Tag Archives: Tiffanie Lenderman

Checking in on ACOs

With accountable care organizations (ACOs) soon to serve more than a million Medicare patients, it is clear that this model of care delivery is receiving an unprecedented test of its viability, and, if it works as intended, may reshape how healthcare is paid for on a larger scale. Cigna alone plans to have more than a million people enrolled in ACOs by 2014, and says it believes that ACOs are going to be important regardless of the Supreme Court’s ruling on the Patient Protection and Affordable Care Act (PPACA).

With so much focus on the topic, it’s worth taking a look back at some of the research and analysis on ACOs published by Milliman on the topic over the past couple of years.

First, for a good summary of ACOs—what they are and how they work—start with this overview video featuring a number of Milliman experts.

For many observers, the key question about ACOs is whether they represent a financially viable model compared to fee-for-service. Effective financial management will be key to success. Milliman has produced a number of relevant papers:

With all the attention on Medicare ACOs, it’s easy to forget that they exist in the private market, as well. For more on such entities, look at “ACOs Beyond Medicare,” which describes the potential advantages for providers who partner with a private insurer rather than with CMS. A 2011 Managed Healthcare Executive roundtable featuring Milliman consultant Rob Parke also discussed ACOs in the private market.

A number of other papers have also been published discussing various aspects of ACOs such as:


ACOs and evidence-based guidelines

Accountable care organizations (ACOs) are an operational and reimbursement healthcare model that is intended to help achieve the dual goals of managing healthcare costs while improving quality of care. Evidence-based guidelines for care management hold great potential for helping ACOs meet these goals in several ways, such as by promoting best practices, by assisting with payment allocation among providers of care, and by facilitating communications among providers and between providers and patients. This paper presents clinical referral guidelines as an example of how evidence-based guidelines can affect and enhance the accountable care concept.

The case for well-researched medical guidelines

This is excerpted from the recent paper, “How hospitals can arm themselves in the war on waste,” by Helen Blumen and Tiffanie Lenderman:

With increased scrutiny by CMS contractors of hospital admission and treatment documentation, scientifically based medical guidelines can be a valuable tool for supporting the physician decision-making process and providing evidence of appropriate care. Whether in reviewing retroactive cases or current billings, contractors will be looking at physician documentation in making their determinations. Supporting records from auxiliary caregivers will count for very little if the physician has not made the right decision and properly recorded it.

As an example, a physician admitted a patient for heart failure, noting respiratory compromise, abnormal renal function ( BUN 27 and creatine 2.0), and a blood oxygen saturation level of 96 percent with the patient on low-flow oxygen at 2L/min. The Milliman Care Guidelines® indications for admission for heart failure include documenting worsening renal function and a blood oxygen saturation level below 90. In this instance, the case manager using the Care Guidelines would provide the physician with the following prompts: “Please document the patient’s renal function prior to admission” and “Please indicate in your notes the patient’s O2 saturation on room air.” With these prompts, the physician taking care of this patient could have chosen to admit the patient for observation and then determine if the patient meets the criteria for admission for heart failure.

Well-researched medical guidelines can help hospitals improve and demonstrate best practices in the face of CMS scrutiny. They can be used to:

  • Provide supporting evidence in case of appeal
  • Help determine appropriateness for admission
  • Prompt physicians to provide documentation to the clinical record

The War on Waste

The United States spends upwards of $600 billion each year on wasteful healthcare, and as the biggest hospital payor in the country, the federal government has an interest in minimizing this waste. For almost 20 years, the Centers for Medicare & Medicaid Services (CMS) has been developing various auditing capabilities. When the recovery audit contractor program was made permanent in August 2009, it became just the latest example of the War on Waste that has been mustering for many years and has now reached maturity. What can physician executives do to arm themselves for the War on Waste? Scientifically based guidelines and documentation of best practices will play an important role and can help ensure more efficient and quality care even as the War on Waste challenges the way hospitals provide care.

Find out more—read the recent article in the Physician Executive Journal.