Diabetes Disease Management and Accountable Care Organizations: A Lean Approach to Improving Patient Outcomes and Reducing Cost

• Main Author: Dinette, David
• Format: Others
• Published: Digital Commons at Loyola Marymount University and Loyola Law School 2013
• Subjects: Engineering; Systems Engineering
• Online Access: https://digitalcommons.lmu.edu/etd/358; https://digitalcommons.lmu.edu/cgi/viewcontent.cgi?article=1362&context=etd

In 2011, Congress passed The Patient Protection and Affordable Care Act (PPACA) to reduce the number of uninsured Americans and reduce the overall cost of healthcare in the U.S. The PPACA encourages healthcare providers to form Accountable Care Organizations (ACO's). Accountable Care Organizations are groups of providers and suppliers that work together to coordinate care for the Medicare-Fee-For-Service patients they serve (RTI International, 2011). The PPACA is managed by The Centers for Medicare and Medicaid Services (CMS), which is responsible for writing, implementing and enforcing the rules of the PPACA. The PPACA has implemented the Medicare shared savings program, which is designed to create incentives for health care providers to work together to improve patient outcomes and lower the cost of care delivery. CMS has established requirements that the ACO must achieve to be eligible to participate in the shared savings program. CMS has outlined 33 required performance and quality metrics that the ACO must improve and report. The scope of this project will focus on the Medicare patient population within the ACO. The cost savings and patient outcomes will be analyzed through the evaluation of a diabetes disease management program that will emphasize the six diabetes related "pay for performance" metrics that are required by CMS. These six metrics include CMS performance metric numbers 22 to 27. The project objective is to design a disease management care model that can be utilized by both new and established ACOs. The care model will demonstrate improved diabetic patient outcomes while reducing the cost of delivery, and also while meeting the expectations of CMS to participate in the shared savings program. The project evaluated the implementation of a diabetes disease management program and the utilization of a diabetes care team. The purpose of the care team is to improve patient outcomes by standardizing the care for diabetes patients throughout the entire ACO. Standards of care were established to ensure that all patients are treated with the same quality of care, from diagnosis through treatment. The system will utilize an Electronic Medical Records (EMR) System that will allow providers within the ACO access to the patient's health record and care plans, allowing communication across the care continuum. The ACO will have the ability to generate reports on the performance metrics required by CMS, allowing the ACO to evaluate their care plans and the cost of care delivery. The standards for reporting and capturing data will be consistent across the ACO to ensure all the proper data is collected and reported to the CMS. A Patient Safety Alert System (PSA) will be incorporated into the EMR to alert healthcare providers if duplicate test or procedures have been order, or if the standards of care are not being followed. The project will utilize the systems engineering tools learned through class work as a student at Loyola Marymount University, as well as the INCOSE and DoD Architecture Framework. Trade studies will be evaluated to identify the preferred alternative that has the lowest level of risk and highest financial incentives, all while meeting the performance and cost savings requirements of CMS. Some key components that were evaluated in the trade studies include the addition of a diabetes care team, diabetes disease management program and the implementation of lean healthcare. The trade studies revealed that the implementation of a diabetes care team, diabetes disease management program with the implementation of lean healthcare provided the ACO with the greatest opportunity to participate in the Medicare shared savings program. The profit sharing due to the implementation of the disease management program ranges from $1. 5 million to $2.5 million per year for a small ACO (5000 beneficiaries) to $23 million to $76 million per year for a larger ACO (150,000 beneficiaries). The implementation of lean healthcare allows the ACO healthcare providers to see more patients per year. The suggested increase is 25 percent more patients per year, regardless of the size of the ACO. The implementation oflean and sixsigma provides a patient centric focus that is concentrated continuous improvement and the elimination of non-value added waste.