ACO Benchmark Breakdown

ACOs are still a work in progress, and their performance varies substantially. Even if you’re not an ACO, you (and your patients) may benefit by sharing their objectives. Here is a list of the 2016-2017 quality measures, grouped into their respective categories.

Patient/Caregiver Experience:

The following 8 measures are assessed using a Consumer Assessment of Health Care Providers and Systems (CAHPS) :

ACO 1 – Getting Timely Care, Appointments, and Information

ACO 2 – How Well Your Doctors Communicate

ACO 3 – Patients’ Rating of Doctor

ACO 4 – Access to Specialists

ACO 5 – Health Promotion and Education

ACO 6 – Shared Decision Making

ACO 7 – Health Status/Functional Status

ACO 34 – Stewardship of Patient Resources*


  • Timely care and appointments depends upon your scheduling software configuration. What is your provider utilization? What is each specialty’s 3rd available appointment metric? How much time do your providers spend with patients? How much time do they spend doing documentation and paperwork? Does your organization have consistent visit types across providers?
  • Patient portals streamline communication, provide patients access to their information, and ease the burden on your office staff.
  • Communication – Does your practice use a messaging app to communicate internally or externally? If so, is it providing value or consuming provider time?How often do you share information with other health systems? Is your EHR configured to do so? It probably can share information, but is this a part of your physician’s workflow?
  • Access to Specialists – this is a combination of timely care and appointments and your organizations referral workflow. Does your organization have a seamless referral workflow? How much revenue does your organization lose to external referrals each month?
  • Health promotion and education – what does your AVS contain, and how frequently is it distributed?

Care Coordination/Patient Safety:

Many of the remaining metrics will be tracked via claims data, and others will be submitted using the GPRO Web Interface.

ACO 8 – Risk Standardized, All Condition Readmission

ACO 35 – Skilled Nursing Facility 30-Day All-Cause Readmission Measure (SNFRM)*

ACO 36 – All-Cause Unplanned Admissions for Patients with Diabetes*

ACO 37 – All-Cause Unplanned Admissions for Patients with Heart Failure*

ACO 38 – All-Cause Unplanned Admissions for Patients with Multiple Chronic Conditions*

ACO 9 – Ambulatory Sensitive Conditions Admissions: Chronic Obstructive Pulmonary Disease or Asthma in Older Adults (AHRQ Prevention Quality Indicator (PQI) #5)

ACO 10 – Ambulatory Sensitive Conditions Admissions: Heart Failure (AHRQ Prevention Quality Indicator (PQI) #8)

ACO 11 – Percent of PCPs who Successfully Meet Meaningful Use Requirements

ACO 39 – Documentation of Current Medications in the Medical Record*

ACO 13 – Falls: Screening for Future Fall Risk


  • How does CMS define readmission rate? The “Risk-adjusted percentage of ACO assigned beneficiaries who were hospitalized and who were hospitalized and readmitted to a hospital within 30 days following discharge from the hospital for the index admission.” Lower rates are better. The denominator is relevant hospitalizations for ACO beneficiaries 65+ at non-Federal, short-stay acute-care or critical access hospitals, and the numerator is unplanned readmissions of those patients within 30 days. See inclusions and exclusions here.
  • Why readmission rate? Preventable readmissions cost at least Medicare $1.9 Billion annually, and readmissions are disruptive to patients and caregivers. I’ll elaborate on readmissions in an upcoming post.
  • The two Prevention Quality Indicator benchmarks – COPD/Asthma and Heart Failure – are best managed in an outpatient setting. How do you proactively and regularly treat these patients? Do you track medication compliance? Do you proactively schedule maintenance visits? The same could be said for diabetes. How do you use your technologies to better manage these populations?
  • Unplanned admissions result in high costs for both the patient and the ACO. How might your technology help you provide more efficient, coordinated, and patient-centered care to your populations with chronic diseases?

Preventative Health

ACO 14 – Preventative Care and Screening: Influenza Immunization

ACO 15 – Pneumonia Vaccination Status for Older Adults

ACO 16 – Preventative Care and Screening: Body Mass Index (BMI) Screening and Follow Up

ACO 17 – Preventative Care and Screening: Tobacco Use: Screening and Cessation Intervention

ACO 18 – Preventative Care and Screening: Screening for Clinical Depression and Follow-up Plan

ACO 19 – Colorectal Cancer Screening

ACO 20 – Breast Cancer Screening

ACO 21 – Preventative Care and Screening: Screening for High Blood Pressure and Follow-up Documented

ACO 42 – Statin Therapy for the Prevention and Treatment of Cardiovascular Disease


  • How do you incentivize patients to participate in regular preventative care? Do you alert patients when it’s time to schedule an annual appointment? Do you alert schedulers and office staff that populations of patients are due for annual appointments? You can likely build reports, work queues, alerts, and batch notifications to help you identify and connect with these patients.

