Home Forums Discussions General Discussion ACOs Accountable Care Organization

Hi all,

The new buzz word around here is ACO, (Accountable Care Organization). I am just the IT person here at the practice, but the owner/provider has heard about this ACO and is invited to a Talk (propaganda meeting) this Friday and told he HAS to choose one of the 4 SUPPORTED EHRs, of course AC NOT being included. The big name, expensive ones are there. I told him NOT to sign up for ANYTHING until he talks to me (he DOES respect my opinion).

Any words of wisdom I can pass along to him to sway away from this change?

Thanks,
Brian

He can ask what does the ACO 'need' from an EHR? Is it certain reports that are necessary for the ACO to obtain from an EHR? Since any conversion from one EHR to another is both costly and time consuming it would be in the ACO's and your practices interest to first determine if the information can be obtained from current EHR before committing to such a costly change that will impact money, time and moral.
Run Forest Run!
Glad ACO isn't on the radar here.

I imagine that "certain reports" uploaded with the billing claim are going to be necessary for certified EHRs in the coming years.

Once we get past ICD-10, and Medicare decides what data is necessary with each diagnosis code, we are in the future. At that point, imho, EHRs will have to be extremely granular, digital, and database oriented, good for those who like standardized, diagnosis dependent templates. We will be paid for translating our patients into an array of zeros and ones.

Our problem is that this is not what AC is designed for. Instead of a box called History of Present Illness that we fill by whatever method we wish, we will choose a symptom and then keep answering questions until the EHR doesn't have another question. Then choose the next symptom.

I have a patient in a research program at UCLA where every participant has been loaned an ipad and they are becoming joined at the hip with a database every day. The programmers are just trying to separate the wheat from the chaff for her diagnosis.

I hope AC can survive the changes ahead.

Suppose that is the goal, EHR not as a 'record' but instead as a decision making tool either allowing or denying a test/treatment. Hope the programmers used 'Best Practice' models we all can believe/capitulate to.
The Future...."Next patient, please enter the exam module,apply the sensors as depicted in the illustration, now please enter your complaint on the screen then answer the following questions."

Brian
I had faced a similar situation at our institution about a year ago and was succcessfully able to have AC grandfathered in .
Enlist some allies. My guess is that they are others in your area who use the system and are in the same boat and do not want to change to a more cumbersome more expensive system. If the decision makers hear from more than one group it becomes much more difficult to imposr their will. Wendell who posts here frequently was probably the most helpful
Be vocal in asking questions about the decision process and why AC was not included. This was actually quites fun for me as I was able to tell them that AC is CCHIT certified , ranked number one by most all of the independent rankings Medscape.KLAS AAFP ACP etc. . I was able as a solo practioner without any assistance or expense attest to Medicare MU without anyones help faster than the people in their chosen system. I also was able to meet the Aco quality requirements as well and susbsequently did quite well financially as a result.
I think the point to hammer home would be that they are excluding a system that works just as well if not better and that it would cost them more in the long run.
Hope this helps Go get em
Jeff Gindorf MD

Been to one of the those dog and pony shows on behalf of a practice, and the guy leading it was a surgeon who did the lap bands; his perspective was PCPs and FPs were a form of a land-rush, every ACO wanted them to help their numbers and drive their revenue.

My rejoinder was the practice had years of patient data on a population of over 6000, and we could provide data in what ever flavor it needed to be, but the practice was not interested in the hospital EMR. There were other practices that were not as 'clear' in their communication, but once I started some discussion to disrail the bums-rush, effect,there was more push to define the value of the arrangement to the FPs and PCPs practices, that is the question that really matters.

As a business mentor you used to say, figure the business arrangement, then logistics flow out of that. From an integration point of view *anything* is possible it just depends on how much time and money you have. There are ways to get any data out of AC, there is no legitimate reason to require the practice change EMRs. Make it worth the practice, and part of that is covering the cost of getting that data out, and the practice [and ACO] shouldn't have to bear the cost of a heavy bureaucracy or a bloated monster EMR.

ACO's have a lot of requirements in terms of data submission to meet guidelines.

The discussion above is fascinating since all of the views above are true. One day EMRs will be more granular and AC may be in some trouble, but that is a long way off and technology may develop to pull the granularity out of text.

AC should be able to provide what they need. More than likely they are not getting raw data from multiple EMRs because each would have to have customized data templates. More likely they have to have reports set up a certain way and those EMRs have been shown to do it in the fashion they want (or at least that was what was promised.)

