Health Care Quality and Value: Travel Further Down the ACO Highway

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  • January 1, 2013
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By Stephen C. Spain, MD, FAAFP, CPC and Angela “Annie” Boynton, BS, CPC, CPC-P, CPC-I, CPC-H, RHIT, CCS, CCS-P

Part 3: Securing the right care at the right time depends on whether ACOs can incorporate EBM into everyday practice.

Editor’s note: This is the final installment in a three-part series on health care quality, value, and the future of health care reimbursement in the United States. Our first article discussed the rise of evidence-based medicine (EBM); and last month we talked about accountable care organizations (ACOs) being the (r)evolutionary next step driving quality and value.

Medicare ACOs are intrinsically linked to performance measures, quality outcomes, and incentive-based reimbursement. The government is betting these links will improve health care outcomes and reduce costs. EBM can secure the right care at the right time: The key is whether ACOs can incorporate EBM into everyday practice.
Quality measures are a critical component of the ACO final rule. The formulation of a quality measure generally begins by identifying a problem, posing a possible solution, and following up with clinical evidence, as shown in the Table A. Supporting evidence in the form of clinical trials and studies, and deference to any existing EBM guidelines, allows the steward organization to create a measure that can be used for tracking or, in the case of ACOs, for incentive-based reimbursement.

Specifics of ACO Quality Measures

The ACO final rule stipulates reporting on 33 quality measures. These 33 individual measures will determine whether an ACO qualifies for shared savings. The measures are divided into two categories: Better Care for Individuals and Better Care for Populations. The quality measures are further divided to span four quality domains: Patient/Caregiver Experience, Care Coordination/Patient Safety, Preventive Health, and At Risk Population.
Patient/Caregiver Experience of care has an ultimate goal of measuring care for individuals. Using a survey mechanism for submission, this domain includes seven quality measures aimed at providing better care for individuals:
1.  How well your doctors communicate
2.  Getting timely care, appointments, and information
3.  Patients’ rating of doctor
4.  Access to specialists
5.  Health promotion and education
6.  Shared decision-making
7.  Health status/functional status
The Care Coordination/Patient Safety domain continues to focus on better care for individuals, with six measures:
1.   Risk-standardized, all condition readmission
2.   Ambulatory sensitive conditions admissions: Chronic obstructive pulmonary disease (COPD)
3.   Ambulatory sensitive conditions admissions: Congestive heart failure
4.   Percent of primary care physicians who successfully qualify for an electronic health record (EHR) incentive program payment
5.   Medication reconciliation: Reconciliation after discharge from an inpatient facility
6.   Screening for fall risk
The Preventive Health domain shifts focus from individuals to better care for populations. Eight measures are included:
1.   Influenza immunization
2.   Pneumococcal vaccination
3.   Adult weight screening and follow up
4.   Tobacco use assessment and tobacco cessation intervention
5.   Depression screening
6.   Colorectal cancer screening
7.   Mammography screening
8.   Proportion of adults 18+ who had their blood pressure measured within the preceding two years
The remaining measures are categorized in the At Risk Population domain. The objective continues to be better care for populations with chronic illness. The measures are divided into clinically deemed, at-risk populations, including those suffering from diabetes, hypertension, ischemic vascular disease, heart failure, and coronary artery disease.

Measures Reporting and Payment

All measures ultimately are reported via the Internet. The Physician Quality Reporting System (PQRS) combines some of these existing measures into its reporting structure, so providers who participate in PQRS and are in an ACO do not face duplicate reporting requirements.
Payments are made based on the three-year commitment. The first year (2012), ACOs are paid to report. This enables the government to begin amassing data from existing, fledgling ACOs, which can be combined with existing Medicare claims data. These combined data allows the government to set benchmarks for quality and begin the scoring process.
Measures are phased in over years two and three of the initial ACO commitment. This avoids the stress and burden that would come from an all-at-once process, and allows ACOs to structure business operations over time and become more familiar with the measures.

