4.3: TOOLS FOR TRACKING PERFORMANCE AND COSTS
5. Care Coordination and Utilization Management Services
Presently, many physicians outsource their billing and collection functions. Physicians should be encouraged to change their referral patterns to be based on efficiency, appropriateness of care, and quality metrics, and to refer patients to participating ACO providers.
5. Care Coordination and Utilization Management Services
Care coordination is a very important function for an ACO. The greater the effectiveness of care coordination, the more likely an ACO is to meet or exceed its budget savings targets. “On the ground” care coordination will likely be accomplished in the physician office, but assistance may be needed with other work related to registries, post-discharge coordination, disease management reminder calls, and other similar activities. Hospital partners may be able to supply assistance. New health IT software may provide further help. However, some practices may want to combine their efforts with support from vendors. An ACO may want to invest in acquiring the care coordination and utilization management services, which can either be “owned” by the ACO or subcontracted to other vendors. For example, specialty benefit management companies that provide criteria and utilization management services for high cost services, such as advanced imaging, may be one of the services to subcontract to an outside vendor.
Possible Sources of Service
While some fully integrated delivery systems will already have the capabilities to perform the above services, the majority of organizations will need to develop or purchase these capabilities. A critical decision for many organizations will be whether to develop the capability in-house, to outsource, or use a combination of the two.
Many health care organizations believe that they must invent their own tools and solutions internally. However, outsourcing has its benefits. The most notable benefit is that a company whose services and products are its core competency can offer the products and services more cost-effectively and efficiently than by doing them in-house. Learning from others not only allows the organization to take advantage of the best practices and the proven ideas, but it could also help avoid costly mistakes. To determine how it can use data systems to achieve improvements in quality and cost, the ACO must initially focus on understanding its needs, planning for these needs in terms of resources, and then carefully evaluating available options. It may provide a competitive edge for the organization to focus initially on adopting the tools and resources that would enable the organization to show positive outcomes early in the process. Multiple resources and tools are available to assist in the development of the ACO, along with the experience and lessons learned of organizations that have managed the transition successfully.
Below are several possible sources of services that can help enable an ACO to function successfully: Private Payer Services
Private payers will be able to provide a variety of services. If the ACO is in a synergistic contract with a major private payer, it is likely to want to make use of many of the services that the private payer offers.
The services include:
•
Access to the payer data to identify and attribute beneficiaries;•
Possible use of payer contract rates with ACO participating providers;•
Use of payer contract rates with providers “outside” the ACO;•
Claims adjudication;•
Data analysis services performed by the payers’ actuarial or analytical staff;•
Use of certain utilization management services such as the nurse help-line or contracts with Radiology Benefit Managers (RBM); and•
Calculation of bonus amounts according to agreed-upon formulas.For some activities, particularly utilization management and care coordination services, an ACO and its management team may prefer to handle in-house. However, it may be more efficient to obtain other services externally through payers or vendors, where the infrastructure is already in place and can be operated at marginal cost rates, such as a nurse help line.
Centers for Medicare & Medicaid Services CMS obtains many administrative services at relatively low per-unit cost rates, and those services are obviously relevant to ACOs providing care for Medicare beneficiaries. In particular, CMS contracts with MACs to adjudicate claims using Medicare payment rules. If an ACO is going to pay all or some of the claims for Medicare beneficiaries at FFS Medicare rates, it would get the most favorable payment rates by going through these existing arrangements. This assumes that the Medicare- ACO rules would permit access to these services. One option would be for the MACs to adjudicate the ACO claims as they do for the FFS members, and in addition (or through another Medicare data contractor) provide regular, detailed, and timely electronic reports on utilization of services by beneficiaries in the ACO.
At the same time, the ACO should be vigilant in the areas of fraud and abuse and in terms of opportunities to address unnecessary utilization. While CMS and its MACs have taken many steps to control fraud and abuse, there are many instances where problems have been found.
