Welcome to PremierOne Plus ACO
Opening Hours : Monday to Friday - 8:30am to 5:30pm
Contact : 714-705-4598
Advanced Premier Physicians ACO
1210 N Jefferson St, Suite D
Anaheim, California 92807
Phone: (714) 451-7788
Fax: (888) 709-9341
ACO Primary Contact:
Standardized measures include, but may not be limited to:
Care for chronic health care conditions using standard guidelines such as implementation of ACE inhibitors, adherence to dietary programs, maintenance of blood sugar testing and insulin administration, or compliance with medication regimen
Evaluation of services against standard frequency of either normalized data such as Kaiser Family Foundation or CMS data to compare emergency department visits, or bed days per 1000
Review of ambulatory care sensitive admissions that could have been avoided with appropriate early intervention. The AHRQ book that contains these types of examples is the Window Into Primary and Preventive Care, 2000, HCUP Fact Book No.5, Agency for Healthcare Quality and Research found at www.ahrq.gov/data/hcup/factbk5/
Required ACO Quality Measurements:
The ACO must demonstrate meeting quality performance standards. CMS will measure quality of care using nationally recognized measures in the following key domains:
Patient /Caregiver experience, Care Coordination/patient safety and Preventive Health;
At risk population: Diabetes, hypertension, Ischemic Vascular disease, Heart Failure and Coronary Heart Disease.
The analysis of the measures will reveal the areas that will require intervention to improve performance. If the performance standard is not met, the medical coordination team will collaborate with the provider in developing interventions and scheduling
re-measures to evaluate the intervention. Re-measures are important to trend the improvement and allow for additional or modification to the interventions. When the measurement goal is achieved and no further measures are required in either a patient experience measure or a clinical improvement area, then new areas of review will be selected based on other desired outcomes.
In performing the measurement analysis and testing the standard measurement, methodology to be implemented may include:
Standardized statistical methods: valid sampling, valid numerator and denominator, sample size confidence, and valid measurement periods
A stated performance goal based on clinical evidence or a goal in satisfaction measures
Comparison of the results of the measures and an analysis of any determined deficiencies in the intervention or process
Identification of opportunities for improvement which can change over time
Comparability of the data with consideration of different populations and time- periods even geographic and cultural differences
The ACO will use nationally developed and accepted written review criteria updated to the most current version available, i.e. Milliman Care Guidelines 12th Edition, Apollo Consultants, InterQual, guidelines in the CMS website for National Coverage Decisions (NCD), General Medicare coverage guidelines, and the local Medicare contractors written coverage decisions, (LCD) [which have to be used as first criteria and guidelines for Medicare members], The American College of Obstetrics and Gynecology, The United States Preventative Services Task Force Standards and other guidelines approved and disseminated to the ACO. Locally used criteria sets include specifications of Title 22 of the California Code of Regulations, the Los Angeles County Department of Health and Human Services Health Care Guidelines and Requirements, and the AHRQ National Clearinghouse at http://www.guideline.gov/. Review criteria are updated on an ongoing basis. For nationally recognized criteria sets they will be renewed at least every two years. Additionally, the ACO governing body recognizes that individual needs and or circumstances may require flexibility in the application of the ACO’s delivery system. Age, illness and co-morbidities, complications, home environment, individual progress and psychosocial needs are all considered in the evaluation of the beneficiary. Providers/participants contracted with the ACO are informed of guidelines used by the ACO through provider newsletters and memorandums or other communications. In addition, clinical criteria may be sent by fax, mail, or read to the physician over the phone. These provider/participants are welcomed to participate in the development of clinical guidelines and review criteria.
Consistency of application of criteria is monitored through retrospective analysis of claims data provided by CMS.
The medical coordination team informs providers/participants and vendors of all treatment guidelines and policies. The guidelines shall be disclosed by the ACO to provider/participants and beneficiaries upon request, and to the public upon request.
