Delivering on the promises of clinically integrated networks and accountable care organizations

Part 1: Put the Background-Foreground Approach to work to improve care quality and decrease cost

In my first quality management role twenty years ago, the foundation for using big data was built to support improving quality while decreasing costs. At that time, mandated public reporting was still in its infancy. Yet, we found ourselves so focused on the overwhelming task of meeting data collection requirements that performance improvement activities and quality of care suffered. If we thought we were challenged with the amount of data needed back then, today’s burden of monitoring, collecting and reporting across the care continuum is enormous.

This concern is echoed by clinicians in Clinically Integrated Networks (CIN) and Accountable Care Organizations (ACOs) across the U.S. A recent study by Health Affairs shows physicians and staff members in four types of practices (primary care, cardiology, orthopedics and multispecialty) spend, on average, 15 hours a week per physician dealing with quality measures—which accumulates to approximately $40,000 annually per physician and $15.4 billion total. Further, it shows only 27 percent of physicians and staff thought current measures, such as Meaningful Use, MACRA, HEDIS, Star Ratings, etc., are moderately or very representative of the quality of care.1

Considering the volume of data required, the burden on the physicians to perform, the challenges with abstracting and submitting hundreds of quality measures, and persuading providers that the data is valuable is a heavy lift. The answer lies in the Background-Foreground Approach, a methodology developed over the past 20 years in quality management to make data manageable and, more importantly, actionable.

The Background-Foreground Approach
The Background-Foreground Approach depicts splitting the quality program in two, with mandated measures in the background and strategic focus areas in the foreground. Monitoring mandated metrics is like watching a patient’s vital signs. These mandated vital signs must be collected, monitored and reported, just as heart and respiratory rate and blood pressure are while caring for a patient. I like to call these mandated measures the “background noise” of the quality program. However, they are not just a box to check, but rather a way to quickly identify negative trends that need attention or positive progress to celebrate.

In the foreground of the quality program are the focus measures. Focus measures are strategically selected based on “background noise” metrics that fall below the baseline, plus the specific operational, financial and clinical measures that can prove attainment of CIN/ACO goals. These foreground measures give an organization its “secret sauce” to deliver value and create differentiation in the market.

Building a Background-Foreground Quality Program
To be successful, CINs and ACOs must implement a quality program that uses data analytics to support high-quality, low-cost operations. Infrastructure is key. Due to the magnitude of background measures, it’s important to build infrastructure for seamless collection and reporting to eliminate silos. This is equally important for the foreground measures that drive ongoing refinement and success.

These background measures will include metrics from quality programs such as Core Measures, MACRA, HEDIS and Star Ratings to represent the CIN/ACO vital signs. Having data on each of the physicians in your network, and monitoring/identifying negative trends for improvement, will assist with meeting regulatory requirements for CMS as well as the Federal Trade Commission (FTC). Optimizing network operations requires the ability to identify gaps, provide data abstraction, communicate performance to physicians, and submit measures to regulatory agencies. All of these lighten the burden on physician practices and offer a significant value to network physicians.

Next, the foreground measures, which typically fall within these four key themes population insights, finance and operations, value to physicians and proof of goal attainment.

Patient data shared by the network contracts is critical to improving care and decreasing cost. Claims data analytics should segment the population into the highest risk/sickest patients, rising-risk patients, and low risk and prevention patients. These insights should drive the care coordination strategy to engage patients and provide support around transitions of care, Emergency Department (ED) and inpatient setting utilization, and disease management and illness prevention campaigns. Clinical outcome measures like preventable admissions, hospital-acquired conditions, readmissions, medication adherence, and discrete lab values will either prove success or show opportunities for improvement.

Clinical utilization data including admissions, readmissions, diagnostics, and pharmacy will equip the network with provider practice patterns and patient habits. Financial utilization data will show if the network is operating efficiently. Identifying opportunities for savings, locating network referrals and leakage, monitoring per-member-per-month (PMPM) trends, and calculating total spend both at the network level and at the provider/facility level, are all key to achieving financial viability and preparing for more mature (and lucrative) risk-bearing contracts.

It’s all in the proof
Ultimately, background and foreground measures populate dashboards for CIN/ACO stakeholders. With the proof of goal attainment now at their fingertips, providers can support network marketing and provide the basis for their distribution methodology, another strong value to providers. The dashboards should provide a quick, easily digestible view of selected mandated metrics, population insights, operation measures and clinical and financial utilization opportunities. The more frequently the data is refreshed for dashboard review the better chance the CIN/ACO can take swift action and achieve success.

Building upon the Background-Foreground Approach, CINs/ACOs can perfect their “secret sauce” to close gaps in care and improve contract performance. Next in our three-part series, Delivering on the Promises of CINs/ACOs, we will discuss a data-driven strategy for provider engagement to improve the quality of care and decrease the cost.

Ronda Hefton, RN, BSN, MBA, is an integrated care consultant and guest contributor for CitiusTech.

1Physician practices spend $15.4B worth of time each year reporting quality measures, study finds,” The Advisory Board. March 9, 2016.

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