CMS may also be able to provide some basic data services to the ACOs; however, CMS staff is already burdened with many activities. Other than determining shared savings and processing and
reviewing claims payments, the extent of assistance that CMS staff or its contractors will be able to provide is not yet clear.
Services from Large Multi-Specialty Provider Groups, Management Service Organizations (MSOs), or Other Similiar Organizations
Certain integrated delivery systems, such as
Intermountain Healthcare, have long and successful histories as health systems. Large, multi-specialty EXAMPLES OF MSO SERVICE OFFERINGS
Based on the websites of several MSO firms, the following types of services are available in today’s capitated medical group environment. These services are the same as or very similar to those needed by ACOs. They may include:
• Efficient method for claims and encounter submission, processed electronically or manually.
• Authorization workflow that provides timely application, processing, storage and emailing back to medical group providers.
• Web-based electronic medical management systems to connect with electronic medical records or through fax-based data entry.
• Compliance reports that allow providers and medical directors to measure their compliance rates and compare them to those of their peers.
• Provider tools and training to continuously educate providers and their staff.
• Referral management, such as using the website and submitting requests online. Systems allow providers to track the status of requests at any time and minimize unnecessary phone time for provider staff.
• Referral tracking reports available to send to each primary care physician (PCPs) on a monthly basis. This report allows the PCPs to ensure all members will obtain the services that they need. A similar report of members with critical conditions is available for the appropriate specialists to ensure that they make arrangements to see the members quickly.
• Customized financial reports tailored to a medical group’s needs, including profitability by contract or by physician, monthly reporting packages, and monthly analytical reports.
• Risk pool reports that can be designed to monitor and analyze pool performance, and pro forma forecasting tools to assist the medical group as needed (e.g., to monitor ACO budgets).
• Member education programs and special classes for members. • Patient handbooks and newsletters.
• Contract Management, including:
- Health plan contracting and negotiations - IPA/Physician contracting and negotiations - Hospital contracting and negotiations
• Credentialing functions for every contracted IPA provider, including hospital-based physicians.
• Developing and maintaining comprehensive Quality Improvement Programs that continually evaluate, monitor, and identify areas to improve the quality of clinical care provided to members and the provider panel.
groups, such as Geisinger in Pennsylvania and Hill Physicians in California, have also successfully met their own service needs over the last 20 years. It is possible that negotiating for services with these provider organizations – or related organizations such as MSOs and actuarial consulting firms – may be beneficial, as these organizations already perform services that are closely tailored to the needs of ACOs. For example, some of these groups have been paying claims and calculating bonuses that are shared among provider partners. Many have experience in the quality measurement metrics, such as the California provider groups that received incentive payments under the Pay for Performance program led by the Integrated Healthcare Association.
Another service that may be contracted is management consulting support to help with the set-up and ongoing management of complex provider organizations. ACOs may be able to draw on the lessons learned by already successful groups, rather than re-inventing the wheel.
Other Third Party Vendors
There are independent vendors, unrelated to private payers that are able to provide some of these services. Various kinds of utilization management services are readily available, such as services that provide hospitalists for hospital management, nurse hotlines, RBMs, and other similar therapy-specific managers.
In addition to clinical management services and claims adjudication, there are many actuarial/ financial consulting firms and a few data analysis
firms available to provide the necessary services. Some of the data analysis firms on the West Coast have provided analytical services to large multi- specialty groups and PHOs for over a decade. While ACOs are different from the capitated provider groups, there are many similarities between the two groups, so vendors could transition to the ACO services quickly.
Possible Timeline for Setting Up ACO Services Organizations interested in forming an ACO need to build in sufficient time to put in place the necessary support infrastructure and processes. Each organization will require different lead time, depending on its own circumstances. Exhibit 4.2 provides a sample timeline for setting up the ACO services. One way for an ACO to set up its operations quickly is to initially rely on leased services provided by existing MSOs or other similar organizations with a proven track record.
This timeline assumes: