By Jeffrey Springer, CitiusTech
As CINs/ACOs expand as a strategy for value-based care, these organizations depend ever more heavily on data – and the expertise to gather, manage and use it – to achieve success. Part 1 of this two-part series, Knock Down Barriers and Achieve CIN/ACO Success, detailed the significant data challenges for integrated delivery systems that include separately owned legal entities. Part 2 outlines how health systems with an owned ACO/CIN provide the usable data, clinical support, proof of compliance, and strategic guidance required for an unwavering focus on care quality and patient experience. While simple to say, only the select few have mastered providing the right care in the right place at the right time – the holy grail for delivering high quality care at lower cost.
Start By Buddying Up With The Legal Team
Your legal team is your friend. Let them safely guide you through the tricky and often treacherous waters of ACO/CIN compliance. Their expertise is critical for considering and understanding legal entity boundaries, organizational ownership (CMS ACO, Commercial CIN/ACO, Medicare Advantage, Employee Health plan) and the compliant ways to navigate them.
This became crystal clear recently when the NIST 800-53 published the requirements for Organizations (CMS ACOs) working with Federal Systems. This not only increased the urgency, but it also highlighted data governance issues that had not yet been at the forefront of compliance attention in the CIN/ACO world. Successfully caring for a population requires a broad mix of claims, financial, clinical and cross-continuum setting data to both support clinical care and prove compliance – no small task for any organization.
Master “Actionable” CIN/ACO Data Your Stakeholders Need
Harness the power of your CIN/ACO data to make it useful to stakeholders. First, the foundational data for successful operations is insight into your contract terms and the populations served within those agreements. Quality measures, clinical outcomes and financial performance are typically addressed in the contract terms. Second, real improvement results from data that provides actionable opportunities, so get clear on what “actionable” really means for your organization. “Actionable” translates into meaningful communication with all stakeholders, specifically health system executives, network operational leaders, participating providers, care managers and patients.
Different stakeholders need different communication from “actionable” data to perform well within your contracts. Typically, the key stakeholders include:
Winning In A World Of Competing Priorities
It’s no longer surprising that today’s patients want instant care, great customer service and quick answers to their concerns. This is important because they are also less concerned about having a relationship with a primary care physician. Hence, if the network does not have access to data from encounters that occur beyond their purview, such as outside the network, hospital, clinic, outpatient diagnostic facility and pharmacy, it is very difficult to identify which patients are truly at risk and need care urgently. Consider that the data required by each of the stakeholders may reside in multiple EHRs, HIEs and registries, or within pre- and post-adjudicated claims. While everyone is supposedly on the same team, some stakeholders can see all data and others cannot.
Here is where the legal entity boundaries become so important. Not only are there data compliance challenges within the CIN/ACO entity but even bigger data compliance challenges exist between the IDN and their owned CIN/ACO.
Requirements Versus Compliance: Who Sees What Data?
CINs/ACOs must understand data governance issues that arise, even when accepted strategies like using a separate server or creating a data warehouse with dedicated data marts are employed:
Proving Compliance Across People, Process And Technologies
The issues outlined above barely scratch the surface. Considering the complex relationships and data access needs, CINs/ACOs are well-advised to consider these recommendations to prove and document that technologies, people and processes are compliant:
As more and more IDNs, CINs, ACOs, IPAs and Payers acquire, merge and partner, data integration, proof of compliance, and appropriate access to data will become more complex. Long-term data governance strategies that allow for growth, technology improvements, and successful management of risk bearing agreements are critical. Take steps now to ensure your long-term success in this complex environment.
About The Author
Jeffrey Springer - Sr. Vice President, Healthcare Solutions, CitiusTech