sustainable approach to better care for all patients. That momentum was
boosted by widespread interest from insurers, building also upon the success seen with pre-Shared
Savings public and private quality reporting incentive programs.
Combined, the movement has led to emerging best practices aligning the core elements of
comprehensive health information technology, multiple payer options, patient-centric engagement and
retention strategies to assure that patients comply with preventive care plans, and the ability to mine
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existing claims and data that offer caregivers a clear benchmarking pathway to their own clinical best
practices.
Adapting to New Delivery Trends
With the overall success to date, the key question now is how far ACO models and coordinated care can
reach into or influence other facets — and long-standing issues — of healthcare delivery, and how
adaptable delivery can be to new trends in the behavior of today’s consumer-patients.
Several factors already emerging that can affect your future success include:

The study and piloting of state Medicaid ACOs now underway, pertinent in that Medicaid
expansion planned for 2014 via the upheld Affordable Care Act (ACA) could cover up to an
additional 16 million Americans

Movement in certain segments of patients seeking accessible care at retail clinics which has
drastically increased in just a two-year period studied, coinciding with increased EHR
functionality deployed within these clinics

Efforts to resolve or standardize caregiver scope of practice that continue to impact state courts,
legislatures and medical associations, and issue related to decreasing trends in primary care
physicians and with a residual effect on growing retail healthcare

The growing interest of employers — many self-insured — who are examining internal
accountable care creation for their employee health plans

Considerations of coordinated care formation resulting from a 2009 ruling1 by the Federal Trade
Commission (FTC) allowing physician-hospital organizations to clinically integrate and negotiate
fee;

How the advent of health insurance exchanges proposed to begin in 2014 could also play a role
in care coordination based on portability factors

