The Medicare Shared Savings Program: Class of 2015

By Gregg A. Masters, MPH

The clock is ticking and the CMS continues its community outreach via their series of National Provider Calls on the application process for ACOs interested in submitting for the Medicare Shared Savings Program.Medicare Shared Savings Program

The deadline for the class of 2015 is approaching with the next call scheduled for Tuesday, April 22nd 2014 from 1;30 – 3PM Eastern.

You can register for this call here.

Space is limited and demand for these calls often exceed available slots, so get your registration in early.

Meanwhile, the description of the program is as follows:

During this MLN Connects™ National Provider Call, CMS subject matter experts cover helpful tips on completing a successful application, including information on how to submit an acceptable ACO Participant List, Sample ACO Participant Agreement, Executed ACO Participant Agreements, and Governing Body Template for the Medicare Shared Savings Program application. A question and answer session follow the presentation.

The Shared Savings Program Application web page has important information, dates, and materials on the application process. Call participants are encouraged to review the application and other materials found on this web page prior to the call.

Target Audience

Potential 2015 ACO Applicants

Presentation

The presentation for this call will be posted at least one day in advance of the call on the MLN Connects™ National Provider Calls and Events web page. Select the call date and scroll to the “Call Materials” section to locate the slide presentation. A link to the audio recording and written transcript of this call will be posted under the “Calls Materials” section in approximately 2 weeks following the call.

Registration will close at 12:00 p.m. ET on the day of the call or when available space has been filled.

An ACO ‘Deck-o-Topia’ at HiMSS14

By Gregg A. Masters, MPH

This is the fourth year in  row that I have participated in the largest annual gathering of parties in interest to the health informatics ecosystem. From payor to provider to regulator to vendor to the patient and/or consumer of healthcare services, there is always much flare to consider, discard or assimilate. HIMSS14

This year’s gathering is expected to attract somewhere between 30 to 35 thousand attendees. Second only to CES the HiMSS sea of humanity is a distinct strain of conversation to experience.

From one of the tracks that directly appeals to readers of this blog is the track devoted to accountable care and/or ACOs in particular. More later with an individual dive into the more interesting presentations, but the entire decks can be accessed via: Transitioning to Fee-for-Value through ACOs, Care Coordination and Clinical Integration.

Patient Engagement in an ACO World

By Gregg A. Masters, MPH

Last June I had the honor or moderating a panel on ‘unlocking innovation in patient engagement’ in an ACO World at MedCity News’s ENGAGE conference. Joining me on the panel are: Libby Webb, Director, Product Management, Athenahealth, Lanie W. Abbott, APR, Senior Communications & Outreach Coordinator, EMHS Population Health Management and Colin Ward, MHS, Executive Director, Greater Baltimore Health Alliance.

During the session we discuss ACO implementation issues and how early movers are mobilizing and organizing to drive sustained patient engagement while conforming to a complicated set of ACO policies. Patient engagement will continue to be the missing link in new value-based reimbursement programs until the quality of patient communications leads to consistent behavior. We discuss how new ACOs are investing in benchmarking tools and communications interventions that will measurably improve the quality of physician-patient communication.

More than Half of ACOs ‘Save Money’ Only 1/4 Bonus Providers

By Gregg A. Masters, MPH

In the narrative matters department and following CMS’s press release on January 30th, 2014 of the ‘interim financial results for select Medicare Accountable Care Organization (ACO) initiatives, an in-depth savings analysis for Pioneer ACOs, results from the Physician Group Practice demonstration, and expanded participation in the Bundled Payments for Care Improvement Initiative’ several downstream headlines are instructive in this continuing battle for the hearts and minds of the American public towards the Affordable Care Act.

Physician Standing Up the ACOOver at Healthcare IT News, Bernie Monegain, Editor chimes in via: ‘More than half of ACOs show savings: Accountable care organizations are helped by the use of health information technology.’

While at Kaiser Health News staff writer Jenny Gold notes: ‘ACOs Saving Some Money, But Medicare Is Short On Details.’

And Melanie Evans at Modern Healthcare asserts ‘Providers net uneven results from ACO experiment‘ re-capping the data as follows:

Slightly more than half of the 114 organizations to join one of two Medicare accountable care efforts in 2012 did not reduce health spending below targets during their first 12 months trying to do so, newly released CMS data show. 

Of the remaining organizations, 29 reduced spending enough to keep some of what they saved during the first 12 months. The rest slowed health spending, but marginally. 

Take your pick, there are plenty more to chose from and whether your view is from a glass ‘half empty’ or ‘half full’ perspective your answer to whether the ACA is working or not, and in particular, can ACOs enable the required transformation is likely to be shaped by whether you have a dog in the hunt if not personal skin in the game.

To sort through and make some sense of this nascent industry ‘report card’ are three industry veterans who will help us dive past the headlines and into the weeds of the ACO experience. Recognizing that ACOs not a homogeneous bunch and vary operationally and by market, there is a fair amount of context setting to actually interpret the results.

On the next episode of ‘This Week in Accountable Care‘ I am joined by three seasoned players in and around the space including Fred Goldstein, Jim Hansen and David Crais.

For live or archived replay of this episode, click here.

Join us for an informative chat and tag your tweets with #ACOchat and will put your questions and/or comments into the conversation.