ACOs = Opportunity for Coders

Understanding and addressing the central position of quality measures, PQRS, and ACOs will be crucial for all health care participants—including coders—in the years ahead. The obvious question for AAPC members is, “How will the evolving focus on EBM and quality measures reporting affect me?”
There are a few key points to consider:

  • Quality measures are reported by codes, and AAPC membership owns the coding world. No one understands coding like our members, and no group is as well positioned to tackle the challenges associated with changes and requirements in health care coding. Coders must begin learning how to identify and use these new codes. Specialty coders must learn and identify the reportable measures pertinent to their field. The National Quality Forum website is a great resource for learning about the specific quality measures and their codes.
  • Apart from providers, no one in health care has a better understanding of navigating the medical record than coders. Providers will have enough difficulty following necessary guidelines and documenting required measures. It will fall on “others” to access the health care record to identify, locate, tabulate, and report measures. In our view, those “others” will be largely the coding membership of AAPC, who will need to work with providers and EHR vendors to simplify entry into and extraction from the record for the required reporting elements. We foresee many coders will become experts in data extraction and reporting. Successful performance of these tasks will have significant financial implications for providers, imparting new responsibilities and heightened importance for coders.
  • At the outpatient provider level, reporting measures is in its infancy. Providers are looking for well-informed and reliable sources to help them understand and participate in quality measures reporting. They are just beginning to realize the looming financial penalties for noncompliance; this will fuel their desire to understand the new initiatives. Proactive coders will be prepared to address this provider need by learning how to implement new reporting requirements. In doing so, the forward-thinking coder will be firmly planted as part of the foundation of this new direction in health care delivery. The CMS website is a good place to start learning about quality measure initiatives.

We are at the threshold of significant and far-reaching changes. Everyone participating in the delivery and reimbursement of medical care is hopeful that we are ushering in a “golden age.” With the proper preparation and education, AAPC members are poised to play a vital role in this new era. Regardless of the outcome of this experiment, AAPC membership and leadership must plan and work together, so it can never be said we were unprepared to meet the challenge.
Table A: Quality measures based on clinical evidence.

Problem Hypothesis Studies Conclusion Steward Measure
Depression is a common illness for which there is effective intervention. Untreated, depression is associated with significant morbidity and loss of productivity. Would routine depression screening lead to increased rates of diagnosis and treatment, improving the quality of life for those patients identified with this condition? U.S. Preventive Services Task Force (USPSTF) evaluates the effect of primary care routine screening of adult patients for depression compared with usual care in 14 randomized trials in primary care settings. USPSTF concludes that, compared with usual care, screening for depression can improve outcomes, particularly when screening is coupled with system changes that help ensure adequate treatment and follow up. The Centers for Medicare & Medicaid Services (CMS) NQF 0418: Percentage of patients aged 18 years and older screened for clinical depression using a standardized tool and documented follow-up plan.
Smoking is associated with significant illness and premature death. Can physician-directed screening and intervention reduce the rate of smoking in a patient population, thereby reducing overall smoking related morbidity and mortality? Multiple studies over many decades confirm that patients who are identified and counseled by health care workers to stop smoking are more likely to be successful in their cessation efforts. An American Medical Association (AMA) advisory group concludes that, while screening alone increases the rate at which clinicians intervene with their patients who smoke, it does not, by itself produce significantly higher rates of smoking cessation. Cessation interventions are also required to impact the outcome of interest. AMA Physician Consortium for Performance Improvement NQF 0028: Percentage of patients aged 18 years and older who were screened for tobacco use at least once during the two-year measurement period AND who received tobacco cessation counseling intervention if identified as a tobacco user.
Complications of influenza include pneumonia, heart attack, stroke, and death. These are associated with significant health care costs, not to mention the devastation to patients and families. Can we identify those at risk for influenza complications and reduce their risk of illness through vaccination? Multiple large studies over many decades have evaluated the effectiveness, cost, and safety of widespread vaccine administration for influenza and multiple other vaccinations. Centers for Disease Control and Prevention Advisory Committee for Immunization Practices concludes influenza vaccine administration lowers the risk of significant illness for patients over 50, and persons with underlying illnesses like asthma, COPD, and diabetes. National Committee for Quality Assurance NQF 0041: Percentage of adults aged 50 and over who received an influenza vaccine within the measurement period and within the respective age-stratified Consumer Assessment of Healthcare Providers and Systems surveys.

For more information on ACOs and the Shared Savings Program, read the CMS final rule in the Federal Register.

Stephan Spain, MD, FAAFP, CPC, has been engaged in the full-time practice of family medicine for 25+ years. He founded Doc-U-Chart, a practice management consulting firm specializing in medical documentation. Dr. Spain can be reached at

Annie Boynton, BS, CPC, CPC-P, CPC-I, CPC-H, RHIT, CCS, CCS-P, is the director of 5010/ICD-10 communication, adoption and training for UnitedHealth Group. She is an adjunct faculty member at Massachusetts Bay Community College and a developer and member of AAPC’s ICD-10 training team.

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