ICD-10 Helps Accountable Care (ACO)

The Affordable Care Act (ACA) improves the health care delivery system through incentives to enhance quality, improve beneficiary outcomes and increase value of care.  One of these key delivery system reforms is the encouragement of Accountable Care Organizations (ACOs).

Making ACO a Reality – Organization Structure

Accountable Care Organization, can be instantiated by a health plan, health care system, or a large self-insured employer.  The philosophy is that ACOs are a physician-led entity – consisting of hospitals, primary care physicians, and specialists – responsible for managing the full continuum of care and accountable for the overall costs and quality of care for a defined population, that is partnered with their health plan. CMS mandates such as ICD10 are separate from health care reform and were mandated before health care reform became law.

Quality Measures, Incentives

Since CMS 5-Star Ratings and other quality measures such as readmissions and the general health of the patient will be expressed in ICD-10, there is a mutual incentive for payors and providers to work together for better outcomes and to measure those outcomes in ICD-10.

Enabling Technology

Business Intelligence and dashboards will be key in measuring process improvements for ACOs.   ICD-10 implementation costs, while high will ultimately assist companies in getting higher payments from CMS because the granularity of the information and “specificity” will improve the precision of the Quality Measures.

Importantly, health insurance exchanges (HIE) that can facilitate the exchange between payor and provider across EMR systems, geographies, multiple providers, and settings (ambulatory, inpatient) are important.

CMS Mandates Force Cooperation

ICD-10 in turn is its own reimbursement system which encourages payor – provider working relationships.  Accountable Care organizations will have the most success when they think about coordinated care.  Coordinated care means working with trading partners and thinking about the patient experience.

Funded vs. Unfunded Mandates – Regulatory Ironies

The American Recovery and Reinvestment Act (ARRA) and the HITECH Act created incentives for adoption of electronic technology. Meaningful Use of Electronic Health Records and Health Information Exchanges are being adopted and creating tremendous wealth for American entrepreneurs.

Yet, ICD-10 implementation, which is the data standard that will populate digital containers including EMR and HIE systems, is not a funded mandate.  ICD-10 will provide the system that enables the expression of NCQA and other quality measures.

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Michael F. Arrigo

Michael is Managing Partner & CEO of No World Borders, a leading healthcare management and IT consulting firm. He serves as an expert witness in Federal and State Court and was recently ruled as an expert by a 9th Circuit Federal Judge. He serves as a patent expert witness on intellectual property disputes, both as a Technical Expert and a Damages expert. His vision for the firm is to continue acquisition of skills and technology that support the intersection of clinical data and administrative health data where the eligibility for medically necessary care is determined. He leads a team that provides litigation consulting as well as advisory regarding medical coding, medical billing, medical bill review and HIPAA Privacy and Security best practices for healthcare clients, Meaningful Use of Electronic Health Records. He advises legal teams as an expert witness in HIPAA Privacy and Security, medical coding and billing and usual and customary cost of care, the Affordable Care Act and benefits enrollment, white collar crime, False Claims Act, Anti-Kickback, Stark Law, physician compensation, Insurance bad faith, payor-provider disputes, ERISA plan-third-party administrator disputes, third-party liability, and the Medicare Secondary Payer Act (MSPA) MMSEA Section 111 reporting. He uses these skills in disputes regarding the valuation of pharmaceuticals and drug costs and in the review and audit of pain management and opioid prescribers under state Standards and the Controlled Substances Act. He consults to venture capital and private equity firms on mHealth, Cloud Computing in Healthcare, and Software as a Service. He advises ERISA self-insured employers on cost of care and regulations. Arrigo was recently retained by the U.S. Department of Justice (DOJ) regarding a significant false claims act investigation. He has provided opinions on over $1 billion in health care claims and due diligence on over $8 billion in healthcare mergers and acquisitions. Education: UC Irvine - Economics and Computer Science, University of Southern California - Business, studies at Stanford Medical School - Biomedical Informatics, studies at Harvard Medical School - Bioethics. Trained in over 10 medical specialties in medical billing and coding. Trained by U.S. Patent and Trademark Office (USPTO) and PTAB Judges on patent statutes, rules and case law (as a non-attorney to better advise clients on Technical and Damages aspects of patent construction and claims). Mr. Arrigo has been interviewed quoted in the Wall Street Journal, New York Times, and National Public Radio, Fortune, KNX 1070 Radio, Kaiser Health News, NBC Television News, The Capitol Forum and other media outlets. See https://www.noworldborders.com/news/ and https://www.noworldborders.com/clients/ for more about the company.

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