People always underestimate AC because it is more like "the Little Engine that could."

But take a step back. Start with simple economic model.
ADVANTAGES
What is the financial incentive to join the ACO? Ideally, make this per patient.
The way the ACO's are set up makes them voluntary. What are the advantages for patients to join the ACO. What makes it THAT much better than regular Medicare (MCR). The advertising that has been sent to seniors emphasizes their need to share data and that scares seniors.

How many patients are currently in the practice with MCR and what percentage are likely to change. This is a very difficult analysis given the above paragraph, but, for the sake of argument assume 20%.
DI
DISADVANTAGES
How much does MegaBucksEMR cost IN TOTAL (program, set up, hardware, training and LOST PRODUCTIVITY.)
Will it change your billing system and what are the associated costs with this?
Are there other factors in the ACO that would also cost money? These might include meeting time (lost productivity,) entry fees, employee time for training to the new rules

ADVANTAGES - DISADVANTAGES = PROFIT
It the profit worth the hassle factor?

I'm sure there are other factors on both sides I have not taken into consideration. But if you assume 1000 MCR patients and the ACO gives an extra $200 per patient (VERRRY generous assumption!!!)

1000 x .2 (percent that may convert to ACO) = 200
200 x $200 per patient is $40,000

Cost of MegaBucksEMR will be put at $50,000 plus $10,000 in hardware and 20% decreased productivity for A YEAR (it will probably start worse and improve, but most providers are not as productive as with AC.) Further assume that the gross revenue in the practice is $500,000.

$50,000 + $10,000 + (.2 X $500,000) = $160,000

While theoretically this would be a 4 year break even point, there are ongoing losses in productivity and probably decreased satisfaction since AC is easier to use and manage. If they were factoring in MU return that would help IFF you were not using an EMR already, but that is a wash, since is has been easier to achieve MU from AC than most EMRs as well.

Finally most EMRs are cloud based, do they want to house their data in the cloud. If they should wish to change EMR's are they willing to move the data (and at what cost.) ARE THEY WILLING TO EXPORT DATA FROM AC TO THE NEW EMR AND ABSORB COST? This would be another disadvantage item.

ACO's require tighter hospitalization guidelines as well as willingness to follow disease guidelines and oversight. Like many things in medicine, nobody wants to actually pay PCPs for their management. Otherwise we would earn the big bucks.

Wendell nails it.

The real bottom line would be a business plan for the ACO, including the all-important projections model in a spreadsheet that identifies capital costs, recurring and non-recurring costs, with input values that allow the potential participants to model different return rates and overhead percentages.

The second part would be how many of the big-$$$ EMRs and the implementers would enter into a implementation contract where *ANY* initial and/or long-term cost overruns come out of their fees.

When the tasks are precisely defined we will do fixed-price contracts, because we are confident of our chosen tools and people. We offered just such an approach to a regional hospital that wanted to use AC at scale, but that was derailed after a big-@$$ EMR company got involved. I suspect someone got 'bought'.

Doctors are increasingly looking for win-win, or they are walking away, which is a good thing. the NYT article is another example.

I'd rather see the PCPs earning those bucks those surgeons making bank on lap-bands. Treat the patient, even incentivize compliance [patient and PCP], not pay for procedures that treat symptoms.

/soap-box

Until a computer can "know" the entire past medical history, make a correct diagnosis and treatment plan, and do it in a way that engenders compliance, we still have a job.

But, Watson, Big Data, ACOs... are already rounding first and heading for second.

If I was young, I think it would be exciting to come up with the algorithms that will guide better healthcare.

The trick to saving money on healthcare is getting earlier correct diagnoses and ensuring compliance with effective treatment plans. Most patients could interact with an app that knows what questions to ask based on the last office visit and their risk factors. Imagine getting text messages from Watson. With some patients it would be cost effective to send a nurse of some level to their house every week and to accompany the patient to our office.

If we could have a patient centered system with filtered information from multiple sources that helped us manage diseases at a much higher level of success, it would be fun to practice, until we weren't needed anymore.

As a family doc, I am oft reminded of the old adage, "To cure sometimes, help often, and comfort always." ACO's and other managerial/technological approaches can only help up to a certain point. Medicine is not auto repair. The sick and the dying--as we all will be at some point--need a caring heart, a listening ear, a wise word, a reassuring touch, a glimmer of hope.