The Droids You Are Looking For Are Not Here

by Gregg A. Masters, MPH

Beneath the ideological crossfire and mostly bluster of the ACA ‘repeal and replace crowd’, while the latest ‘new, new, thing‘ aka the defacto Rorschach upside of a litany of mostly vaporware or me too ‘meh‘ digital health apps, platforms or S-1 filings (see: ‘Disruptive Idiots from Silicon Valley‘) stumble into maturity amidst growing calls for validation and evidence of tangible ecosystem sustainability, a pulse of innovation can be found in some less ‘sexy’ sectors.

Some time ago physician innovation pioneer Richard Merkin, MD, the founder and principal visionary behind the Heritage Provider Network and all of its sequelae (Heritage Medical Systems, Heritage ACO, etc.), opined from the stage at the ACO Summit that perhaps the biggest contribution (gold) from the ACA was to be mined from the forward leaning work stimulated by the law’s enablement of the Centers for Medicare and Medicaid Innovation (CMMI) aka @CMSinnovates on twitter.

Richard Gilfillan MDThe indisputable driver of what was then invested in Richard Gillfilan, MD the first CMMI Director (now stewarding the transformation at Trinity Health System, @TrinityHealthMI), was the volume to value imperative.

Into this challenge was cast considerable public capital/incentive funds to model what that meant from a delivery system and financing re-engineering perspective. Perhaps fueling the discounting of CMMI’s early efforts was the poorly constructed ‘Pioneer ACO‘ program, ostensibly designed to attract a more risk savvy pool of players who could reasonably assume greater risk and therefore earn more meaningful bonuses for doing what they already know how to do principally via Medicare Advantage participation. This early cohort of 32 ‘Pioneers’ has dwindled recently to 19 with the recent defection of the trophy Darmouth-Hitchcock ACO, see:Dartmouth-Hitchcock exits Medicare’s Pioneer ACO program‘.

With that as backdrop, consider the following timely guide from the Cooperative of American Physicians titled ‘The Physician’s Guide To Value-Based Compensation‘. Consider this an essential ‘blocking and tackling’ primer of how to incentivize the granular behavior of those who write the ‘purchase orders’ for an essentially supply driven healthcare economy. As my colleague and surfing buddy John Mattison, MD (@JohneMattison), Assistant Medical Director, and CMIO Kaiser Permanente Southern California (@KPshare) often says: ‘we get what we incent’.

CAP_guide to value based comp

[Editor’s Note: and for those of you really interested in where the AMA stands on the bridging the volume-to-value divide, listen to: Health 2.0 Fall Conference 2015: An AMA Deep Dive on ‘The App Cure’].

Whether the ACA is repealed (highly doubtful) or materially modified (also not likely) its essence will not and cannot be ‘undone’ – the horse is out of the barn. Like it or not, the controlling DNA driving the many moving parts articulated in the ACA (and its state lab version ‘RomneyCare’) builds on decades of established health policy thinking on what works in the uniquely American public/private pluralistic partnership of healthcare financing and delivery.

Watch the ‘enablers’

Whether ACOs, fully integrated delivery systems (real IDNs – NOT their IDN lite versions), PCMHs, or one of a number of strains of risk bearing organizations (RBOs) from bundled pricing to full blown per member per month (PMPM) capitation, this is where the sustainable action can and will be found. This other stuff, plays well at CES and the many wannabe healthcare industry copy cat conferences playing an up the ante ‘cool factor’ card to an often ADD crowd, yet it’s tangible contribution to the triple aim or sustainable healthcare economy remains squarely ‘on the come.



Courtesy of our friends at AJMC: ‘5 Things to Know About Accountable Care Organizations’

by Laura Joszt

This week, The American Journal of Managed Care was in Palm Harbor, Florida, hosting the fall live meeting of its ACO and Emerging Healthcare Delivery Coalition, where stakeholders from across the healthcare industry discussed best practices. As the country moves from volume to value, accountable care organizations (ACOs) can play a key role during the transition from fee-for-service. However, ACOs not only remain largely a mystery to the average consumer, but also to providers who may be part of an organization participating in an ACO. Here’s what you need to know about ACOs:

1. ACOs are older than the Affordable Care Act. At least, the theory of ACOs is older. While the inclusion of ACOs in the health reform law has accelerated adoption of the delivery model, the term “accountable care organization” was first coined in 2006 by Elliott Fisher, MD, director of the Dartmouth Institute for Health Policy and Clinical Practice.

