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Using available data to identify potential high-risk patients before they become high-cost patients can reap rewards for accountable care organizations.
On the day after Congress repealed the Medicare Sustainable Growth Rate (SGR), Farzad Mostashari, a former Brookings Institution fellow and U.S. National Coordinator of Health Information Technology, was prepared to wager that the winners in this new era of healthcare payments would be primary-care physicians and practices.
"Who's going to win in this new world?" he asked during one of his sessions at the Healthcare Information Management and Systems Society (HIMSS) Annual Conference. "I would say it's the people who have the least to lose and most to gain."
Many large health systems are reliant on the fee-for-service model for survival and have a disincentive to prevent hospitalizations because they make money when patients' conditions worsen, explained Mostashari, who created and now runs start-up Aledade to help practices form accountable care organizations (ACOs). But primary-care physicians have long taken a more holistic view of their patients and are in a good position to take charge of keeping their patients healthy through physician-led ACOs.
This path is not an easy one, however. He cautioned that so far, 75 percent of the physician-led ACOs aren't yet profitable. But by 2018 the changes in reimbursement associated with the SGR repeal, which offers physicians a 0.05 percent annual fee increase, will make ACOs and other Medicare-driven alternative models more attractive, Mostashari said.
"We have to nail [ACOs] in the next two- to two-and-a-half years," he said.
Keys to ACO Success
Fortunately, the secrets to physician-led ACO success have been well publicized. Mostashari and his former Brookings Institution colleagues published a free toolkit describing the keys to ACO success. During his talk at HIMSS15, Mostashari summarized this information.
The first thing successful ACOs must do is harness their data to identify the highest-risk patients so they can prevent them from being hospitalized or having other expensive negative outcomes. But it is not as easy as just finding the most expensive patients, he said.
"Often we can't do anything about the highest-cost patients," he explained. "It's too late; the springs have come off. We've failed them."
Instead, he said ACOs must to use data to identify the patients helped before they become high-cost patients. For example, patients who have a high fall risk, who are taking several medications, who have congestive heart failure, or who are living in a dangerous home situation. Mostashari acknowledged, however, that it may be difficult to extract relevant data from current EHRs leaving some practices to rely on a separate population health system.
He noted it is important for ACOs to also tap their physicians' clinical experience and intuition because they may know about factors that mitigate or exacerbate the risks outlined in the data. For example, if a patient has regular family visits and support with their medical care.
Physicians also need to be alerted when their patients enter a hospital and be prepared to respond and share data with hospital clinicians.
"You are not doing population health if you don't know when your patient is in the hospital," he said. "Good luck managing health costs if you don't know that."
A primary-care physician sending an emergency department physician relevant patient data or discussing the case may well be a deciding factor in whether the patient is admitted, Mostashari explained.
Additionally, physicians must build a network of other physicians and facilities so they can ensure the quality and continuity of their patients care. Finally, Mostashari emphasized the importance of engaging patients and their families in care.
"Do what is right for the patient and the quality measures will follow," he said.