At-Risk Population Depression

ACO 40 – Depression Remission at Twelve Months

At-Risk Population Diabetes

ACO 27 Diabetes Composite – Hemoglobin A1c Poor Control

ACO 41 Diabetes Composite – Eye Exam*

At-Risk Population Hypertension

ACO 28 – Hypertension (HTN): Controlling High Blood Pressure

At-Risk Population IVD

ACO 30 – Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic

At-Risk Population HF

ACO 31 – Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)

At-Risk Population CAD

ACO 33 – Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Reception Blocker (ARB) Therapy – for patients with CAD and Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%)


  • For these more specific metrics, clinical content, alerts, and reports can help clinicians identify these patients when necessary. Reporting dashboards can help clinicians track progress across populations. How do your clinicians manage these conditions today?

*New measures that will phase into pay-for-performance for the 2017 reporting year and benchmarks will be released prior to the start of the 2017 reporting year.

CMS has developed a phased-in approach to holding ACOs accountable to the 33 quality standards.  Each ACO agrees to participate in the program for three years.

Pay for performance will be phased in over the ACO’s first agreement period as follows:

  • Year 1: Pay for reporting applies to all 33 measures.
  • Year 2: Pay for performance applies to 25 measures. Pay for reporting applies to eight measures.
  • Year 3: Pay for performance applies to 32 measures. Pay for reporting applies to one measure that is a survey measure of functional status. CMS will keep the measure in pay for reporting status for the entire agreement period. This will allow ACOs to gain experience with the measure and will provide important information to them on improving the outcomes of their patient populations.

In future posts, I’ll delve into research supporting clinical measures like readmission and unplanned admissions.



Buzzword of the Day: Strategy


Strategy is hard. Leaders are expected to develop and implement strategies that move organizations forward. This requires a sound understanding of business drivers, industry direction, technological advances, upcoming regulations, etc etc etc. It might be easier to focus on the success of a single implementation, upgrade, or project, but this myopic strategy might undermine your ability to realize maximum business value from your (often expensive) technologies. Leaders of healthcare organizations must therefore begin with the end vision and work backward. That end vision should be the potential business (or patient care) drivers that technologies might improve.

A few folks at MIT Sloan published findings about the relationship between technology and strategy:

“What separates digital lea­ders from the rest is a clear digital strategy com­bined with a culture and leadership poised to drive the transformation. The history of technological ad­vance in business is littered with examples of companies focusing on technologies without in­vesting in organizational capabilities that ensure their impact. In many companies, the failed imple­mentation of enterprise resource planning and previous generations of knowledge management systems are classic examples of expectations falling short because organizations didn’t change mindsets and processes or build cultures that fostered change.”

Without an effective and coherent strategy, the benefits of technology go unrealized. A digitally immature organization tends to focus on existing operations, while a digitally mature organization develops and executes a strategy to transform its business. Without a strategy that seeks to derive value from technology, IT doesn’t matter, as Nicholas Carr argues in his oft-cited HBR article. According to Carr, unless a given technology is proprietary to a company, that technology does not provide any inherent competitive advantage on its own, because eventually all companies will adopt the technology. Leaders cannot view technology as an end in itself, but should instead view technology as a means to strategic ends.

Talent is essential to digital transformation, and Sloan found that only 19% of organizations in the early stages of technological transformation are able to build the necessary skills to capitalize on digital trends. Agility may be more important than developing long-term technology skills, because demands will change rapidly and this rapid rate of change requires an agile staffing strategy. Investment and risk precede the rewards of a well-executed strategy, and organizations must invest in the right people.

Leaders should also maintain a strong physical and digital presence to inspire confidence, generate innovative dialogue, and excite team members about organizational vision.

“Employees in digitally maturing organizations are confident in their leaders’ ability to play that digital game. More than 75% of respondents from these companies say that their leaders have sufficient skills to lead the digital strategy. Nearly 90% say their leaders understand digital trends and technologies. Only a fraction of respondents from early-stage companies have the same levels of confidence: Just 15% think their leaders possess sufficient skills, and just 27% think their leaders possess sufficient understanding.”

John Halamka provides a great a example.

