Value-based pay adds to physicians’ paperwork burdens, but the right accountable care organizations can help
Membership in an accountable care organization (ACO) can reduce the burden of quality reporting to Medicare’s value-based payment programs and to commercial health plans. But physicians should not join an ACO for that reason alone, because they may be unprepared for the kinds of practice changes that an ACO requires, experts say.
Many ACOs do most or all of the data collection, while also giving physicians feedback on their performance. This can be especially helpful for small, independent practices that don’t have any other way to measure how well they’re doing in relation to their peers.
However, practices should ask some hard questions about these capabilities before joining an ACO, healthcare consultants say. They should find out, among other things, how much of the data collection they will have to do, how timely and useful the feedback will be, and whether there is a separate charge for the service.
“The value-based payment systems require quality reporting, and in order to participate and get the funding they want, the practices are sort of driven to ACOs to provide a little bit of support,” says Erin Mastagni, MPH, a senior manager at ECG Management Consultants. “But that’s only if they want that sort of payment and can agree to the other care model changes. So it’s more about the shift to value-based care.”
Mastagni and David Zetter, PHR. a practice management consultant in Mechanicsburg, Pennsylvania, emphasize that practices must weigh the pros and cons of ACO participation beyond just quality reporting. For example, an ACO can help a practice with contracting, prepare it for value-based care and support it with population health management software.
On the other hand, physicians in ACOs must follow certain practice guidelines and they may have to hire care managers. In Zetter’s view, no practice should join an ACO just for quality reporting.
But why would it be easier for a practice to have the ACO do their quality reporting than to do it on their own or through their EHR vendor? Also, how could it help them improve their quality scores?
For one, physicians can benefit from having the ACO report data because “we simplify the process of reporting,” argues Rob Fields, MD, medical director of Mission Health Partners, an ACO in Asheville, North Carolina. “You send us the canned report and we do the formatting and validation and take on the audit risk of making sure that it gets to the federal government in the way it should.” Also, he says, the ACO members’ practice managers regularly network and exchange ideas to improve their quality scores.
The ACO gets a lot of questions from members about the Merit-based Incentive Payment System (MIPS) of the Centers for Medicare & Medicaid Services (CMS), he notes, because the program is difficult to figure out.
“That’s one of the biggest value propositions we offer: We can provide the education and simplify the process,” says Fields. “You don’t necessarily need to understand all of it. You just have to understand enough to give us the quality reports, and we can take care of the rest.”
Josh Israel, MD, lead of clinical quality initiatives for Aledade, a company that manages two dozen primary care ACOs across the U.S., says that the firm offers informational materials, live training sessions and weekly “ask anything” phone seminars to help practices improve their quality measures.
“Effective and seamless quality reporting is a challenge, but a combination of technology and direct support can ease the transition to a healthcare system focused on value with the lowest burden to physicians,” he says.
Of the 923 ACOs active in commercial payer and federal programs, 563 hold Medicare contracts, according to a recent study published in Health Affairs. Most of these ACOs participate in the Medicare Shared Savings Program (MSSP), which requires them to report on a specific group of quality measures. When that data is reported to MSSP, it is also reported to MIPS, so ACO participants do not have to send their quality data separately. They also get credit for clinical improvement activities-another MIPS requirement-if their ACO is in the MSSP.
However, ACOs average the data of all their participating practices when they report to Medicare. For a practice with low quality scores, this can be an advantage. But if a practice has higher quality scores, ACO reporting can drag down its scores, not only in MIPS, but with commercial insurers. In other words, the quality scores that affect value-based payments to a practice depend largely on how well the other ACO participants do.
Practices that are considering joining an ACO should ask to see the ACO’s quality data to get an idea of its historical performance, says Krista Teske, a physician practice roundtable consultant for the Advisory Board Co., a Washington, D.C.-based consulting firm. In addition, ACO quality scores are available on the CMS website. But those posted scores are a year or two out of date.
Wendy Coin, MD, a primary care physician in a 21-provider practice in Asheville, North Carolina, says that her group is not happy with the average quality data for the Mission Health Partners ACO, in which it participates.
“We knew that we had higher quality scores and a higher level of sophistication [than other local groups] when we entered the ACO,” she says. “So we had concerns about that, but we’re taking a deep breath and having faith. Joining an ACO seemed like the right thing to do to prepare for the coming changes in the reimbursement systems.”
Jennifer Brull, MD, part of an eight-provider primary care practice in Plainville, Kansas, says she has no concerns about quality score averaging, although her group is one of the top performers in its ACO. “I am hoping to increase our revenues with shared savings, and we cannot do that as an individual practice, so reporting quality as a group makes sense,” she says.
ACOs usually collect clinical data from the EHRs of member practices for quality reporting, Teske says. If there are many different EHRs within the organization, it may be cost-prohibitive to write interfaces to all of those systems. On the other hand, if an ACO consists mostly of practices within a single organization, or requires its members to use a single EHR, it’s easy to extract the data electronically, notes Zetter.
This often happens in ACOs formed by healthcare systems that employ doctors, but some hospital-owned ACOs include community practices with multiple EHRs.
ACOs owned and operated by independent physicians are also likely to have different EHRs, says Mastagni. In that case, the ACO may have to send people into the practice to pull the quality data, which can be an expensive and time-consuming task, she says.
