The measure of success for an accountable care organization (ACO) is the quality of patient care it provides. For an ACO, capturing shared savings is not simply a matter of keeping costs below benchmarks determined by the Centers for Medicare & Medicaid Services (CMS). The ACO must also meet specific CMS quality performance standards, in addition to controlling costs.
What are those standards? How is an ACO’s performance assessed against them? How will the standards change in the future? What role can labs play in improving the quality of care?
Our panel of ACO experts answer these questions and more as we take a deeper look at the critical importance of quality to ACO success.
Improving the quality of patient care is an ACO’s reason for being. Above all else, ACOs must diligently pursue quality. It is the engine that drives performance and determines profits.
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 health care:
Note that two of the three dimensions pertain to quality, not cost. For an ACO to succeed it must deliver high quality care across the board, first and foremost. If it fails to do so, it will pay a price.
Under its Medicare Shared Savings Program (MSSP), CMS evaluates ACO performance across 34 quality measures categorized under four domains. Click each of the following domain boxes to learn more.
See references at the end of this article for full list of quality measures.
CMS establishes its quality benchmarks 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 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 those data and assigns points to the ACO on a sliding scale for each of the measures.1
According to Les Duncan, the quality measures CMS provides may not always be the most current. Fortunately, ACOs have the ability to communicate concerns about outdated measures to CMS, though their performance will still be evaluated against published target metrics for the reporting year.
Achieving CMS quality measures requires an ACO to implement strategies that elevate care in key areas. The nature of those strategies 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 claims data they receive from CMS through an analytical engine. The results will identify patient segments with critical illnesses such as COPD, congestive heart failure (CHF) and diabetes. Once identified, the ACO might develop targeted programs designed to improve care by meeting quality benchmarks in a greater percentage of these patients.
An ACO should also analyze individual patient 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 find out why. What is the cost-effective doctor doing that the other is not? How are they treating their patients differently?
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 improves.
Claims data are powerful. Used properly, they can help ACOs direct patients to the best possible care for the best possible outcomes.
By analyzing claims data, an ACO knows which hospitals in their area are the most expensive and which ones have the best outcomes. With this information, physicians can send patients to the most cost-effective hospitals with a proven record of positive 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.
Today’s quality measures for ACOs are very process-oriented. They’re designed to assess how well an ACO cares for patients through the processes and procedures it puts in place.
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 reporting challenges for ACOs that will need to be skillfully addressed.
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 improving quality is just beginning to be defined. Our lab leaders identify several important areas where labs might improve processes and outcomes. These include:
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. By lending their expertise in finding solutions related to care logistics, laboratorians can help improve ACO quality.