2. There are multiple models established by CMS. There are a number of different ACO models being offered by CMS. The most common model is the Medicare Shared Savings Program (MSSP), which has 404 ACOs and is accepting more. The Pioneer ACO Model is for healthcare organizations and providers already experienced in coordinating care, and while it started with 32 ACOs, just 19 remain today. The Advance Payment ACO Model is designed for physician-based and rural providers. And the newest model is the Next Generation ACO, which takes on greater performance risk with potentially greater rewards. The Next Generation ACO model is….

Complete article by Laura Joszt posted here.

FLAACO? What’s That?’

by Gregg A. Masters, MPH

First there was section 30222 prescribed by the Patient Protection and Affordable Care Act (“ACA”), which added section 1899 to the Social Security Act that requires the Secretary of Health and Human Services to establish the [Medicare] Shared Savings Program (MSSP), see: ‘Summary of Final Rule Provisions for Accountable CareOrganizations under the Medicare Shared Savings Program‘.

Leading up to and continuing to this day is a literal potpourri of aligned industry stakeholders and interests who support this emerging ‘new, new thing‘. From the ACO Congress to the ACO Summit and a host of others including the National Association of Accountable Care Organizations (NAACOs) and most recently the ACO Coalition forged by principals at The American Journal of Managed Care (who launched a sister publication the American Journal of Accountable Care) they advocate for and provide both networking opportunities and continuing education into best practices for these nascent entities on which much of the success of the ACA is vested.

ACOs, a once ‘DOA’ (dead on arrival) too little too late or ‘HMO-lite’ model version, seems to be working it’s way into not only the lexicon of managed competition via a growing body of endorsements and reported outcomes data by many both in the public (CMS) and private (Aetna, United, Blues plans, etc) sectors as the preferred mechanism to implement the vision of the triple aim and fuel the transition from volume to value based medicine.

Like much of its era-specific innovation industry predecessors HMOs, PPOs, EPOs, OWAs), i.e., greasing the skids for if not enabling the HMO industry migration beyond the limited appeal of staff models to mainstream medicine penetration via Independent Practice Associations (IPAs), and later followed by the growth and penetration of PHOs (physician hospital organizations), ACO ‘enablers’ (as well as this value based platform) seem to be here to stay.

Enter the Florida Association of Accountable Care Organizations (“FLACCOs”) led by former health plan executive Nicole Bradberry (for context listen to interviews with Nicole here and here), which holds its annual conference in Orlando, Florida October 1 & 2nd 2015.

FLAACOs Orlando Conference

The agenda is packed with entrepreneurs and operators in the space from ACO enablement companies including Aledade, to ACOs and vendors who support their risk readiness assessments if not assumption such as RowdMap. Aledade founder and CEO Farzad Mostashari, MD will keynote (see: ‘Former ONC Director Farzad Mostashari, MD Launches @AledadeACO).PopHealthWeek-logo-TWTTR-sq (2)

For the FLAACO agenda, click here and the list of participating faculty click here.

This year my colleague and co-founder of PopHealth Week (formerly, This Week in Accountable Care) Fred Goldstein and I will broadcast live from the event.

If you are not following FLAACOs and are interested in the road to accountable care, you may want to take note and perhaps even consider attending this gathering.

Health Insurance Industry Consolidation: Any ‘Qui Tam’ Exposure?

by Gregg A. Masters, MPH

If you’re a health policy junkie like me, then the best show in town (or anywhere for that matter) was in the Dirksen Senate Office Building in Washington, D.C., where HMO industry veteran and Chairman, President and CEO of Aetna Mark T. Bertolini and Anthem President and CEO Joseph R. Swedish among other industry stakeholders testified before the Senate Judiciary Subcommittee on Antitrust, Competition Policy and Consumer Rights on health insurance industry consolidation, for video replay click here or watch below:senate hearing health insurance industry

As most of you reading this blog know, subject to the Department of Justice review Aetna will acquire Humana, and Anthem will acquire CIGNA. Thus, the submitted testimonies and ad hoc answers to sitting Senators on the Subcommittee were potentially a high stakes exchange.

