On Tuesday, the comment period closed on the 2015 Physician Fee Schedule Proposed Rule and includes many proposals that will affect ACOs and value based purchasing.
Aledade is a company founded on the belief that the future of health care delivery lies in value-based models, not the fee-for-service system that currently dominates the U.S. market. To understand value, you must be able to measure quality as well as cost. While “pay for performance” and value modifiers are initial steps in the right direction, the most transformative effort to fundamentally change health care is the Medicare Shared Savings Program (MSSP). Aledade has recently formed two ACOs to participate in the MSSP and the excitement couldn’t be higher.
There are three reasons to hold ACOs accountable for specific quality measures as well as total cost:
• Ensuring health and health care are improving alongside cost savings
• Knowing how the cost savings are achieved
• Protecting against “stinting” or the forgoing of necessary care
To be successful, the shared savings program must improve the quality of delivered care while lowering costs. Savings generated by “stinting” will invite the type of backlash seen against HMOs in the late ‘90s. That is why at Aledade our first principle is “Place the patient’s interests above all”. Accomplishing “more with less” will require ACOs to achieve mastery of massive amount of data, the ability to navigate and the ability to change rapidly. At Aledade, we believe that health information technology not only enables the collection and use of data, but rapid cycle test and learn processes. It is not enough to generate savings, but we need to know how we generated savings and replicate it across our ACO primary care providers.
But the measurement of quality must be valid, meaningful, and not impose undue burdens of data collection and reporting. We encourage CMS to look beyond just traditional clinical quality measures and at newer measures and electronic submission established through the meaningful use and other program measures for the ACO program as well.
There are three examples where specific quality measurement proposed by CMS fall short.
First, the leap from requiring medication reconciliation at hospital discharge to requiring it at every office visit is too far. The meaningful use measure provides a much more suitable transition going from hospital discharge to every transition of care and is an established measure.
Second, we are deeply concerned with the removal of all measures related to LDL management. Instead of removal, we suggest that a rapid cycle development process be undertaken to include the revised measures in the final rule, or to use measures already under development (e.g., NQF 0455- statin adherence among individuals with diabetes). Absent that, we recommend that the measures be kept, but de-linked from performance due to change in guidelines.
Thirdly, we urged CMS to create and adopt more measures to protect against stinting. While existing measures around preventive services and ambulatory care sensitive admissions offer some indication of care adequacy, this is an area where broader public discussion and creativity is needed. Can patient-reported experience (eg ease of getting needed referrals) be relied upon? Are there indicators of stinting (“trigger measures”) that can be derived- much as readmission measures protect against early discharge (e.g., ambulance dispatch within 7 days of an office visit?)
We are excited about the inclusion of the chronic care management code and its availability to Medicare beneficiaries regardless of what aspect of Medicare they and/or their providers participate in. We want CMS to ensure that this code can be integrated with ongoing chronic care management efforts by allowing the use of previously established individualized care plans. Aledade will use data to identify those beneficiaries who would benefit the most from CCM and continuously improve our processes to deliver the best chronic care management possible. We are currently working on a CCM guide, and we look forward to sharing it soon.
CMS must be able to adapt programs quickly and be transparent not just with their data, but also their methods. Providers must be able to adapt their own systems with a speed unheard of just a few years ago and still very rare today. Complete transparency by CMS makes this rapid adaption possible.
In our comments to CMS, we first suggest that the government should make public the actual contractor specifications and code for establishing attribution of beneficiaries, quality composite, benchmarks for savings and performance year costs in MSSP. While CMS provides narrative PDFs, this is simply not how requirements for measurement are communicated today. If CMS wants ACOs to move towards more integrated use of health information technology – as we are doing at Aledade right now — then CMS must communicate their methods in the language used by technology developers. At minimum, CMS should develop CQM specification style resources for all measurements in the MSSP.
Given the rise of data availability, coming changes in the health care system will be evidence-based, voluminous, and rapid. This trend will make rapid adaptation of clinical quality measure reporting and workflows the price of entry to succeed as an ACO. CMS must break through traditional norms when it comes to transparency and communication with the public to do their part.