Enhanced revenue cycle management services that can assist providers in navigating emerging
payment models as well as coding initiatives
That care coordination and accountable care can stem the growth in healthcare costs — which CMS
estimates2 rising from 2010’s $2.6 trillion to $4.6 trillion in 2020 if left unchecked (per capita $8,000 to
nearly $14,000) — is being recognized as vital to America’s economic and quality of life future.
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In light of this foreboding forecast, a further examination of several of the above dynamics is warranted,
followed by the detailing of healthcare information technology best practices and an interview with a
physician practice working within a care coordination model.
The Value of Medicaid ACOs
Given the large purchasing power of state Medicaid agencies, and the noted plans for coverage
expansion, a logical and timely pursuit of Medicaid ACOs is underway.
Detailed in a policy brief3 by the non-profit Center for Health Care Strategies (CHCS), pilot programs are
underway in Oregon, Utah, New Jersey, Colorado and Minnesota utilizing a mix of provider-led and
MCO/provider hybrid models.
Variable payment models are also being examined in anticipation of multi-payer interest, such as
incentives to the ACO and primary care physicians within one entity, global payments, or shared savings
with upside risk only, or upside and downside risk.
As a coordinated care emphasis on low-income patients often with complex conditions due to sporadic
primary care — which itself leads to cycling in and out of hospitals — advancements in Medicaid ACOs
can have a large and positive impact on healthcare costs.
Taken a step further, it is not beyond reason to examine the delivery of integrated services for Medicare
and Medicaid enrollees within an ACO structure.
Tracking Patient Behavior
Many of the nation’s uninsured and elderly are increasingly taking advantage of the growth and
accessibility of retail health clinics, and the clinics in turn are increasingly ramping up the use of EHR
technology.
The number of Americans visiting for vaccinations, treatment for respiratory and ENT infections and for
preventive measures, for example, quadrupled — from nearly 1.5 to 6 million people — between 2007
and 2009, according to an Aug. 15, 2012 Rand Corp. study. It is notable the study found that nearly 33
percent of these patients lack health insurance, causing them to seek lower cost care (30 to 40 percent
lower than primary care and 80 percent lower than ED on average) often paid for by cash.
This trend has no doubt grown since 2009, in part because retail clinics in the nation’s drug stores are
promoting increased services in these locations. And as they increase EHR technology toward data
capture and data exchange, there is a real opportunity to bring these entities and their patients possibly
living outside of other healthcare safety nets into coordinated care communities.
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The issue of insurance coverage will be impacted by the ACA coverage mandate and the future of health
insurance exchanges. This could bring positive and challenging results, even combining to fuel an
increase in patient volumes at traditional primary care practices, adding stress to an already strained
delivery system in terms of the documented decline in the number of primary care physicians.
Or if long wait times at the doctor’s office drives patient to or back to retail clinics, a crossover dynamic
needs to be addressed.
Retail clinics are typically staffed by nurse practitioners, along with pharmacy techs or a PharmD nearby.
While placing primary care physicians in retail clinics will prove challenging, scope-of-practice
considerations — specifically for nurse practitioners — is another consideration to advance care
coordination within and beyond these settings.
Addressing Scope of Practice
Scope of practice expansion has been a long-standing and widespread issue, often involving areas such
as podiatry, optometry and anesthesiology, which have served to fuel debate about just how far the
scope can or should go.
But as detailed in a recent Institute of Medicine report4, a dedicated focus on nursing scope of practice
by state and federal officials could break much of the logjam, as the study notes that state legislatures
have been increasingly receptive to expanding nursing scope of practice to alleviate the pressures of
sufficient primary care.
ACOs and patient-centered medical homes (PCMHs), for example, are designed around primary care
cores, leading to the conclusion that these advancements being universally embraced would benefit
from national standardization around nursing scope of practice gains.
The IoM continues to call for the growth and recognition of advance practice registered nurses (APRNs),
for example, to help alleviate future shortages. These APRNs would encompass certified nurse
practitioners, clinical nurse specialists and certified nurse-midwives as eligible for more education and
autonomy.
It is an issue with many voices, evidenced by the more than 350 scope-of-practice bills submitted in 48
states since January 2011, according to the National Conference of State Legislatures.
The American Medical Association (AMA) has continued to promote model legislation to state
lawmakers to establish scope of practice review panels as well.
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This is an issue that must remain in the forefront toward resolution if care coordination, ACO models
and communities of care are to touch every American life.
Employers Seeking an Accountable Future
According to a survey5 published following the Shared Savings Notice of Proposed-Rulemaking (NPRM)
preceding the Final Rule, employers are gaining interest in accountable care.
If companies opt into an ACO plan, the obvious result is the ability to be a driver of where employees are
eligible to seek care, which would impact the patient load of your practice and considerations of the
future benefit of practicing within an accountable care community.
The survey included 674 respondents providing healthcare coverage to more than five million
employees and dependents. It found that 77 percent are likely to remain in employee healthcare
management when external health insurance exchange (HIE) options become available in 2014 as
planned. Sixty-five percent therefore expressed interest in the use of an ACO for providing healthcare
benefits.
When factoring the importance of accountable care goals, more than 80 percent listed quality of care
and the ability to manage costs as top ACO factors. Those surveyed were largely evenly split on who
should share in the cost of an ACO among health plans (21 percent), hospitals (22 percent), medical
groups (23 percent), employees (15 percent) and employers (18 percent). That result speaks to the
necessity for multiple payers or flexibility within the ACO structure.
Employers may also seek their own flexibility in a coordinated care community structure by seeking to
create their own ACO or pursuing a corporate on-site clinic. Another option would be direct contracting
with a provider group within an existing or forming ACO, or accessing an ACO through a private health
insurer.
Health IT Best Practices and User Case Study
The Accountability of EHRs
At the heart of care coordination technology is an integrated electronic health record (EHR) providing
clinical, financial and administrative functions. The EHR must be able to exchange data among care
