Monday, April 4, 2011

Ambulatory Care Sensitive (ACS) Hospitalizations and Accountable Care Organizations: A Complicated Measure of ACO Quality

Food fight!
Imagine being a C-suite, VP or lead administrator in a newly formed Accountable Care Organization. At some point, you'll need to have a physician meeting to go over the terms of the CMS contract.  Because such meetings often occur after clinic hours, you may be tempted to provide dinner.  While the docs are working on their chicken breast, white bread rolls and iced tea, you'll remind them there's a Medicare claims-expense threshold to beat.  You'll point out that once savings being to accumulate, the ACO will get a percent as a bonus that could add up to millions of dollars. 

However, you'll also need to point out that certain quality measures also have to be met in order to get the full bonus.  That's when you'll say:

".... and every time we admit a patient with urosepsis, pneumonia, dehydration diabetes (short and long term complications), COPD and heart failure, we lose quality points."

The DMCB suggests, at this point, that is when  hospital administrators will rue the decision to provide dinner. That's because the doctors will be throwing it at them.

The DMCB explains.

As noted in a prior DMCB post, ACOs shared savings will be contingent on attaining sufficient levels of clinical quality in their attributed population. Go to the just-published New England Journal "Perspectives" article by CMS Administrator Don Berwick on ACOs and you'll find this table that summarizes CMS' proposed measures for assessing ACO quality.  That Journal table is taken from a more complicated table in the proposed rule (go to page 174) on how ACO quality will be assessed.  

As the DMCB understands it, CMS is proposing 65 quality measures. Each would be worth "two points," for a maximum of 130 points.  With a few "all or none" exceptions (for example, diabetes), each participating ACO would be compared to a yet-to-be-determined benchmark on each of the quality measures.  The more the ACO "beats" the 30th percentile for each of the 65 benchmarks, the greater the fraction of the available two points that is awarded.  Divide that rolled up point sum by 130 and that will be the fraction of the shared savings that is awarded.

All well and good, but this is where it gets interesting.
In the suite of ACO "Care Coordination" quality measures is a subcategory called "management of ambulatory sensitive conditions."  It includes diabetes (short and long term complications), COPD, heart failure, dehydration, urinary tract infection and pneumonia.  That's 14 points.
Just what are "ambulatory sensitive conditions" (ASC) you ask?

ASC is all about measuring the rate of "avoidable" hospital admissions in each of those disease categories.  It assumes that a hospitalization for an ASC can be used as a surrogate measure of access to appropriate outpatient primary health care.  If the patient had optimum outpatient access, evidence-based care and close follow-up, the hospitalization could have theoretically been avoided.  An excess number of hospitalizations in those seven disease categories could mean that the outpatient primary care system is failing.

For more information, here's the definitive AHRQ summary on the topic.  It's testimony to how ASC-logic has been used for years by academic researchers and health policy types to assess managed care, health care quality, Medicare and Medicaid.  For example, CMS has looked at ASCs to scrutinize managed care.  States have also relied on them (example) to assess quality of care. Here's an example of ASC methodology being applied to conclude that 7% of hospitalizations among Medicare beneficiaries with diabetes "could be avoided."  Here's a ten year old Medicaid study showing there's a link between ASC hospitalizations and not having at least 3 outpatient visits in the prior year.

To put this in perspective, imagine that you or a loved one has just come down with pneumonia.  Laypersons may expect to be hospitalized for intravenous antibiotics.  The research-based rationale on why you may be wrong is here.

The ultimate question in all these studies is - and for the ACOs will be - whether the observed rate of ASC hospitalizations is "disproportional" to what would be expected.  That's why the AHRQ summary mentioned above prominently points out that some ASC hospitalizations are always expected to happen and why CMS will use benchmarks for ACOs.  As the DMCB understands it, the "specifications" and risk-adjustment methodology that will be used to establish those benchmarks has not been "refined" yet and will be subject to feedback obtained during the 60 day comment period.

The DMCB has been thinking about this and has several worries:

1.  ASC are not a familiar metric to physicians, who will misinterpret them as an attempt to deny hospitalizations for all patients that need them.  Administrators won't do a good job of dissuading the physicians from that point of view.  What should happen is that both administration and physicians need to think about systems of expedited management for patients with those seven conditions upstream in the course of care.  Do that and the hospitalization rate will go down - but not vanish.

2. It may invite coding gamesmanship.  The detailed ACS methodology relies on ICD-9 coding in its calculations.  While this was a subject of research, most hospitals had no reason to code around ACS-based metrics.  Now that there's money attached to it, ACOs could change that.

3. And finally, the DMCB is unaware (readers?) of  a nerdy corner of health services research like ACS hospitalization rates being tied directly to reimbursement in such an astonishing scale.  Assuming they're adopted, if this part of the regulations collapses under the weight of misinterpretation, mismanagement or bad measurements, it could put the ACO concept at risk.


thinktanker said...

Ah yes, good ol' ACSCs (the last C representing Conditions).

You are spot on in your tying bulk of usage of ACSCs to date to think tanks. When I was at such a shop years ago we pumped out ACSC reports for hospitals and physician groups as part of nearly every standard quality reporting package we handed out.

These reports included many more conditions beyond those mentioned in the ACO proposed rule, (asthma, for example).

In selling the idea to physicians and hospital administrators, the key talking points centered on the method of severity adjustment: only the "low severity" ACSCs were the ones to worry about and focus on. 3M's APR-DRGs were the basis for making the distinction between low and high severity inpatient ACSC admissions. Specifically, the APR-DRG's severity of illness assignment (SOI) per admission, where SOI = 1 or 2 (low to moderate severity) was a true ACSC, but SOI = 3 or 4 (high to extreme) were not really ACSCs.

SOI was calculated, as you mention, from discharge record ICD-9 codes. Primary Dx sets the base APR, and the secondary Dx's drive out the SOI score.

When we'd hand out the reports, there were always plenty of oohs, ahs and head nodding, especially if a hospital's rate of "low severity ACSCs" was significantly higher than other peer hospitals. The question of "what is an ACSC" always came up, and the definition closely mirrored the one you provided - with the additional discussion of severity of illness determination methodology.

I always found these reports to be one of temporary amusement on the part of recipients, but nothing taken seriously to the point of doing anything actionable. There was no real driver for action. So our admissions for these conditions are higher, so what? You want me to turn these folks away at the door and tell them to get better primary care coordination? Really?

But now that there are some downstream repercussions with dollars attached, I am sure that there will me more than just mild amusement. Frustration and bewilderment at first, and I would then predict that any actions taken will be more on the coding side than the practice side.

Jaan Sidorov said...

Wow Tsquared - thank you for that input. I've dealt with ACsCs in a superfical manner but your comments are quite illuminating!