Moreover, the hearing today was nothing short of a tutorial into the dynamics of the managed competition marketplace (both theory and practice since absent complete transparency assuming the salutary benefits of such competition may be more ‘wishful thinking‘ than reality as noted by Senator Blumenthal – CT, the home of the insurance industry) and whether this unique American strain of public/private collaboration can deliver on the oft repeated promises of such integration, i.e., that scale via consolidation drives operating efficiencies, improves quality and lowers costs to end users. We shall see…

As I heard the pitches from the various representatives assembled to offer perspective to the sitting Senators (see list here), I began to wonder if any of their testimony would be subject to the ‘false claims Act‘ if post consolidation the promised benefits do not accrue to the intended benefactors.

For those of you not familiar with the ‘False Claims Act‘ or otherwise known as Qui Tam filings, here a summary including its recent expanded scope via the Affordable Care Act:

The False Claims Act, expanded by the Fraud Enforcement and Recovery Act of 2009, P.L. 111-21 (S. 386), 123 Stat. 1617 (2009), now proscribes: (1) presenting a false claim; (2) making or using a false record or statement material to a false claim; (3) possessing property or money of the U.S. and delivering less than all of it; (4) delivering a certified receipt with intent to defraud the U.S.; (5) buying public property from a federal officer or employee, who may not lawfully sell it; (6) using a false record or statement material to an obligation to pay or transmit money or property to the U.S., or concealing or improperly avoiding or decreasing an obligation to pay or transmit money or property to the U.S.; (7) conspiring to commit any such offense. Additional liability may also flow from any retaliatory action taken against whistleblowers under the False Claims Act. Offenders may be sued for triple damages, costs, expenses, and attorneys fees in a civil action brought either by the United States or by a relator (whistleblower or other private party) in the name of the United States.
If the government initiates the suit, others may not join. If the government has not brought suit, a relator may do so, but must give the government notice and afford it 60 days to decide whether to take over the litigation. If the government declines to intervene, a prevailing relator’s share of any recovery is capped at 30%; if the government intervenes, the caps are lower and depend upon the circumstances. Relators in patent and Indian protection qui tam cases are entitled to half of the recovery.

Not sure if qui tam consideration can or even remotely applies to the upside representations proffered in favor of the acquisitions, since as noted by one or more witnesses today much of the empirical (public) record is incomplete and inconsistent with respect to supporting or discounting the arguments that will or have been made to DOJ as they conduct their anti-trust investigation into the proposed acquisitions or mergers.

[Editor’s Note: Two examples of previous health insurance industry consolidations were noted, including Aetna’s 1999 acquisition of PruCare, and United Health Group’s acquisition of Sierra Health Services. I will post the submitted witness testimony once it becomes available online, including any current discussion ‘tea leaves’ of what and where the DOJ investigation may be headed in both transactions. If you have anything, please feel free to add in comments section.]

This Subcommittee hearing is rich with both fundamentals and nuance considerations of the Affordable Care Act and whether it’s many moving parts can indeed align to meet the legislative intent of its authors.

Stay tuned!

ACOs: The Results So Far (It Depends)

by Gregg A. Masters, MPH

It might have been prescient but minimally it was perfect timing. While Fred Goldstein, President of Accountable Health, LLC, and me were prepping for our session to re-cap on PopHealth Week (@PopHealthWeek) some of the insights from our deep dive series into Population Health and ACOs, reporting insights from embedded executives at physician led, hospital sponsored and health plan enabled ACOs respectively, CMS yesterday (August 25th) posted the results from their participants in the MSSP and Pioneer Programs.

The Pioneer results are displayed below (for a description of the Pioneer program click here):CMS_ACO_Results_Pioneers
Again, while we’re still very early in this game, one bit of ‘cognitive dissonance’ that I experienced is worthy of note and further exploration.

That being the Heritage ACO a physician led enterprise fielded by managed care industry veteran and disruptive innovator Richard Merkin, MD, et al (including my former American Medical International colleague Mark Wagar, President Heritage Medical Systems and most recently CEO Empire Blue Cross and Blue Shield) untethered in any way from an institutional portfolio of healthcare infrastructure (i.e., hospitals) booked zero savings for distribution while hospital tethered and a card carrying member of the Association of American Medical Colleges (@AAMCtoday) (as the principal teaching hospital for Einstein College of MedicineMontefiore ACO booked massive (relative to ‘aligned beneficiares’) savings.

