How an ACO provides and arranges for the best patient care using clinical and operational analytics (Becker's Hospital Review)

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[Written by Gregory Spencer, MD, FACP, Chief Medical and Chief Medical Information Officer at Crystal Run Healthcare]

Healthcare is transitioning from a transaction-based, fee-for-service payment model to a value-based model designed to deliver higher-quality, less wasteful care at the lowest possible cost.

This new model emphasizes population health management and requires providers to take on risk and collaborate to an unprecedented extent.

The need for this level of collaboration has led to explosive growth in the number of accountable care organizations (ACOs). In 2013, there were a total of 606 public and private ACOs in the United States with 51% led by physicians and another 33% jointly led by physicians and hospitals.

One pioneering, physician-led ACO is Crystal Run Healthcare in New York. This rapidly growing and forward-thinking organization has received national recognition as one of the first six ACOs to be accredited by the National Committee for Quality Assurance (NCQA), and one of the first 27 ACOs to be selected by CMS to participate in the Medicare Shared Savings Program.

Focusing on growth in preparation for value-based care and population health management

Like the majority of ACOs, Crystal Run still receives most of its reimbursement—approximately 80%—under the fee-for-service model, but the organization is beginning to experience the long-anticipated shift toward more value-based reimbursement. To ensure financial stability as they assume more risk, the ACO is implementing a strategy focused on rapid growth. Crystal Run already has more than 300 providers in 40 medical specialties with multiple practice locations. The ACO plans to grow to more than 1000 physicians, significantly expanding its geographic reach.

Crystal Run views its enterprise data warehouse (EDW) and applications as critical to the success of this strategy. This technology foundation enables sophisticated analysis necessary to position Crystal Run for continued success in an increasingly value-based reimbursement environment. In addition to population management, the ACO is leveraging the EDW and analytics to inform critical decisions about clinical excellence, operational optimization and growth targets and to identify new revenue sources such as government grants for treatment of Medicaid patients.

ACO challenges: managing risk and patient populations

As Crystal Run leaders searched for technology to support their growth and population health management strategies, they knew they would need an analytics solution that would enable them to continuously improve in the following areas:

– Reducing clinical variation, enhancing operational efficiency and positioning the organization to better manage risk
– Supporting informed decisions by giving clinical and operational decision-makers efficient and effective access to all necessary information
– Using data from a “single source of truth” integrated from multiple disparate source systems (EMR, billing, costing, patient satisfaction and other operational systems) to answer increasingly complex clinical and operational questions
– Avoiding prolonged decision-making processes by making self-service analytics available to decision-makers. In the past, much of the ACO’s analytics required the business intelligence (BI) team to write customized reports. The report turnaround times depended on the complexity of the request and the number of other reports within the BI report queue. Once the clinicians reviewed the report, they often had additional questions, which required another BI request and further delays in receiving the information.

In addition to these general requirements, Crystal Run needed an analytics solution that could help address the day-to-day operational and clinical challenges that ACOs face. These challenges include:

Growth and practice expansion

Crystal Run’s growth has required and will continue to require the construction of new office buildings to support a growing patient base in expanded geographical locations. They were tasked with determining the best locations for these clinics and what provider mix was necessary to best serve patients. To tackle this question, they needed to understand where to locate the new sites and what types of providers they should staff to meet patients’ needs. The cost of large offices is not insignificant—often running into the tens of millions of dollars.

Risk-based contracting

Like many healthcare providers, Crystal Run is anticipating increased participation in risk-based contracts involving bundled payments, shared savings and capitation. They need to understand what it costs to take care of a given patient population. Without this data, Crystal Run has little leverage, which means that payers will dictate the terms based on a risk score that is based on the average for the region. However, not all patient populations align with the regional average—and, in the case of Crystal Run, the bulk of the specialists…Click to read more

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