Precision Medicine v. Accountable Care: A Faux Choice?

By Gregg A. Masters, MPH

Whether you call it personalized medicine or as Eric Topol MD prefer’s ‘individualized medicine’ or even via the possible conflation of the two c/o the President @BarackObama ‘Precision Medicine’s’ initiative (see fact sheet here), it strikes me that we may need an emerging business model glossary to make sure we’re comparing, contrasting and discerning health reform and clinical practice innovation correctly.

Precision Medicine Fact Sheet

Further considering the difficulty in separating healthcare innovation or clinical practice transformation/re-engineering from political spinmeisters and their ideological agenda’s, it’s vitally important to gain a grasp of the range of conversations now in play under a ‘big tent’ of widely variable practice in health[care] innovation circles.

It’s tempting to dumb down the debate by assigning those ventures in the ACO or accountable care derivative play space to ‘tweaks at the margin’ of business as usual medicine, while reserving the more promising frontier represented by precision medicine as a life sciences and biotechnology fueled new breed of medicine enabling us to walk away from the business as usual burning platforms required by the current financing and delivery of care paradigm.

A few articles will help with the discernment and formation of a common taxonomy of accountable care and precision medicine practices – which I will use to include both personalized and individualized medicine.

In Specialist Doctors Head for Exit as U.S. Shifts Payments we revisit the perennial dispute between cognitive vs. procedural medicine specialists and the relative embrace or resistance of ‘bundled payment’ as a transitional practice to value (vs. volume) based medicine. Disorganized medicine has a history of ‘circling the wagons’ and shooting in to solve differences. Unfortunately, the current developing divide between primary care specialists and their sub-specialty peers will likely continue this tradition of internecine warfare.

InPrecision medicine takes genetic mapping to the next level Florence Comite, MD (@comiteMD) an endocrinologist turned precision medicine evangelist unbundles the biotech and genomic medicine fueled promise of this emerging field.

And at Will patients pay for Personalized Medicine? Rob Wright (@RfwrightLSL) dips into the ‘follow the money’ question given the continued practice (now somewhat codified by the ACA via a metals designation of plan type) of cost shifting from health plans to patients/members the increasing burden of health benefits coverage.

Finally perhaps tangential though relevant to the conversation is the recent ruling in the Massachusetts Attorney General v. Partners Healthcare litigation where the delivery system merger is being challenged as anti-competitive. Fueled by accountable care strategy roll-outs (formerly ‘managed care’), market trends and the ACA, consolidation is one of the key themes likely to influence both the alchemy and market conditions under which both of these models will continue to evolve before before their inevitable convergence into a sustainable health[care] ecosystem.

Yes, we do live in ‘interesting times’.

 

 

The ACO: Seen One? You’ve Seen One…

A/C/O

Accountable/Care/Organization

According to the Centers for Medicare and Medicaid Services (CMS) an Accountable Care Organization (ACO) is defined as:

…groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare patients.

While the goal of such broadly cast and some may say overly ambitious agenda onto the backs of [under-powered or ‘HMO-lite]  entities is to:

…ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors.

On the ‘upside’ of participation, CMS notes:

When an ACO succeeds both in both delivering high-quality care and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare program.

And finally, the regulatory framework and market context in which these entities are organized (at least at the Federal level) is via the ‘three legged (wobbly?) stool’ of:

Yet there is quite a bit more to the ‘ACO Story‘. As noted in ‘More or Less Confusion in ACO World: Who Really ‘Certifies’ ACOs?’, the portfolio of Federally certified ACOs omit the financing and service delivery innovation in the commercial or private pay space. To fully grasp the range and complexity of innovation in the accountable care industry, one must also look outside the limited albeit large purview of CMS.

Reports from the Front

For recent insights and a comparative view checkout ‘ACO Contracting With Private and Public Payers: A Baseline Comparative Analysis‘. The report summary is noted below:

Screen Shot 2014-12-16 at 10.04.02 AM

And for both strategic and tactical guidance on the road-map towards implementation of an ACO, ‘Adopting Accountable Care: An Implementation Guide for Physician Practices offers real world guidance via case studies from innovators walking the talk of the ‘triple aim’.

Adopting Accountable Care

Comment

Sidney Garfield MDAt the end of the day, the mission of the accountable care industry and the challenge presented to healthcare leadership is perhaps best framed as a v3.0 version of the vision and genius of the ‘under-celebrated’ Sidney Garfield, MD.

While the ‘triple aim’ expression had yet to be coined, his vision of coordinated, high quality healthcare at affordable price points was the source DNA of the then emerging Kaiser Permanente (culture of health) HMO model, and a consistent theme entrusted to the stewards of the predominantly non-profit healthcare sector in the United States.