One must ponder the question and ask how can this be so?

It’s common knowledge that ACOs ‘untethered’ from (heads in beds) legacy hospital interests are more nimble and therefore better positioned to manage the volume-to-value transition. Further, when you add into the mix the history of successful risk assumption across a distributed network of ‘aware’ coordinated care practices (both IPA and medical group) you have a material competitive advantage.

So perhaps the ‘devil is in the details‘ as it often is, and the answers are to be found in the formulaic world of risk adjusters, corridors, baselines and severity of illness calculations. We hope top hear direct from Heritage ACO as this author has made that request a number of times previously.

Another interesting result that stands out as it arguably tethers to the presumptively competitively disadvantaged ‘health plan enabled‘ camp of ACOs is the incredible savings generated by the Banner Health Network (a Pioneer ACO), which if memory serves me well is a co-creation of Banner and Aetna via their ‘payor agnostic’ Healthagen subsidiary.

For complete details see the CMS release ‘Medicare ACOs Continue to Improve Quality of Care, Generate Shared Savings‘ and ‘Medicare ACOs Provide Improved Care While Slowing Cost Growth in 2014‘.

Meanwhile for a bit of reading the tea leaves color via Beckers Hospital Review see CMS releases 2014 Medicare ACO quality, financial results: 10 things to know):

1. Ninety-seven ACOs qualified to share in savings by meeting quality and cost benchmarks. Together, they earned shared savings payments of more than $422 million.

2. Fifteen of the 20 participating Pioneer ACOs generated a total of $120 million in savings in 2014, their third performance year. This is up 24 percent from the second performance year when they generated $96 million in savings. Of those that generated savings, 11 earned shared savings payments of $82 million.

3. Five Pioneer ACOs generated losses and three owed CMS shared losses of $9 million.

4. Pioneer ACOs increased their average quality scores to 87.2 percent in performance year three from 85.2 percent in performance year 2. They improved an average of 3.6 percent compared to performance year two on 28 of the 33 quality measures and showed significant improvement in medication reconciliation, clinical depression screening and follow-ups, and EHR incentive payment qualification…

Read complete article here.

Yes we do live in interesting times. And ideological prism not-withstanding there is no way this Genie (ACOs et al, and whatever formulaic derivatives may be forthcoming) gets put back in the bottle – the best efforts of Governor Scott Walker’s ‘bold’ The Day One Patient Freedom Plan (more likevaporware‘) effort to repeal and replace the Affordable Care Act.

This train has left the station. Time to deal with it?

ACOs and Population Health: The Value Narrative

by Gregg A. Masters, MPH

Before there was ‘accountable care’, the current full court press towards innovation – whether digital health app, platform or service delivery model, an emerging culture of transformation or the attendant pursuit of the triple aim, not to mention the most recent obsession with ‘retail as cure’ for that which ails healthcare, the best and the brightest minds (both clinical and administrative guided by thoughtful health policy wonks) convened in the grand theater of ‘managed care’ or managed competition.

The model and industry writ large (both public and private sectors), variably expressed as HMO, PPOs and derivative strains of contracting models stimulating the development of IPAs, PHOs, PPMC’s, MSOs and DPOs (direct purchasing organizations) had a run from the mid 70s until its abandonment as the official vehicle to restrain the rising cost and variable quality of healthcare in the late 90s. What followed was somewhat of a meandering decade of incremental tweaks here and there to an otherwise burning platform of fee-for-service healthcare delivery and financing.

In 2015 with healthcare costs now approaching 20% of the U.S. Gross Domestic Product and the viability of the entire U.S. Government at risk to projected costs increases and unfunded liabilities of the Medicare and Medicaid programs (estimated at $64 trillion), business as usual fee-for-service medicine is no longer an option and the many cathedrals of medicine built by ‘do more to earn more’ largesse are clearly at risk in the shifting sands of value based care.

While the ‘value’ v. volume agenda has been around for a while via risk based contracting including case rates, bundled payment and even capitation – both global and professional only versions – their penetration of mainstream medicine was relatively modest – until now. That is if you can believe the growing prevalence and penetration of risk bearing ACOs arrangements, a tapestry of bundled payment participation via Federal programs and a less transparent portfolio of privately negotiated ‘value based arrangements’.