providers, payers and patients, and be capable of interoperability with private and/or public HIE
infrastructures. While storing digital patient data and care plans, the HIE must also be able to adhere to
quality reporting criteria such as those within the EHR meaningful use initiative.
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Core functionalities such as evidence-based clinical alerts and clinical decision support within the EHR
must be aligned with patient data elements such as allergies, lab results, imaging tests such as MRI and
ultrasound, therapies and medication history, and even family history to complete the care plan picture.
Integrated analytics solutions are equally important to understand predictive care, and subsequent cost
modeling in conjunction with risk assessments of medication or surgical care, further enhanced by
access to comparative research. Integrated revenue cycle management elements include the ability to
compile and submit claims along multiple payment structures, complete with the real-time coding
efficiencies.
Patient-centric technologies that focus on beneficiary care plan adherence and understanding range
from online portals and personal health records accessible to patients and providers, telehealth
capabilities and the emergence of remote monitoring, all again integrated into the longitudinal EHR.
The importance of accessible, sharable and pertinent data cannot be overstated. Kaiser Permanente, for
example, houses a Total Joint Replacement Registry of more than 100,000 cases offered for clinician
review via standardized formats within an EHR infrastructure. Such data must continue to be unearthed
and put into the public realm.
Genesis OB/GYN: Focus on Interoperability, Patient Retention
For Becky Little, director of operations at Genesis OB/GYN, Tucson, AZ, using EHR technology to manage
patient enrollment and identification is a key component of her practice’s membership in the Health
Information Network of Arizona (HINAz).
HINAz is representative of many of the care coordination programs that have formed. A mix of hospitals,
group practices, labs and even academic institutions (The University of Arizona Health Network), HINAz
includes 15 health plans within its network such as Aetna, United, Phoenix, CIGNA and Humana, and is
administered by a board of directors.
Combined, HINAz represents more than 340 healthcare facilities, 15,000 hospital beds, 3.3 million
patient days, 721,000 admissions and 2.5 million ED, urgent care and trauma center visits, according to
its internal research.
Through the EHR capabilities of Genesis’ own 40 providers in 11 locations, “We can get data out to the
network in a mapable fashion and generate summaries and facesheet documents,” Little explained.
“Providing data to not only manage patients but identify who they are is a huge component of
coordinating care.
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“We are developing a flagging functionality with our EHR provider to bridge those patients within the
reach of our care community into the HIE data share, for example,” she continued. “Many women who
see us don’t go to their primary care doctors, and to manage the provisions for patients who can opt in
or opt out of a given ACO means fashioning technology for that tracking, and how you get that
information to an ER when patients come in.
“I believe you must have multiple payers involved for an ACO to work, and we know that self-funded
employers are also talking to their management structures about joining these initiatives,” she added.
Little is confident the model will prove successful, but to be so, she circles her emphasis back to the
patient.
“We talk about patient retention every day in terms of identifying them within the system, keeping
them in the system, and keeping them compliant with care plans. How do you bring them in and then
prevent them from leaking out into the community?”
To that end, Little is pursuing strategies already underway at Genesis, and new ideas going forward, all
around the concept of incentivizing the patient.
“We have a huge emphasis in our model of nurse case managers being in the field, and for the network
we are up-staffing on that side. Genesis already provides incentives to some of our patients through gift
cards they receive for ongoing compliance. In an ACO we also believe patient incentives through co-pay
options could work, and we plan to propose that idea to the payers.”
Putting Your Best Practices to Work
It is clear from the assembled information that a new healthcare community paradigm based on
evidence-based, preventive medicine within a coordinated provider structure that includes elements of
new payment and care delivery models are gaining widespread acceptance. The historic existence of
public and private “P4P” quality reporting programs have shown that incentive-driven programs can
work. Meaningful use has too. At the same time, health information technology has advanced and
innovated to the point where there is confidence it can produce, share and categorize the needed data
to coordinate care.
As accountable care models continue to emerge from multiple resources and options, they are striving
to put best practices to work and to create a smarter, sustainable healthcare system.
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The challenge for every provider and provider organization is to seek out your options and potential role
in your community. Engaging your peers and seeking out informational gatherings that are assuredly
taking place as a starting point toward inclusion into these new models of healthcare delivery and
payment.
References
(1) Federal Trade Commission, Bureau of Competition, Health Care Division: TriState Health
Partners, Inc. Advisory Opinion, April 13, 2009
(2) Centers for Medicare & Medicaid Services (Online)
https://www.cms.gov/NationalHealthExpendData/downloads/proj2010.pdf
(3) Center for Health Care Strategies Policy Brief; Accountable Care Organizations in Medicaid:
Emerging Practices to Guide Program Design; February 2012
(4) Institute of Medicine of the National Academies; The Future of Nursing: Focus on the Scope of
Practice; Jan. 26, 2011
(5) 2011 Employer Driven Accountable Care Organizations Survey Report; Aon Hewitt and Polakoff
Boland, authors.
About the Author
Justin T. Barnes is a Vice President with Greenway Medical Technologies and also serves as Co-Chairman
of the national Accountable Care Community of Practice (ACCoP) and as Chairman Emeritus of the
HIMSS Electronic Health Record Association (EHR Association). Barnes has formally addressed and/or
testified before Congress as well as the last two presidential administrations on more than 15 occasions
between 2005 and 2012, with statements relating to accountable care, ACOs, EHR meaningful use,
health IT innovation, interoperability, health information exchange (HIE), and patient safety and quality.
About Greenway
Greenway Medical Technologies, Inc. delivers smarter solutions for smarter healthcare™. PrimeSUITE® —
Greenway’s certified and fully integrated electronic health record, practice management and
interoperability solution — helps improve care coordination, quality and cost-efficiency as part of a
smarter, sustainable healthcare system. Thousands of providers across more than 30 specialties and
sub-specialties use on-premise or cloud-based Greenway® solutions in healthcare enterprises, physician
practices and ambulatory clinics nationwide. www.greenwaymedical.com.
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