Yes, it’s deja vu all over again. The names and faces of the stewards at the controls of the ‘healthcare borg’ change, but the challenges remain the same (see: The Committee on the Costs of Medical Care and the History of Health Insurance in the United States circa 1920s) while both scale and complexity of the ecosystem grow.

Previously the cost of employer sponsored healthcare benefit plans or Government funded healthcare programs (Medicare, Medicaid, etc.) threatened only companies (or Government budgets) and considered remedies contained often behind the closed doors of healthcare enterprise Board rooms (or on Capital Hill), today absent the value based paradigm shift whole countries and Governments are at risk of insolvency.

Perhaps this time former CMS Administrator Don Berwick’s ‘all hands on deck..’and ‘…full court press’ nature of the change (re-invention) imperative will be taken to heart and truly guide the actions of a volume fueled industry into the brave new world of value based medicine.

Again, only time will tell….

The Medicare Shared (ACO) Savings Program – A Tale of Transition

By Gregg A. Masters, MPH

In pursuit of the no longer optional ‘triple aim‘ and as once suggested by industry innovator Richard Merkin, MD the founder and CEO of Heritage Provider Network, the ‘gold’ in the ACA may be the programs and outreach of the CMMI. But we’re not obsessed with acronym’s in healthcare, right? So for clarity, the ‘ACA’ is the Patient Protection and Affordable Care Act, while the ‘CMMI’ is the Center for Medicare and Medicaid Innovation in the ‘CMS’ – the ‘Centers for Medicare and Medicaid‘.

While health policy and politics are energetically if not occasionally often toxically entwined, the release of NPRM (the notice of proposed rule making) is the current reflection of a feedback loop inherent in our public/private system of ‘partnership governance’. Since we’re coming up on three years in the implementation of the ACA including its principal dog in the hunt of a sustainable healthcare economy (ACOs and their derivative entities) the delivery of these insights have been eagerly anticipated.

For context, the initial reviews of the ACO NPRM (see: The ACO Proposed Rule: A [Skeptical] View From ‘The Street’‘, and ‘Proposed vs. Final ACO Rule’) logged upwards of 1,300+ comments many of which telegraphed the concerns now recognized in the proposed rule ‘Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations‘. The summary notes the intent of the filed NPRM as follows:

This proposed rule addresses changes to the Medicare Shared Savings Program (Shared Savings Program), including provisions relating to the payment of Accountable Care Organizations (ACOs) participating in the Shared Savings Program. Under the Shared Savings Program, providers of services and suppliers that participate in an ACO continue to receive traditional Medicare fee-for-service (FFS) payments under Parts A and B, but the ACO may be eligible to receive a shared savings payment if it meets specified quality and savings requirements.

Since issued, many have chimed in including analyses from Mark McCllelan, MD et al at Brookings (see summary below), the ACO management company founded by former National Coordinator for HealthIT Farzad Mostashari, MD AledadeThe National Law Review, HealthLeaders via ‘Proposed MSSP Changes Don’t Go Far Enough, Providers Say‘ and Rob Lazerow at The Advisory Board.

Proposed Updates to the Medicare Shared Savings Program

Risk Assumption, Attribution and Rebasing Savings Baselines

The good news is CMS took provider feedback to heart and addressed the issues above in a meaningful way. The retrospective attribution issue was perhaps the ACO ‘achilles heel’, while a three (3) year contract year extension to upside only participation (Track One) formula recognizes the immature state of many of the ACOs in the MSSP, and the need for additional runway to implement a value based healthcare delivery culture. Finally, the remaining Pioneer class were rather vocal about the dis-incentive of a progressively lowered baseline from which savings (or losses) are calculated.

Comment

We’re clearly in an innovation inspired learning mode thanks to the principle mission of CMMI which is to test:

innovative payment and service delivery models to reduce program expenditures …while preserving or enhancing the quality of care” for those individuals who receive Medicare, Medicaid, or Children’s Health Insurance Program (CHIP) benefits.   

So amidst this toxic health policy and ‘politics of what’s possible’ health reform environment we find ourselves with some cause for optimism as many of the key drivers of ACA begin to take hold in a very difficult to restrain volume driven healthcare ecosystem.

The jury is and will remain out until the ACA is fully implemented and the accountable care industry writ large (including ACOs, PCMHs and derivative plays both commercial and public market) post the results of their efforts to improve user experience (outcomes), quality and lower per capita healthcare costs.

