4th National ACO Summit: Some Contextual Reflection

By Gregg A. Masters, MPH

When ‘Acting Administrator’ of CMS Don Berwick gleefully announced the final rule guiding the development and Federal certification of Accountable Care Organizations (ACOs) on October 20th, 2011, he thereby officially unleashed the power of the largest single payer for healthcare services in the United States to simultaneously govern while informing the future of healthcare transformational business models.

For the ‘red letter day’, upbeat announcement, see: Accountable Care: Reports from the Front.

Since the release of the final rule, sentiment has been somewhat of a challenge to gauge and report accurately. Unlike the HMO era, the ACO market is not a homogenous one, since you have the ‘book of business’ associated with Medicare Shared Savings Program, as well as the commercial (i.e., private market) derivative book organizing under ‘accountable care collaborations’ and even patient centered medical homes.

So while a relatively small subset of the Affordable Care Act the sections specific to ACOs represent a disproportionate yield in terms of the transformational upside of the Act to deliver on it’s promises of the ‘triple aim’ (whether planned and realized via intended as well as the ‘meta unintended consequences’ of unleashing both statutory and pilot/demonstration fueled innovation).

Thus the context, if not the metrics associated with the results reported to date, of the 4th National ACO Summit leads this observer to conclude that the ACO market sentiment has shifted from skepticism to the outright bullish determination to get in the game.

Indecision is a decision….with increasing market risk.

Leavitt Partners Report: ACOs, Their Growth and Dispersion

On the Wednesday, November 30th, 2011 broadcast at 11AM PT / 2PM ET my special guests include two principal co-authors of the recently released Leavitt Partners study titled: Growth and Dispersion of Accountable Care Organizations‘. For an extract and link to download the full report, click here.

More about the guests:

Andrew Croshaw is Managing Director, Health Care Practice, at Leavitt Partners. Founded by former U.S. Health and Human Services Secretary and EPA Administrator Michael O. Leavitt, the partnership advises clients in the health care and food safety sectors. As Managing Director of the Health Care Practice, Croshaw helps clients enter new markets, enhance the value of their products, navigate dynamic regulatory and reimbursement systems and improve health conditions around the world.

Thomas Merrill is a strategic analyst at Leavitt Partners. As a member of the knowledge development team, Merrill collaborates with others to analyze and research issues associated with health reform and more specifically, emerging care models and the various factors that influence the modern health care landscape.

We’ll discuss the key findings and implications of their report. To listen live or via archived replay, click here.

Berwick v. Hatch, Enzi & the Gang of 42. Lunatics 1, America 0

Reprinted in portion below:

Berwick’s resignation a signal of a faulty political system

via Healthcare Finance News by Stephanie Bouchard

WASHINGTON – It came as a surprise to no one that Donald Berwick, MD, the administrator of the Centers for Medicare & Medicaid, would not be carrying on in the position once his term ended on Dec. 31, but many were surprised last week when he announced his resignation would be effective on Dec. 2.

[See also: Berwick to step down at CMS, Obama nominates Tavenner .]

While much of the focus now is on Berwick’s replacement – the Obama administration is nominating Marilyn Tavenner, a nurse who is the principal deputy and chief operating officer at CMS and has already served as CMS’ acting administrator prior to Berwick’s appointment – some in the industry are reflecting on Berwick’s departure and the larger issues it signifies: a political system that is too polarized to be effective.

Berwick’s resignation – and the opposition he faced in Congress – is an example of the shallowness of our political system said John Chessare, MD, president and CEO of the Greater Baltimore Medical Center. “He gave the American people a gift,” said Chessare, who calls Berwick his mentor. “He accepted President Obama’s request to do it (become CMS administrator) and then because of the foolishness and the pettiness of our national political system, he’s leaving.”

“While I do support his vision for making healthcare more patient centered, focusing on decreasing hospital mistakes and errors and making healthcare more affordable for everyone, I’m more disappointed that he’s become a casualty in the political struggle over Obama’s signature healthcare reform law,” said Andrew Spanswick, MSW, chairman and CEO of KLEAN, a residential treatment center in West Hollywood, Calif.

The much acknowledged “problem” with Berwick wasn’t his qualifications – he spent 30 years at the forefront of healthcare innovation and improvement…

Read complete article, here

Follow HFN associate editor Stephanie Bouchard on Twitter @SBouchardHFN.

Dr. Don Berwick on ACO’s: From Volume to Value

By Donald Berwick, MD

Editors Note: Thanks to a tweet today via @AxSys_Health

CMS Administrator Don Berwick, M.D., explains ACO’s in plain language.

Hi, I’m Don Berwick, CMS administrator. Today’s a kind of red letter day, October 20th 2011. That’s the day in which we launch the Accountable Care Organization final rule and I just want to spend a minute describing this to you a bit.