PREVENTATIVE HEALTH CARE SERVICES-CLINICAL GUIDELINES
The ACO will distribute Preventive Health Guidelines to providers/participants annually. Review of the preventative health care measures is a component of the ACO governing body or any appointed committees. Annually, the CDC Preventive Guidelines are reviewed and approved by the ACO governing body or appointed committees.
The ACO follows guidelines mandated by the State Department of Health Services (SDHS). Guidelines may include, but are not limited to those of the U.S. Preventive Services Task Force, the Centers for Medicare and Medicaid Services and national guidelines distributed through the AHQR.
The U.S. Preventive Services Task Force (USPSTF) was convened by the Public Health Service to rigorously evaluate clinical research in order to assess the merits of preventive measures, including screening tests, counseling, immunizations, and preventive medications.
Preventive Health Guidelines are distributed through a variety of methods:
Use of Preventive Health Guidelines is promoted throughout the year through a variety of channels to increase both awareness of the guidelines and beneficiary utilization of preventive health services.
The ACO shall cover and ensure that contracted primary care provider/participants provide of all medically necessary diagnostic, treatment, and follow-up services, which are necessary given the finding or risk factors identified in initial health assessments or during visits for routine, urgent, or emergent health care situations. The ACO shall ensure that these services are initiated as soon as possible but no later than 30 calendar days following discovery of a problem requiring follow up.
The AHRQ website contains not only the Preventive Health Guidelines but also recommended treatment guidelines. These guidelines may be more up to date than the state guidelines. http://www.ahrq.gov/clinic/cps3dix.htm.
The ACO will be responsible for identifying any variance from the standard of care, either as a sentinel event if an unjustifiable adverse outcome warrants immediate action or based upon a pattern of practice which falls out of the established program and community standards over a period of time. Utilization patterns may be identified by historic claims data retrospective utilization review. When utilization, quality assurance or quality of care concerns are identified, a corrective action plan is required to be established by the ACO Governing body or its structured committees which may include but is not limited to provider/participant education, staff development, administrative changes, provider/participant contract changes and alteration of provider/participant privileges.
The ACO Governing body shall follow the successive guidelines in the event a Provider/participant or provider/participant/supplier does not comply with utilization management patterns or quality management as set by the ACO Governing body:
The Board of Directors on the Governing Board have been appointed through an election by the participants and representative from the Medical Groups.
The Board of Directors on the Governing Board has exclusively exercise powers of the ACO and shall manage the business and affairs of the ACO in a manner consistent with the ACO agreement. The Board of Directors shall appoint and delegate to an Administrator for day-to-day business of the ACO in the ordinary course of its business, and as may require by Center for Medicare & Medicaid Services in Medicare Shared Savings Program. The Board of Directors are responsible for oversight and strategic decision of the ACO. The Board of Directors on the Governing Body have complete discretion in managing the affairs of the ACO, including without limitation, the authority to purchase, sell, encumber or lease; to form or acquire interests in other ventures, partnerships; and all other such activities as may arise in the normal course of managing the business Company.
For shared governance Prime Healthcare Services (“Hospitals”) has appointed following participants as Board of Directors on ACO’s Governing Board.
• Chaewon Song, M.D
• John S. Kim, M.D.
Hospital will appoint one more specialist to be on ACO’s Governing Board to have shared governance.
Advanced Premier Physicians ACO has reached an agreement with ChoiceOne EHR Inc. through its subsidiary Collaborative Health Solutions to form an Accountable Care Organization (ACO). An ACO is a provider based organization authorized by the Centers for Medicare and Medicaid Services (CMS) to provide care for Medicare Fee-for-Service beneficiaries. To directly quote the CMS website, the purposes of an ACO include: “…help doctors, hospitals and other health care providers better coordinate care for Medicare patients.” “…create incentives for health care providers to work together to treat an individual patient across care settings.” “…reward ACO’s that lower their growth in health care costs while meeting performance standards on quality of care and putting patients first.” This is a very exciting development for the physicians in Health First Network. It not only places them in the forefront of health care reform, it gives the physicians the ability to make their own determinations of how care is to be coordinated and delivered to patients. Added to this is the fact there is opportunity for the physician to earn a share of any savings achieved with no downside risk.