Vetting the ACA’s Impact on Health Insurance Operators

by Gregg A. Masters, MPH

Milliman Health 2013 Briefing Paper ACA ResultsIn contrast to the comprehensive ‘go live’ implementation of ‘RomeyCare’ in the Commonwealth of Massachusetts, the phased (and some would say diluted if not ‘fatally’ compromised) implementation of the Affordable Care Act (ACA) has been muted via a staggered on-boarding schedule of its various component parts and further selectively waived or delayed provisions primarily for political considerations.

Yet, we’re now some 3 1/2 years since enactment of the spirit of the ACA in March of 2010. One of the arguably principal accountability players to advise, measure, and report on the success or failure of the Act’s specific provisions are the good folks at Milliman Health – principal ‘actuaries to the stars’ of sorts.

Milliman often consults on the front end of risk assumption, mitigation – if not avoidance – in the shift from volume-to-value. They also measure and monitor the aggregate performance of the law based on their access to propriety client derived data sets, those residing in the public domain as well as tapping secondary sources in the market place as proxies.

Recently Milliman issued the Briefing Paper: ‘2013 Commercial Health Insurance – Overview of Financial Results’ wherein the report notes:

‘With the Patient Protection and Affordable Care Act (ACA) enactment in March of 2010, health insurers have had to comply with minimum loss ratio requirements, more stringent rate reviews, removal of annual benefit limits, first dollar coverage of preventive care, and other requirements. The insurer experience for 2013 reflects the third year insurers have been required to comply with minimum loss ratio requirements. Additionally, 2013 marks the final year that medical underwriting was not prohibited for new business in the individual and small group comprehensive health insurance markets in many states. Therefore, 2013 commercial health insurance can be used to both evaluate the impact of ACA reforms that were implemented prior to 2013, as well as serve as a benchmark to evaluate insurer financial results moving forward’.

Suffice it to say, there is more meat in the report sourced from various indicia of market performance, but witness the Milliman general conclusion noting:

Milliman  Health Breifing Paper on ACA Results 2010 - 2013

The report provides ‘an overview of health insurer financial results in 2013 and evaluated changes in the health insurance industry’s expense structure and profitability from 2010 to 2013, including changes in the medical loss ratio.’ 

The report’s conclusions are rather instructive and a testimonial of how imposing ‘order’ (or some degree of plan standards and thus comparability to an arguably cowboy market – primarily the individual insurance domain) – has impacted the operations of market participants.

Basically, Milliman is saying some patterns can be more clearly discerned (in group market) while in truth there are too many moving parts and it’s perhaps to early to tell at least in the individual market.

For complete report access click here.

Comment

It remains to be seen how the political theater if not continuing litigious climate will impact the future performance of this initially proffered conservative health policy ideology muscled only into law via straight party line voting. The complexity of our healthcare system is such that any material effort to arrest, mitigate and redirect its underlying healthcare economics will be met with special interest agenda driven resistance if not outright mass public deception.

So in the spirit of the 70s rock band Kansas viaCarry on my wayward son‘, lets be mindful of the timeless advice of Mr. Rogers offered during times of deep national tragedy:

Look for the helpers. You will always find people who are helping.’ ~ Frederick “Fred” McFeely Rogers

 

The State of Accountable Care: Evidence to Date and Next Steps

by Gregg A. Masters, MPH

Brookings Med: ACOfuture

So I registered for the webcast version of this Brookings event titled: ‘The State of Accountable Care: Evidence to Date and Next Steps‘ which noted at 9AM start time. My assumption was Pacific time, so when I dialed in (really logged onto twitter to monitor the webcast hashtag #ACOfuture), the first tweet I saw was thanking everyone for a great program. Yup, the start time was 9AM Eastern, so I missed the live stream. The good news is this event was recorded and is now available for archived replay.

The full program agenda is here and principal deck here.

The line up is impressive and well worth watching for continuing insights into the accountable care theater. What’s working, what’s not, and why?

Enjoy this timely event!

Farzad Mostashari MD Unbundles the ‘Healthcare Borg’ at Engage

By Gregg A. Masters, MPH

I have been following the career of Dr. Mostshari since his tenure at ONC as Director of the Office of the National Coordinator for Health Information Technology.

Upon learning of his launch of the startup ACO management company Aledade, we posted some thoughts here and here.

Yesterday at MedCity Media’s ‘ENGAGE’ conference in Bethesda, Maryland he literally tutored the in-person audience as well as many others following the feed via Google Hangouts, or the twitter stream tagged #mcENGAGE. Mostashari illuminated both the burning platform nature of the ‘business as usual’ through a prism of ‘good for doc’, ‘good for patient’, ‘good for society’, as well as probable indicia of the likely solutions. This is a masterful performance by a physician executive turned entrepreneur worthy of widespread distribution. Apparently there’s quite a bit more to Mostshari than EHR adoption and the national e-connectivity backbone.