This is one of the most exciting and important elements the Affordable Care Act. When we think about the goal of transforming American medicine into the kind of care that we all want for ourselves and our loved ones. American medicine is fragmented right now.

You get lost between the slats because we built the system that way, we pay for it that way, we train for it that way and institutions manage themselves separately. That’s not what patients need. That’s not what you want and I want. We want continuity and seamlessness and most of all we want to stay home and healthy instead of being in hospital beds or sick if we can avoid it.

We are trying now through all the policies in the Affordable Care Act to change the structures of incentive in support for the American health care system, so we can better support that seamless care. Right now in a fragmented payment system hospitals get rewarded, for example, for keeping their beds full. Doctors get rewarded for doing as much as they can. We’re, shifting that game. It now becomes not how much you do but how well you do, that determines the rewards you get and the support you get from us at CMS.

That’s really what doctors and nurses and hospitals want to do anyway. What’s the idea behind an Accountable Care Organization, is to set up a structure, in which doctors and hospitals and others can join together and take responsibility for a group of patients, Medicare beneficiaries, who are attributed to them.

We watch the beneficiaries, we watch where they get their care and if they get the majority of their care from a group of doctors who want to form an ACO then those patients are attributed to the ACO. They still can go anywhere they want, it’s still a Medicare fee for services to the patient lost no choices. But now that ACO conformance say we want to take responsibility for these people that come to us for care, as the ACO then begins to better coordinate care for those people building more cooperation, investing in care coordination, adopting electronic records, working in such a way that people can stay out of the hospital and stay healthy.

What will happen is cost will fall and quality will go up and now in the Accountable Care Organization world they can share in the savings. We split the savings with them. Medicare keeps some, some goes back to the providers of care We don’t want them skimping on care and so we watch quality very closely. The ACO rule has in it 33 measures of quality that we’re going to track really closely, and all of the normal functions of anti-trust regulations and others are watching for good behaviors.

I think the provider community will rise to that. In the ACO rule we’re offering a range of options about how you can get into this shared savings environment all the way from the track one of the rule in which you’re allowed to share savings but you don’t have any downside risk if costs go too high, way over to the pioneer program, offered now by the center for Medicare and Medicaid innovation which you can actually share more savings but take more risk if costs go too high. In all cases we’re protecting the beneficiary but watching care very, very closely to make sure that it’s improvements that’s generating the savings that we can now share.

There’s lots of interest in this all over the country. We’re going to see ACOs of many forms develop and I’m pretty excited about getting this rule into final form. I’ve got to thank, literally hundreds of your colleagues, people all over CMS, all over HHS indeed, and other government agencies have been getting together to help shape this rule to download and read the over 1200 comments we got to travel all over the United States getting feedback so that the final rule can be much better than the proposed rule as indeed it is.

I think we have a really exciting program on our hands. Many of you will be called upon to explain this rule to beneficiaries, to your friends and neighbors and your family. Now I’d like to make sure you have all the information you want about this. So log on to cms.gov/aco or find other ways to get information, inform yourselves and we’ll be reaching out with information to CMS employees so you can understand this wonderful, wonderful new program.

It’s part of the transition to the American health care system we want, which is really supporting care, to keep people healthy and which the whole structure of care shifts from volume to value from how much you do to how well the patient does and that’s what the ACO is intended to do. It’s a pretty exciting day. Thanks.

For the complete video and original transcript posted, click here.

Proposed v. Final ACO Rule

By Gregg A. Masters, MPH

Deep in the 690+ pages of the document filed with the OFR, is a nifty little matrix that compares key provisions of the ‘notice of proposed rule making’ to the final rule which theoretically incorporated the best and brightest suggestions pro-offered in 1,300+ comments supplied to CMS.

That pre/post matrix can be accessed here. It is a good cheat sheet to follow along with some of the key provisions providing a fair amount of ‘stakeholder heartburn’.

In the end, and in the hard to please everyone department, AMA acknowledges CMS for reducing the number of quality measures, while ASCO expresses it concern over their reduction and failure to reflect the QM measures specific to oncology.

ACOs: It’s Not Just About Medicare [shared savings]

By Gregg A. Masters, MPH

A recent report attached to a Tweet posted by Brian Ahier caught my attention in the blitzkreig of ACOs postings this past week.

 @ahier Building #ACO‘s & OUtcome Based Contracting in the Commercial Market

The complete title of the attached report is ‘Building ACOs and Outcome Based Contracting in the Commercial Market: Provider and Payor Perspectives‘.

