The Brave New World of Oncology ACO’s – Inverted Incentives & Inverted IT System Requirements

The Brave New World of Oncology ACO’s – Inverted Incentives & Inverted IT System Requirements

The Brave New World of Oncology ACO’s

Inverted Incentives & Inverted IT System Requirements

January 15, 2013

Wes Chapman & Steve Maker

           Inverted incentives

Are your oncology IT systems rated for Inverted Flight?

Reality came crashing in yesterday: 106 new accountable care organizations (ACOs) were approved by Medicare (CMS), including a 1-million+ person ACO formed and operated by Walgreen’s. That’s right, Walgreen’s the pharmacy chain.

The wave of primary care ACOs is turning into a tsunami. These CMS-endorsed primary care ACOs are the first step in moving to capitated payment models, driven by quality metrics to ensure patient satisfaction and high quality. Blessedly, only 33 metrics are required for the first couple of years as these organizations get moving – with the vast majority of the metrics already being captured in patient surveys and existing EMRs.

Not waiting for Medicare to figure out the metrics and operating formulas for specialty ACOs, two oncology-specific ACOs have been formed by private payers in Florida, with 6 more being formed in other venues. These oncology ACOs offer unique opportunities for care improvement and cost reduction, but demand vastly more complex data gathering and management systems to function – not to mention meet their full potential for cost savings and care improvement.

Clinical and financial success in oncology ACOs depend on the same three key factors:

1)      Expanded patient education, involvement and shared decision making,

2)      Dramatically expanded palliative care, and

3)      The use of and documented adherence to best practice clinical pathways and multi-modality care plans – increasingly paid as “bundled payments”.

From an IT system perspective, the fundamental problem is that none of these three factors is adequately captured in any oncology setting today, and many are not captured at all. Some of the more advanced “oncology tuned” electronic medical records (EMRs) capture some of the more popular oncology oriented metrics – such as the core QOPI metric package promulgated by the American Society of Clinical Oncology (ASCO) – but none even begins to adequately capture the detail necessary to verify compliance with best practice guidelines.

How did this happen? The answer is pretty simple. Like most hospital IT environments, oncology clinical data systems are a patchwork quilt of interconnected systems – all pointed at the financial goal of revenue maximization. Data flows are dictated by revenue cycle management software systems designed to maximize revenue through coding optimization. Best practice pathway compliance and related quality/cost improvement systems are antithetical to the fundamental design precepts of existing oncology data systems.

Compounding the problem, most private payers are currently encouraging pilot projects (and in some cases the full implementation) of bundled payments for medical oncology. We have seen these in a large variety of shapes and sizes, but in all cases either requires: 1) the use of proprietary payer-sponsored external IT systems (always requiring double sign-on and data entry), or 2) manually documented internal compliance systems. Not too surprisingly, the resistance to the use of external data systems and duplicate data entry is enormous, and documented internal compliance currently means monthly “hair-on-fire” chart reviews – neither accurate nor sustainable.

Oncology ACOs have the potential to be uniquely profitable while simultaneously dramatically improving care quality and patient satisfaction – but only if the data required for operation is readily available on nearly a real-time basis.

PCD is building an oncology-specific quality and management system to address these issues immediately, but more importantly, to allow the full benefit in both cost and quality to oncology ACO operators. Our market research and work with current clients have revealed myriad obstacles for providers trying to create a sustainable system on their own. Here’s a sample of the user issues:

  • We have no good means to collect data to support our claims for payment under bundles.
  • We have no way of keeping up with the evolving requirements (particularly bundles) for the multitude of payers we deal with.
  • We have no way to calculate metrics against targets to guarantee payments.
  • We use bundles, but have no way to determine whether our clinicians have picked the approved bundle, let alone are following it.
  • We are a multi-organization ACO, and have no way to link all the systems needed for reporting.
  • The data we do collect doesn’t have enough detail to let us manage performance or tell us whether we’re improving.
  • We have no way of knowing whether we’re on track for success. We have to guess until we finally pull it all together right before deadline—which is too late to make adjustments.
  • We have no capital to put a big system in place. We need a solution that’s both fast to set up and has realistic ongoing costs for which we can budget.

Our system design contemplates 6 fundamental design requirements to address these salient issues:

1)      All data must come via push or pull from existing clinical data systems – double entry simply won’t work,

2)      Data must be available on customizable dashboards rapidly enough to be clinically actionable,

3)      All relevant quality metrics, standard care plans and clinical pathways must be maintained in the system, with data extracted from the clinical environment used for compliance validation

4)      The system must function in a HIPAA compliant cloud environment, with no additional infrastructure investment required at the customer site

5)      All data access is roles and permission based

6)      Day-to-day operation and configuration is controlled at the customer site

If you have any thoughts about the design of IT systems for oncology ACOs, let us know your thoughts below – we’re all ears on these design requirements.

Wes Chapman
Written by Wes Chapman

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