Enjoy!

ACO Onramp: Reading the Pioneer [Exit] Tea Leaves

By Gregg A. Masters, MPH

Whenever someone buys a stock for the most part they make a decision that weighs available public (and sometimes ‘non public’) information and concludes that the company’s value exceeds (currently or shortly will) that which is expressed in the bid/offer price points the day the purchase is executed. Yet, there is always a seller who may more often than not hold the opposite opinion. After all why is he/she selling if the stock price undervalues the company’s enterprise fundamentals?buy sell

Absent the expressed manipulation of a third party intermediary (broker dealer, hedge fund, etc.) this buy vs. sell ‘call’ can reasonably and accurately reflect the aggregate market based ‘tug of war’ between the public perception and actual fundamentals of a company – at least as reflected in it’s stock price or ‘market cap’.

This same tug of war might equally apply to the battle for the ACO narrative at least as it relates to interpreting the reported ‘signals’ of movement inside the accountable care space.  However, instead of stock prices we’re looking at certain metrics including the number of players entering or conversely exiting the accountable care theatre as a proxy for the underlying health or efficacy of the Affordable Care Act – or at least that piece allocated to the provision in the Act specific to ‘accountable care’.ACO growth medicare vs non medicare

Of late the headlines have predictably served up a mixture of news for public consumption and therefore fodder for the talking heads to spin in the media and the ‘credible’ blogosphere writ large to explain to their audience.

If only healthcare where as simple as buy/sell equity transactions on public exchanges (lets not get into ‘dark pools’) mostly immune from ideological spin as to the broader significance of a move up or down in standing, valuation or growth vs. contraction. Unfortunately the health reform space is littered with agenda driven spin to drive an ideological outcome in one way or the other. And we know who the usual suspects are…

Meanwhile, several headline examples meriting interpretation including original source links are posted below. Further, since the launch of Aledade and several other entrepreneurial players (Privia Health) to bolster the vision, leadership, capacity and management infrastructure including the healthIT spine that supports independent physician led participation in the ACO initiatives, we include a recent Commonwealth Fund deep dive titled Profile: Rio Grande Valley ACO Health Providers’ exploring a physician led ACO effort in the Rio Grande Valley of Texas.

Context for the ACO pulse check narrative is perhaps best framed via a JAMA piece titled: The Pioneer Accountable Care Organization Model Improving Quality and Lowering Costs which is instructive on the significance of select Pioneer exits, while a deeper dive into the weeds of ‘Shared Savings in Accountable Care Organizations: How to Determine Fair Distributions (abstract only) addresses a problem most ACOs would aspire to have, i.e., a formula to distribute actual savings generated. 

The later abstract notes:

Accountable care organizations (ACOs) are playing a major role in health care reform. In the last 2 years alone, Medicare ACOs have proliferated to cover more than 5 million Medicare beneficiaries in more than 360 organizations nationwide.1 In ACOs, individual clinicians (including physicians, physician assistants, and nurse practitioners, among others), group practices, and, in some cases, hospitals contract with payers to be jointly accountable for the health outcomes and expenditures of a defined patient population. By meeting specified quality measures while keeping expenditures below defined benchmarks, ACOs share in the monetary savings generated.

Over at Modern Healthcare, Melanie Evans notes in ‘Medicare’s Pioneer program down to 19 ACOs after three more exit‘: 

Franciscan Alliance in Indianapolis, Genesys PHO in Flint, Mich., and Renaissance Health Network in Wayne, Pa., have exited the program, which is now in its third year.

For further discussion into quality performance measurements checkout ‘Medicare gives first glimpse of ACO quality performance’.

Perhaps the biggest piece of news was wrapped into the announcement of the launch of Vivity Health, see: ‘Reform Update: Will Anthem’s Vivity gain traction among large employers?‘.

This ambitious announcement by Wellpoint spawned the following two tweets today:

.’s ambitious ‘Vivity’ alliance [a response to ] will make merger look like a walk in the park!

Although saw light when it green-lighted as chassis to build out/express MA care delivery innovation.

Finally until job descriptions change reflecting better deployment of professionals working at the ‘top of their license’, as well as non clinical or administrative staff support re-engineered workflows, we’re probably not witnessing the movement of the needle towards the triple aim. In ‘ACOs, other delivery reforms shift job roles at hospitals’ we learn a little more about this continued labor pool tweaking.