Accountable Care Transformation Framework (Executive Report)

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There is currently a great deal of chatter in the world of healthcare about the terms “Accountable Care” and “Population Health Management.” They’re often used interchangeably – but that usage is not entirely accurate. Population Health Management is complementary to and a part of Accountable Care, but the two terms are not one and the same.
This paper discusses in greater detail the connection between Population Health Management and Accountable Care by highlighting the six competencies that sponsors of an Accountable Care solution will need in order to succeed in the new value-based payment environment. It is my sincere desire and intent to simplify these topics and make them understandable. In doing so, I’ll also keep with an aphorism one of my associates recently shared with me: “Simplicity sells at a premium, while complexity sells at a discount … if at all.”


Developing the Asset: The Five Building Blocks of Population Health Management

It’s easy to see why Population Health and Accountable Care might be used interchangeably: a full five of the six competencies of Accountable Care are associated with Population Health Management. Accountable Care solution sponsors use these five Population Health competencies as building blocks to develop the asset they’re going to market – metaphorically, a diamond – to purchasers desiring to enter into value-based, shared-accountability agreements.
These five building blocks of Population Health Management include:

    • Infrastructure. The infrastructure that forms the foundation upon which the Accountable Care solution is developed.
    • Population Evaluation. The ability to evaluate the financial risk based on disease density and severity of illness of a population of members offered by a potential purchaser of the services of the Population Health Management network.
    • Provider Network. The ability to define the service area in which the population of members resides, then evaluate how well the sponsor’s current provider network provides continuum of care coverage for the service area.
ACO requirements stem from population health competencies

Figure 1: Five Building Blocks of Population Health Management

  • Quality and Safety. The ability to use quantitative outcomes and process measures to demonstrate the quality and safety of the clinical care provided.
  • Waste Reduction. The ability to reduce waste in the care provided by the network by reducing variation in what is ordered by the clinicians, improving the efficiency with which the care ordered is delivered and reducing the mistakes that are made in the process of delivering the care, which cause harm to patients.

At-Risk Contracting: How Financing and Administration Act to Package and Market the Asset (Building-Block Six)

An old adage states “Public relations is 98 percent doing a good job and 2 percent telling about it.” Population Health Management follows a similar construct: developing the Population Health Management asset – the diamond referenced above – is the “98 percent doing a good job.” Putting that asset/diamond into an attractive setting and a lovely velvet box is the “2 percent telling about it.” In this case, that gold setting and velvet box equate to the financing and administration of those five Population Health building blocks.

Figure 2: Population Health Management creates the asset: financing and administration is how the asset is packaged and marketed

Figure 2: Population Health Management creates the asset: financing and administration is how the asset is packaged and marketed

As Population Health Management networks lack these much-needed financing and administration skills, they look to purchasers to enter into shared-accountability contracts, which become the sixth competency of Accountable Care – at-risk contracting. These purchasers have skills in healthcare financing and administration, including functions such as health benefit program design, enrollment, eligibility, underwriting, claims adjudication and payment, financial risk and reserve management as well as regulatory compliance, all of which are required to package and market the asset. At-risk contracting establishes a shared-accountability contract with the purchaser to provide care to the members or beneficiaries enrolled in the purchaser’s health benefit program.

Category Federal Government State Government Commercial
Third-party payers Medicare fee-for-service, Medicare Advantage plans Medicaid fee-for-service, Medicaid HMOs Aetna, Anthem, Blue Cross, Blue Shield, Cigna, United
Exchanges MNSURE Towers Watson, Mercer, Aon Hewitt

The most common categories of purchasers are shown in the chart (right) using examples from Minnesota.

One major dimension of the relationship between the Population Health Management network and the purchaser is the negotiation of the terms and conditions to be included in the contract (covered in more detail in later sections). A second dimension is a dashboard to track performance under the contract including such things as leakage of members and the dollars for their care to non-network providers, budget to actual variances and voluntary disenrollment of members. A third dimension is the ability to report the 33 (soon to be 37) metrics that CMS requires Accountable Care Organizations (ACO) to report.

Appendix A includes additional details about the shift taking place.

The Six Competencies of Accountable Care through the Health Catalyst Product Development Roadmap

The six competencies of the Accountable Care Transformation Framework are summarized in the following graphic.