Into this theater steps one of the trophy consulting companies with both wide (global) and deep (extensive client penetration into the health plan, provider and IDN communities) aka Accenture Health (follow via @AccentureHealth).

value based care meklausInto this developing narrative with a ‘value tutorial’ of sorts steps Gerry Meklaus, the Managing Director of Accenture North America for Clinical & Health Management Services. We speak with Gerry Wednesday at 12 Noon Pacific/3PM Eastern at Pophealth Week where my colleague and co-founder Fred Goldstein, President of Accountable Health, LLC will engage Gerry in the value conversation and the many touch points between a value framework for ACOs and population health strategies of provider organizations.

Key terms to un-bundle and digest are the ‘BIG Three’: 1) to ‘improve outcomes’ via emerging best practices, the reduction in variation and effective engagement of the patient in shared decision making, 2) the effective lowering of costs from a ‘total cost of care’ perspective (not just niche wins – if you will), and 3) the well known challenge to de-silo the many silos in the healthcare ecosystem driving fragmentation, redundancy and a less than patient centric experience.

Join us as we gain insight into the challenges and successes in the market to date!

Another Milestone Marker in Favor of the ACO Model?

by Gregg A. Masters, MPH

I awoke this morning to an email from a PR rep who supports outbound news for one of the emerging ACO management companies enabling physician led participation in the Medicare Shared Savings Program (MSSP) aka Aledade (@AledadeACO).

I then copy, pasted and tweeted the headline: ‘Aledade Creating New Medicare Accountable Care Organizations in Seven States.

I usually ignore ‘PRs’, yet this announcAledade newsement is material as it lends support via a growing body of evidence on the viability of the ACO model and its enabling ‘consciousness’ if not ‘sentiment shift’ in the prevailing market narrative.

While some still slam the ACA – and by proxy it’s ACO ‘workhorse’ – via relentless yet ‘diminishing returnsimpact of the ‘government takeover‘ fear mongering fueled by strategically sourced oppositional research, there is a building steady body of evidence supporting both the model and the broader context of efficacy of the competitive dynamics the ACA has unleashed on the stewards of our at risk (some say collapsing) healthcare economy.

Ergo my tweet:

Aledade news tweet

Ever since the Senate Finance Committee took up the debate and relentless series of ‘amendments‘ proffered by the ‘Rs’ trying to ‘improve‘ the proposed legislation that eventually emerged as the Patient Protection and Affordable Care Act (I NEVER use the pejorative term ‘Obamacare’), I’ve been a voice in the narrative of trying to get the facts of competitive market dynamics into the post political conversation around reforming our complex healthcare economy.

This is no easy task as the complexity of both the political process and objective reporting of how legislation becomes law including its contextual historical narrative is addressed in ‘A Legislative History of the Affordable Care Act: How Legislative Procedure Shapes Legislative History.

A challenge recognized upfront via admittedly ‘apolitical’ or ideologically agnostic ‘law librarians’ (yeah, you know those agenda driven bullies):

“Using the health care legislation passed in 2010 as a model to show how legislative procedure shapes legislative history, this article posits that legislative procedure has changed, making the traditional model of the legislative process used by law librarians and other researchers insufficient to capture the history of modern legislation. To prove this point, it follows the process through which the health care legislation was created and describes the information resources generated. The article concludes by listing resources that will give law librarians and other researchers a grounding in modern legislative procedure and help them navigate the difficulties presented by modern lawmaking.”

Since social media was starting to pick up in 2009 – 2010 time-frame, and given the angst associated with the public’s consumption of the ACA, I started ACO Watch and latter the hashtag #healthreform to track tweets associated with ACA consideration.

None-the-less, 5 years later the disinformation campaign persists though some of the pieces of the ACA are starting to show some promise of the law’s original intent. ACOs often referred to as a flawed model, perhaps an ACO lite if you will or too little too late to make a difference, the emerging datasets (both government and private market tea leaves) are building a case that the law is working.

Tomorrow on PopHealth Week, join my colleague, co-host and co-founder Fred Goldstein as we chat with Aledade Founder and CEO Farzard Mostashari, MD. This month we’re conducting a series on Population Health and ACOs talking to leadership from each ACO type: physician led, hospital sponsored and health plan enabled.

Listen here! We’re live 12 Noon Pacific/3 PM Eastern, and on demand thereafter.