The final rule for accountable care organizations relieved providers from some of the immediate pressures of establishing health IT, but electronic health records and other technologies will be critical to coordinate care to improve quality and lower costs.
The rule still contains significant language for evidence-based medicine and processes as the way to deliver patient care in an accountable care organization (ACO), said Dr. Scott Weingarten, CEO of Zynx Health, a clinical decision support provider, which is working with a number of providers that are making the changes to become ACOs. He is also a practicing internist.
“The way that can be accomplished across an ACO in a sustainable and scalable manner will require electronic health records (EHRs) and clinical decision support (CDS) that enable evidence based health care that can shared with clinicians at the point of care,” he said.
The Centers for Medicare and Medicaid released on Oct. 20 its final ACO rule, in which providers will share in the savings when they reduce costs and improve quality. CMS will publish the regulation in the Nov. 2 Federal Register. CMS has said ACOs could save Medicare up to $940 million over four years.
Among the changes from the proposed rule, CMS no longer demands that half of the participating physicians meet requirements for meaningful use of EHRs to be in the ACO program. That may be an acknowledgment by CMS of the pressures providers are under to meet competing technology and reporting aspects of other initiatives, such as for ICD-10, electronic prescribing and other CMS quality programs. Achieving meaningful use, however, can help prepare providers as an ACO, Weingarten said.
To succeed as an ACO, organizations need to influence clinical decisions, and they do that by providing context-specific information to clinicians at the point of care, Weingarten added.
“I am not aware of any sustainable or scalable way of doing it other than clinical decision support through electronic health records. It really needs to be done with the aid of an EHR because it’s integrated into the workflow,” he explained, such as through notifications and alerts.
Virtually all quality outcomes, for example mortality rates and re-admission rates, are affected by clinical decisions at the point of care.
On the other hand, Premier Inc., a performance improvement alliance of providers, stated that waiving the meaningful use requirement was important to reduce a barrier to entry to the ACO program.
"Existing penalties associated with an inability to meet meaningful use requirements should provide appropriate incentive on its own, and such a duplicative policy would only serve to limit the inclusion of innovative physicians who are seeking to improve their patients’ care,” the organization said in a statement.
The final rule also reduced the number of quality measures from 65 to 33 because commenters said they were burdensome and duplicative. The measure categories include patient and caregiver experience, care coordination and safety, preventive health and at-risk population conditions. CMS said it will phase in more measures and revise current ones over time.
Premier called this “a wise step,” in that it will “give providers adequate time to demonstrate capacity to improve care and the health of their ACO population."
The rule retains the use of EHRs as a measure, but “to further signal the importance of EHRs, we will score the EHR quality measure with higher weight than the other quality measures,” CMS said in the rule.
"ACOs with more IT infrastructure integrated into clinical practice will likely find it easier to be successful," the agency said. As providers gain more experience, CMS will reconsider using certified EHRs as an additional reporting mechanism used by ACOs in future program years.
[Reporter’s notebook: The biggest surprises in final ACO regs.]
Providers can submit quality measure data using surveys, claims, EHRs, or a group practice reporting option (GPRO) Web-based interface, which CMS said it will build out and refine for ACO reporting, the agency said in the rule. Large providers have used it in the agency’s Physician Quality Reporting System program.
Zynx’ Weingarten said the quality measures appear largely achievable, with plenty of planning, use of EHRs and resources. In fact, the agency officials who wrote the ACO rule were likely very familiar with the requirements to demonstrate meaningful use, he said.
"There is a convergence between HITECH Act and the final rule for ACOs, and I believe that was intentional so that organizations would be well on their way toward achieving what’s required for becoming an ACO,” Weingarten said.