This immediately caught my attention as for the better part of 30 years in the healthcare industry I spent a considerable amount of time in the managed care contracting business negotiating and signing my share of upstream (payor) as well as (downstream) hospital, physician and network agreements. From full risk, global capitated network deals to discounted fee for services to specialty care subcontracting and essential re-insurance backstops, I lived and breathed c/o/n/t/r/a/c/t/i/n/g.

Since the release of the proposed rule to implement the ACO provisions in the Affordable Care Act, most of the mainstream discussion has been about the ‘Medicare Shared Savings Program’, and considerably less attention has been paid to the activities delegated to the Center for Medicare and Medicaid Innovation (CMMI).

This report may change that singular focus since it broadens the loop and recognizes the market shift which is and has been rather active since the passage of the Act in March of 2010.

Call it ‘managed care 2.0, or 3.0′ or whatever you choose, the fix in healthcare, i.e., bending the cost curve. demonstrating the value proposition and improving access while reducing the rate medical inflation, if not lowering the cost of care, is rather well known: integration (legal, financial and operational) of medical practices under a banner of patient centered and coordinated (v. solo-ed or fragmented) care, enabled by information networks linked and seamlessly integrated across the continuum of care.

This was the same mission in the 70s and 80s when primarily HMO’s and to a lesser degree PPO’s were the mantra, yet the pain points did not exist as they do today, nor did the enabling technologies. The difference today is our house of cards sick care system is in the ICU on life support, and no one is defending the more is better, fee for services paradigm that drove our ‘healthcare borg’ to these heights of inefficiency and diminishing returns. Yet technology along with a determined shift in consciousness if not the sober recognition that ‘business as usual’ is not an option, gives us a materially different palette on which to collaborate towards a changed paradigm.

Check out this report and see what is already happening below the radar. You might be surprised. There is enough here to parse out over several posts and perhaps even invite the authors into a conversation on ‘ACO Watch: A Mid-Week Review’.

ACO Final Rule: A Round Up of Early Opinion and ‘Go To’ Resources

By Gregg A. Masters, MPH

Like some of you, I woke up the morning of Friday, October 21st, 2011 to a literal ‘blitzkrieg’ of tweets flooding two TweetDeck columns tagged ‘ACOchat’ and ‘ACO’. Everyone it seems has a dog in the hunt to make known their standing or interest in Accountable Care Organizations (ACOs), the Medicare Shared Savings Program and related stuff, i.e., the Pioneer Program, Advanced Payment Model, etc.

Shortly after the final rule was published in the Federal Register, CMS conducted a ‘background’ stakeholder conference call. If you missed, you can listen via ACO Watch: A Mid-Week Review re-broadcast (note: we had some audio glitches, but got the entire call plus questions in).

Meanwhile for a list of some notable write ups and contributions, checkout:

As always first out of the box via @KHNewsHHS Releases Final Regulations for ACOs.

As well as the excellent contextual and opinion piece by Dr. Don Berwick in the New England Journal of Medicine, ‘Making Good on ACO’s Promise – The Final Rule for the Medicare Shared Savings Program‘.

My friend Michael L. Millenson and occasional guest poster on this blog chimes in with an insightful and witty Forbes piece titled: CMS Wants Docs to Ante Up to ACO Poker Game.

Meanwhile, the American Medical Association, one of several professional medical associations to back the Patient Protection and Afforable Care Act (bravo!), opines the net gain for docs via: Final ACO Rule Offers Promise to Improve Care Delivery, and CMS spotlights physician-friendly changes in final ACO rule.

The health plan and payor community checks in with AHIP’s, their trade association, posting: AHIP Statement on ACO Regulation.

While Esptein Becker’s Douglas A. Hastings posted on Health Affairs BlogValue-Based Payment, Accountable Care, and the ACO Final Rule: Are We Making Progress?

Also from the legal domain, McDermott Will Emery published: Medicare Shared Savings Program Final Rules  complete with comments and historical markup of key provisions in the PPACA the ACO final rule implements.

Of course the reference final rule summary from CMS is here, as well as the ‘fact sheets‘ previously posted to this blog, here.

From the ‘connect the dots’ health IT side of the conversation, i.e., hey you want an ACO…..gotta have the infrastructure, check out HealthData Management: ‘ACO Barriers‘ by Gary Baldwin.

And one of my favorites is from CMS in the Appendix titled: Proposed Rule versus Final Rule for Accountable Care Organizations (ACOs) In the Medicare Shared Savings Program.

There is more to come as we’re building the ‘go to’ resource portal for everything ACO.

p.s. Thursday, October 27th at 1PM Eastern there’s a FREE webinar that we’ll be following and tweeting from organized by @HCPlive and featuring fellow healthtweep David Harlow, aka @healthblawg, titled: Accountable Care Organizations, Bundled Payments, and the Future of Health Care. 

You can register here.

More later!