Mission Health Partners, Coin’s ACO, takes a middle course. Its member practices, which have nearly 20 EHRs, generate electronic clinical quality measure (eCQM) reports and send them to the ACO, notes Fields. This process does not require interfaces, he says. The ACO then aggregates the data, formats it correctly and submits it to Medicare and the Medicare Advantage plans it contracts with.
While this approach is easy for the practices, which don’t need software beyond their EHRs, “the quality of these [eCQM] reports is highly suspect,” Fields says, because some of the data may be missing or inaccurate. So the ACO has to send people into the practices to do random chart reviews to validate the reports.
Brull and her colleagues, in contrast, manually enter the majority of the data required for their ACO’s quality reports. Their EHR interfaces with the ACO’s system, but the practice is “responsible for ensuring that the information obtained through our EHR is valid and that any data gaps are filled in,” Brull says.
The interface automatically populates about 20% of the required quality reports-an amount that will soon rise to 50%, she says. The data that automatically goes to the ACO also populates a quality dashboard that shows gaps in patients’ preventive and chronic care.
In order to improve their quality scores in MIPS and other programs, physicians need feedback on their performance.
CMS provides some feedback on quality, but it comes several months to a year after the data is submitted, according to Zetter. In contrast, ACOs usually supply feedback quarterly or monthly, Teske and Mastagni say. Zetter notes, however, that some ACOs provide infrequent or no feedback. He advises physicians to avoid those ACOs.
CMS compares the data on individual clinicians and groups to that of other entities reporting to MIPS. ACOs are supposed to pass that information onto their members, and they may also provide comparisons of practice scores with those of other ACO member groups.
Mission Health Partners supplies feedback only at the group, not the individual provider level, Fields notes. Each quarter, the ACO publishes spreadsheets on its member practices, and aggregates the data by tax identification numbers. The data are based primarily on MSSP metrics, he says.
The ACO is in the process of transitioning to an interactive scorecard that will incorporate both quality and financial performance. Practice managers will be able to click on various areas of utilization such as emergency department and inpatient usage. (Some of this information will come from Medicare claims data.)
At present, Coin doesn’t feel that the ACO’s feedback is very useful, because her group is “a well-oiled machine” on quality measures. But in the future, she anticipates, it will become more important, especially in the area of costs. She’d like to see the utilization data derived from Medicare claims information, she says.
Brull, who is her ACO’s quality director, says that her practice uses the ACO’s feedback on quality every day. “We continuously are examining the data that is available and working through potential gaps in care,” she says. The group uses the data to close care gaps for patients without pneumonia shots and those who have abnormal HbA1c’s and elevated blood pressure, among others.
In deciding whether to join an ACO, physicians should understand that the range of quality measures they can select for MIPS is limited. Eligible clinicians reporting on their own can pick any six quality measures from a list of 271 metrics.
In contrast, ACOs that participate in MSSP are reporting on 31 quality measures in 2017, and those are also reported to MIPS. While the number of ACO metrics is greater than for individual practice reporting, there is no choice of measures.
Many ACOs also have commercial payer contracts that require data reporting on a large number of quality measures, Mastagni says. Some ACOs, she notes, are tracking as many as 100 different metrics. This is also a problem for practices that have multiple value-based care contracts.
ACOs can help practices handle these requirements, as well as population health management, but they need an information technology infrastructure that is equal to the challenge. “Sophisticated data systems are something that organizations should look for in an ACO,” Teske points out.
To assess an ACO’s technology, Mastagni says, practices should ask how often the ACO updates quality measures and how it disseminates that information to providers.
In addition, practices should find out whether the ACO uses a quality dashboard that simply conveys members’ quality scores or whether the dashboard also includes a registry that generates lists of patients they should contact to close care gaps and improve quality rankings. “Assistance with interpretation of the data and outreach to patients are common services of an ACO,” she says.
Practices should also investigate their requirements for supplying data to the ACO, and what they’ll get back in return, she notes. In addition, she suggests asking about the ACO IT staff’s ability to optimize the use of its technology.
While there is an option for practices to send quality data directly from their EHRs to CMS, Fields says navigating MIPS “is complex and hard to understand if you do it on your own.” But independent practices can also choose between using a CMS-approved registry, a CMS-approved EHR vendor or an ACO to report their quality data electronically.
Alternatively, practices can use a manual claims-based method, which requires physicians to enter special codes for each patient visit for which they provide services subject to quality measures. Zetter says that practices without EHRs and those that don’t trust their EHRs may report quality data through claims.
CMS-approved commercial registries and qualified clinical data registries, which are mostly run by specialty societies and quality collaboratives, charge only a few hundred dollars per provider per year, Zetter says. But practices have to find a registry that will work with their EHRs, he notes. Mastagni says that registries’ fees don’t include the cost of EHR interfaces. Vendors don’t need those interfaces, and, according to Zetter, charge about the same amount as registries.
Mission Health Partners doesn’t charge for quality reporting beyond its initial participation fee of $500 per provider, Fields says. However, while independent doctors control the ACO’s board, a large healthcare system owns the ACO, which may account for the low cost.
According to Mastagni, healthcare systems that form ACOs generally don’t charge independent practices to join them. They are looking for referrals rather than a direct financial return, she says.
Brull’s ACO, which is managed by Aledade, has a different kind of business model. It provides quality reporting for free, but takes a percentage of the shared savings achieved under its contracts.
“Reporting did take work, but the process was well organized and easy to understand,” Brull says. “At the end of it, I felt that I was submitting the most accurate quality data I have ever been able to turn in.”