The measure of success for an accountable care organization (commonly referred to as an ACO) is the quality of patient care it provides. For an ACO, capturing shared savings is not simply a matter of keeping costs below the benchmarks determined by the Centers for Medicare & Medicaid Services (CMS). The ACO must also meet specific CMS quality performance standards, in addition to controlling its costs. Regardless of the amount of savings, if the quality measurement is not met then the ACO will not receive these savings identified.
What are those standards? How is an ACO's performance assessed against them? How will clinical quality measures change in the future? What role can labs play in improving the quality of care?
Our panel of ACO experts answer these questions and discuss more as we take a deeper look at the critical importance of quality improvement to an ACO's success.
Improving the quality of patient care is an ACO's reason for being. Above all else, ACOs must diligently pursue quality assurance. It is the engine that drives performance and determines profits. ACOs must consciously take a quality-first approach when examining their care delivery processes and clinical guidelines.
Quality is also a key imperative in the Institute for Healthcare Improvement's (IHI) Triple Aim Framework, which recommends the development of systems like ACOs to address three key dimensions of healthcare:
Note that two of the three dimensions listed pertain to quality improvement, not cost. This reinforces just how vital quality measures are to an ACO. While reducing healthcare costs is beneficial, it is not everything. For an ACO to truly succeed, it must deliver high-quality care across the board, first and foremost. If it fails to do so, the ACO will pay the price later down the line.
Under its Medicare Shared Savings Program (MSSP), CMS evaluates ACO performance across 34 quality measures categorized under four different domains. Click each of the following domain boxes to learn more about measuring healthcare quality.
See references at the end of this article for full list of quality measures.
CMS establishes its quality measurement system based on three years of Medicare fee-for-service data. This includes data reported through the Physician Quality Reporting System (PQRS), MSSP, Pioneer Model ACOs, and other data sources.1
ACOs are required to report their quality data “completely and accurately” for the reporting year. CMS then evaluates the ACO's performance based on the data collected and assigns points to the ACO on a sliding scale for each of the different measures.1
According to Les Duncan, the quality measures CMS provides may not always be the most current or up-to-date. Fortunately, ACOs have the ability to communicate any concerns about outdated measures to CMS, though their performance metrics will still be evaluated against published target metrics for the reporting year.
Achieving CMS quality measures requires an ACO to implement strategies that elevate and improve care in key healthcare processes. By focusing on health systems, an ACO can determine the best quality initiatives to implement, ultimately improving patient experiences and outcomes.
Finding the correct strategy for an ACO to implement is a case-by-case situation. The nature of the strategies recommended will depend a lot on the structure of the ACO itself and the demographics of the population it serves. A vertically integrated ACO with a largely healthy and active patient base, for example, will initiate quality measures that are much different than one made up of individual physicians who serve a more sedentary population.
A good place to start is with an analysis of at-risk patients. ACOs can run the electronic health record claims data they receive from CMS through an analytical engine. The results will identify patient segments with critical illnesses such as chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and diabetes. Once identified, the ACO might develop targeted patient-centered programs designed to improve care quality by meeting quality benchmarks in a greater percentage of these patients. This is just one strategy ACOs can take to avoid patient complaints and improve quality measures.
An ACO should also analyze individual patient electronic health records to spot troubling trends and correct them. For example, an ACO might have two physicians from the same geographical area treating patients with diabetes. One physician's diabetes-related costs may be well under control while the other doctor's are sky high. The ACO should look critically at its process measures to find out why they have such high costs. What is it that the cost-effective doctor is doing that the other is not? How are they treating their patients differently? Is there a difference in their healthcare processes?
Once these questions have been answered, the ACO can develop evidence-based protocols for diabetes care. If both physicians follow the same protocols, chances are the second doctor will begin to control costs better as the quality of care sees improvement.
Another method identified to improve physician performance protocols is making achieving quality measures a part of their incentive programs. This helps assign a score to a physician's performance when trying to place an emphasis on the importance of quality measures in ACOs. The physician can play a key role when trying to quantify healthcare processes.
Claims data are powerful. When used properly, they can help ACOs direct patients to the best possible care for the best possible patient outcomes ensuring patient satisfaction.
By analyzing claims data, an ACO knows which hospitals in their area are the most expensive and which ones have the best patient outcomes. Claims data helps develop measures for an ACO to better organize different hospitals in a specific area and assess the quality of the hospitals' offerings.
With this information, physicians can send patients to the most cost-effective hospitals with a proven record of positive health outcomes. So a patient with a hip fracture, for example, would have a greater chance of getting surgery that gets her back on her feet sooner and keeps her out of the hospital longer. Claims data can be used by ACOs to help with their risk management processes.
Today's quality measures for ACOs are considered to be very process-oriented. They're designed to assess how well an ACO cares for patients through the processes and procedures it puts in place. While focusing on the process measures an ACO has in place is a good thing, there is a need for more outcome-based measurements.
Our lab leaders see a trend emerging toward more outcome-based measures. Focusing on outcome measures could potentially improve the health of ACO patient populations. However, it also presents some data collection challenges for ACOs that will need to be skillfully addressed.
If a patient had a heart attack, they would follow this patient over time to see what health services they received and the outcomes of the action taken. For example, our patient who had a heart attack would have heart surgery. After the surgery, the ACO would continue to follow the patient to see if there were any surgical complications or heart failure. This is just one example of taking a more outcome-focused approach to quality measures for ACOs.
I do a lot of expert witnessing and the number one call I get is patient harm due to failure to retrieve a test. And the top three reasons for litigation related to patient harm in the lab services industry is ordering the wrong test. If you ask lab people they say, oh, it's probably mislabeling or an analytical problem. But it's not. It's ordering the wrong test, failing to retrieve it, and misinterpreting it and they're related and it's worse for all send-out testing because send-out tests go away and they all come back—they all take any—you know, a few days, at least a day, sometimes eight weeks in the case of genetic tests. So it's a big, big issue. And I think labs—laboratorians can do a big value for ACOs for their health systems by participating in the various patient safety committees that are trying to address the problems related to the logistics of care and retrieval and I think we should be in there.
Division Chief of Laboratory Medicine, Clinical Professor of Laboratory Medicine
Seattle Children's Hospital
Because ACOs are in a nascent state, the role labs play in quality improvement is just beginning to be defined. Our lab leaders identify several important areas where labs might improve processes and outcomes to ultimately improve healthcare quality. These include:
Predictive diagnostics – developing lab tests to predict which patients are most at risk for high-cost conditions, allowing for more vigilant care quality
Test utilization management – developing test-ordering algorithms for healthcare providers that mitigate the risk of over or under-ordering tests
Efficient delivery of lab results – including at the point of care, to facilitate timely and meaningful follow-up discussions to improve structural measures
Test retrieval – taking steps to help ensure healthcare providers retrieve test results and communicate those results back to their patients
Laboratorians can create enormous value in the pre-analytic and post-analytic phases, areas where there is arguably less focus today than there should be. It is critical for laboratorians to be diligent in the pre and post-analytical phases as their work done in these steps will directly impact the outcome-based measurements. By lending their expertise in finding new and different solutions related to patient care logistics, laboratorians can help performance improvement at ACOs.