In today’s agile environment, the costs of inaction almost always exceed the costs of action. To assess your organization’s strategy, ask yourself these three questions:

  1. Does out healthcare organization have a strategy that goes beyond implementing technologies?
  2. Does our company culture foster digital initiatives?
  3. Is our organization confident in its leadership’s digital fluency?


The Quadruple Aim

Back in 2008, Berwick, Nolan, and Whittington authored a paper outlining the Triple Aim of healthcare. It challenged US healthcare organizations to pursue three objectives: improve the care experience, improve population health, and reduce per capita costs of care. Most organizations have since invested heavily in EHRs. While information can be immensely valuable if leveraged properly, EHRs often add to physician workload.

In late 2014, Bodenheimer and Sinsky proposed the Quadruple Aim to alert the community to caregivers’ deteriorating conditions:

“In a 2011 national survey, 87% of physicians named the leading cause of work-related stress and burnout as paperwork and administration, with 63% indicating that stress is increasing. Forty-three percent of physicians surveyed in 2014 reported spending over 30% of their day on administrative tasks. Physicians spend more time on non–face-to-face activities (eg, letters, in-box management, and medication refills) than with patients. Even when in the exam room with patients, primary care physicians spend from 25% to 50% of the time attending to the computer. Between 2009 and 2010, primary care physicians at a Veterans Affairs facility spent 49 minutes per day responding to inbox-type alerts in addition to documentation of care provided. One-half of such alerts have little clinical significance or could be handled by other team members; 80% of the text in the alerts is unnecessary. The volume of alerts and texts overshadows important information that requires action. Moreover, the alerts create interruptions known to adversely affect patient care.

A 2013 survey of 30 physician practices found that electronic health record (EHR) technology has worsened professional satisfaction through time-consuming data entry and interference with patient care. Emergency medicine physicians spend 44% of their day doing data entry, with 4,000 EHR clicks per day; only 28% of the day is spent with patients. In a 2011 survey, over three-quarters of physicians reported that the EHR increases the time it takes to plan, review, order, and document care.” (Please see article for citations)

Because burnout imperils the Triple Aim, we must consider and improve the work life of health care providers. The authors offer the following suggestions to improve work conditions for primary care physicians. How many of the below has your organization automated with technology? Pre-visit planning can be automated in EHRs, staff roles can be expanded in EHRs, and prescriptions refill workflows can be optimized in EHRs with the aid of a patient portal.

  • Implement team documentation: nurses, medical assistants, or other staff, present during the patient visit, entering some or all documentation into the EHR, assisting with order entry, prescription processing, and charge capture. Team documentation has been associated with greater physician and staff satisfaction, improved revenues, and the capacity of the team to manage a larger panel of patients while going home earlier.

  • Use pre-visit planning and pre-appointment laboratory testing to reduce time wasted on the review and follow-up of laboratory results

  • Expand roles allowing nurses and medical assistants to assume responsibility for preventive care and chronic care health coaching under physician-written standing orders

  • Standardize and synchronize workflows for prescription refills, an approach which can save physicians 5 hours per week while providing better care

  • Co-locate teams so that physicians work in the same space as their team members; this has been shown to increase efficiency and save 30 minutes of physician time per day

  • To avoid shifting burnout from physicians to practice staff, ensure that staff who assume new responsibilities are well-trained and understand that they are contributing to the health of their patients and that unnecessary work is reengineered out of the practice

The authors also point out that an estimated 59% increase in staffing is needed to achieve the patient-centered medical home. How many of those functions can be automated with technology?




Hello readers, thank you all for visiting this blog. My goal is to help healthcare organizations realize the full potential of their information technologies. As hospital systems get creative and enjoy IT success, I’ll share their stories and suggest ways to generalize to other organizations.

A bit about me – my name is Jon Galante and I’m 26 years old. I spent 3.5 years in implementation at an industry-leading EHR vendor. As I worked with healthcare organizations a theme emerged: hospital systems work very hard to implement and maintain complex IT systems. IT shops spend a lot of time managing issue lists, triaging release notes, and fielding optimization requests. Amid the flux, some organizations discover valuable ways to advance the quadruple aim – improved clinical outcomes, improved patient experience, lower costs, and improved provider experience. I believe these stories should be shared and implemented across the US.

This is my first blog, so I welcome feedback. I also welcome help – if any reader knows about something good in healthcare IT, please share it. I plan to build a community where members share interesting IT work they’ve done at healthcare organizations, and it begins with this blog.

I hope the ideas shared here help leaders, providers, and techies move healthcare forward.