Rx for Medicare value-based programs, Part 2: Data at the right time and in the right format

In my last post, I discussed how participants in the Medicare Shared Savings Program (MSSP) and Pioneer Accountable Care Organization (ACO) program are clamoring for access to the “right data” on their members for the purposes of population health management. In this post, I’ll discuss how critical it is that the right data be delivered at the right time and presented in the right format.

Data at the right time is needed for timeliness.

  • Data related to care transitions must be a “push” data set. Information about a patient’s admission Miles Snowden, MD, MPH, CEBS Chief Medical Officer, OptumHealthon or discharge from a hospital, emergency department, or long-term care facility, is highly time-sensitive and should be shared with – or “pushed out” to – providers as quickly as possible. The earlier a provider is notified of a care transition event, the sooner he or she can intervene to assure the best clinical outcomes. While it is not possible to meet this need for timely care transition data through its claims analysis, CMS could consider ways to assist and encourage facilities to notify ACOs of care transition events through standardized data feeds.
  • Data related to population health management should be administered as a “pull” data set. Population health management data is less urgent than data related to a care transition. As such, it should be delivered to a data warehouse (a central repository of integrated claims data from a variety of sources) so that ACOs can “pull” that data for analysis at whatever frequency and for whatever data elements they believe will help them deliver the best patient care outcomes. The current process of pushing monthly or quarterly claims data to ACOs is not sufficient to support contemporary population health management activities. ACOs will want to monitor for time-sensitive diagnoses (e.g. wounds) on as much as a daily basis, and monitor for longer-term, chronic conditions (e.g. diabetes) on a less frequent basis.

Data in the right format is needed to achieve standardization.

  • Standardize all payer formats. Many of Optum’s ACO clients are operating multi-payer ACO initiatives. They receive data from CMS in a format that does not conform to industry standards, and therefore cannot be analyzed in the same manner—or in an integrated process—with data from commercial payers. As a result, a great deal of manual work is required in order to effectively utilize all data, adding expense and potentially diminishing provider interest in participating in future CMS ACO pilots or programs. In addition, this manual work could make it prohibitively expensive for smaller provider groups to participate in these programs in the future.
  • Standardize all provider IDs. CMS Pioneer ACO and MSSP programs, as well as some commercial payers, use different methods to identify participating providers. This causes administrative problems where Pioneer ACO, MSSP, and commercial programs operate in the same market. The same identification method should be employed by all payers so that multiple payer contracts can be administered by provider groups with integrated member outcomes and cost allocation to participating providers.
  • Standardize quality measures for all payers. CMS programs use quality measures to gauge how an ACO is performing. However, the focus of these measures is primarily on “underuse,” which is a measure of not providing necessary care. Our ACO clients believe that measures of  “misuse” (providing the wrong care) and  “overuse” (providing care the patient doesn’t need) are equally important as indicators of quality, and are likely more important as methods of achieving affordability than measuring underuse. Commercial payers have reflected this approach to gauging the quality of their programs  by examining all three types of measures. CMS should consider re-balancing its quality and performance measures to be more consistent with those used by commercial payers. In addition to supporting efforts to improve outcomes, this will ease some of the confusion that results from using different measurement methods. It will also decrease some of the administrative burden for our ACO clients, who are currently required to communicate to their physicians and monitor their performance on very different measures between CMS and other payers.

Early participants in CMS value-based reimbursement programs and pilots are quickly determining what is needed to be successful for years to come— access to the right data, at the right time, in the right format has rapidly emerged as a common need. This and other innovative experiences will serve to make these early efforts a basis for a sustainable health care system for our society.

Miles Snowden, MD

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