Figure 3 - Six Competencies Required for Accountable Care Transformation

Figure 3 – Six Competencies Required for Accountable Care Transformation

Figure 4 - Current state => Future state

Figure 4 – Current state => Future state

It is important to note that the dashboard described briefly in the At-Risk Contracting section above provides a snapshot only of the current state. Making a transition from the current state to the desired future state requires the work anticipated in the four building blocks of Population Health Management that sit on top of the infrastructure foundation.

Overlaying the building blocks of Accountable Care below are the products and services Health Catalyst provides that help organizations develop the six competencies. The legend shows where the individual applications and services are in their development cycle.

Health Catalyst’s goal is to develop one or more products and/or services to help organizations it works with close the gap between the current state and the ideal state in each of the six areas of Accountable Care competency. The sections that follow take a deeper look at the components of each competency, provide practical help to organizations wishing to develop an ACO and describe how Health Catalyst’s products and services support these efforts.

Figure 5 - Health Catalyst Product Development Roadmap

Figure 5 – Health Catalyst Product Development Roadmap

Appendix B includes an assessment to help you determine how ready your organization is for Accountable Care.

Enterprise Data Warehouse Platform

The enterprise data warehouse platform enables the integration of data from disparate transactional source systems into a single source of truth. At a minimum, the following data are aggregated into a single data warehouse: EMR, financial, costing, revenue cycle, supply chain and patient experience.

There are three common types of data models within a data warehouse:

  • Enterprise data models, which work very well in other vertical sectors of the economy where the data are pretty much static (e.g., financial, retail); however, these data models are unable to deal with the complexity and frequency of change of healthcare data. Enterprise data models require a long time to construct and configure (e.g., 2-3 years) and are very expensive to build.
  • Dimensional data models, which can be built much more rapidly than the enterprise models, but break down as more and more demands are placed on them. They also run the risk of becoming a burden on IT as a result of redundant data feeds from source systems to subject area data marts.
  • Adaptive, Late-Binding™ data models, which bring data from source systems into the source data marts in the data warehouse with only minimal transformation and apply common linkable identifiers to it (e.g., patient ID, provider ID, location ID). Then, when the data from the source data marts are needed to build subject area data marts (e.g., readmissions, diabetes, sepsis), the data warehouse team does “just-in-time” (late) binding of vocabulary and rules to optimize agility and flexibility to allow rapid adaptation to change (e.g., changes in scientific knowledge, technology and clinical indicators). Health Catalyst solutions employ a Late-Binding™ data model.
Figure 6 - Schema of the Health Catalyst, Late-Binding data model

Figure 6 – Schema of the Health Catalyst, Late-Binding data model

Figure 6 shows the schema of the Late-Binding™ data model developed by Health Catalyst. Additional components of a successful infrastructure are outlined below.

Data Governance

In 7 Essential Practices for Data Governance in Healthcare, author and industry expert Dale Sanders defines data governance as encompassing the concepts of “managing and influencing the collection and utilization of data in an organization.”

Sanders outlines an incremental approach to data governance in order to avoid operating in extremes of either too much governance or too little. His seven essential practices are:

  • Balanced, lean governance
  • Data quality
  • Data access
  • Data literacy
  • Data content
  • Analytic prioritization
  • Master data management

Patient Registries, Workflow Registries and Patient Injury Registries

In order to prioritize and implement healthcare delivery improvements, a link must be created between the three systems of care delivery (analytics, clinical content and deployment). To provide that link, Health Catalyst has developed a three-level Clinical Integration hierarchy consisting of the following elements and illustrated in Figure 7.

  • Clinical Programs (e.g., Cardiovascular)
  • Care Process Families (e.g., Ischemic heart disease)
  • Care Processes (e.g., Acute myocardial infarction)
Figure 7: Health Catalyst Clinical Integration hierarchy

Figure 7: Health Catalyst Clinical Integration hierarchy

The Clinical Integration hierarchy is the foundation of the healthcare transformation framework. The Care Process level of the hierarchy was constructed historically by mapping APR-DRGs to the hierarchy, but they are applicable only to inpatient care. Value-based care, Population Health Management and Accountable Care have underscored the need for an analytics system that can address the continuum of care, not just inpatient, as more and more care shifts to outpatient, clinic care and post-acute care.

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