ACA, Accountable Care and the @HealthcareGov Fiasco

By Gregg A. Masters, MPH

With the quiet time afforded this ‘Thanks Giving-Kah’, I feel called to express some ‘dis-ease’ with the progress towards our pursuit of the triple aim or sustainable healthcare ecosystem.

healthcareGov cartoon

As if the health reform battle hasn’t been a power partisan exchange from day one. Think again…

If you weren’t paying attention during the run up to the Act’s passage in March of 2010, be reminded that the process was NOT imbued with the goodwill and fair consideration of grounded health policy arguments – both pro and con – to vet what might emerge from our bi-cameral legislative process and stand in the marketplace of ‘workable reform’.

But who among us could have predicted that health information technology performance or more accurately the lack of said ‘e-commerce performance’ might emerge as the likely candidate fulfilling the oppositions’ intent to stand in the way of ‘real’ health insurance for some 75 millions Americans?

Seriously HealthIT as the tipping point in the demise of the Act? Who saw that? As noted by a colleague on twitter:

Margalit Gur-Arie ‏@margalitgurarie 20 Nov
@2healthguru Oh yeah If someone said a year ago that Obamacare will fail on account of technology, I would have laughed them out of the room

In the midst of 46 attempts by the Republican controlled House to defund or repeal the ACA, a tapestry of lawsuits filed by AGs in ‘red states’, an unexpected SCOTUS affirmation of the law coupled with ‘discretionary’ state participation in the Medicaid expansion provision, and relentless Tea Party backed efforts to tag the Act as the end of freedom itself and the institutional permanence of ‘big government’ in the lives of all Americans – what most failed to appreciate is the market based nature of the effort. Health reform and the provisions in the Act express macro trends deeply rooted in the connective tissue of provider/payor/patient/consumer marketplace experience, wholly independent of the exquisitely orchestrated though faux political narrative – the crown jewel in the playbook of ‘weapons of mass deception’.

I have been in the ‘managed competition’ side of this business for 3+ decades and often can’t understand the nature of the beast we’ve created. The ‘healthcare conundrum‘ so aptly coined by Atul Gawande quite some time ago is a complex and unwieldy beast I have affectionately tagged the ‘healthcare borg‘ as a reference to the ‘resistance [as in change] is futile’ reference in Star Trek. Yet, many who lack even an undergraduate grasp on the nature of the American sick-care economy are unreasonably certain in their opinions on the nature of the malady and what might pass as proper remedies. Unfortunately, this certainty seems to be rooted in cheerleaders who might be characterized as ‘frequently wrong, but never confused.’

In this absence of anchorage to facts and contextual truths where is one to start in an ideological fueled echolalia of lies, misrepresentations, partial truths architected by armies of K-street funded special interests and their partner PR machines? Unfortunately for the rest of us K-street and the balance of the often morally bankrupt (chase the buck) beltway bandits find gold in them their hills of fueling ‘conflict’ as a contractual or ‘annuity solution’ to their recurrent ‘bill-ability’ concerns.

Let’s be clear. If the ACA were repealed do you think any of the macro trends would slow or reverse? Would Accountable Care be set aside for an ‘unaccountable care’ status quo? How about the movement into value based or performance based payment? Might this be moved to the quicksand of failed ideas while the return to fee for services ‘happy days’ plays on and on? Will selective movement into direct or retainer based medicine somehow disappear as well (note the return to direct practice is merely the reinvention of the HMO only in more micro practice terms)? Or will care management and coordinated care be seen as merely a passing fad with an immediate return to silo based episodic care and unit revenue or pricing maximization? I don’t think so…

None of these granular market tectonics would reverse if the Act were to be defunded, repealed or somehow re-litigated in the court of public opinion or elsewhere.

So let’s place the change or transformational energy impulse where it can best serve us. Since we’ve just recognized the 50th anniversary of the tragic JFK assassination I’m reminded of this bit of timeless wisdom:

‘if you’re NOT part of the solution, you are [part  of] the problem.’

Have you looked in the mirror lately?

ACOs ‘In the News’

Gregg A. Masters, MPH

heritage masthead

As the drip, drip, drip of the reported collateral fallout – both perceived and actual – of the stalemated resolution of the Federal shutdown makes it way into the American psyche we’re also seeing reports from the front on the success, indifference or failure of the ‘ACO vision’ to successfully pivot the healthcare borg from a fee-for-services (volume) to a fee-for-value paradigm.

Today’s news reports on two entities with which I am somewhat familiar – Texas Health Resources (THR) and Heritage Medical Systems (Heritage Provider Network) both parents respectively of first generation CMMI Pioneer plays. I served as the Vice President for Managed Care and Network Development at THR’s branded affiliate ‘Wellspan Health Network” (including System Health Providers (SHP) and consulting roles to Genesis Physicians Group) pre and post merger of Presbyterian Healthcare Resources and Harris Methodist Health System into THR, while at Heritage Southwest Medical Group, I championed provider network development and management including capitating specialty services for a global risk contracts.

Sourced from: ‘Digging Deeper: Lessons from an ACO Success Story.‘ Texas Health Resources

Perhaps framing the irony surrounding the confused narrative associated with the signature accomplishment of this President against a history of persistent previous legislative failure, the author notes:

We all know that the word “Obamacare” elicits immediate emotion from a good chunk of the American public. Thanks to late night TV host Jimmy Kimmel, and a media poll or two, we know that the words Affordable Care Act (ACA) do not elicit the same kind of emotion.

This only makes sense if you can buy with a straight face the sensibilities of the Tea Party cheerleading line of ‘keep your stinkin’ Government hands off my Medicare’ rant.

Meanwhile, the decisions of these two entities shed light on the underlying motivations likely to be driving in one case the decision to ‘step down’ in the risk ladder (THR) while in the second expressing a warp speed determination to proactively manage the risk exposure and deliver on the triple aim.

The author cites THR’s CIO Ed Marx aka @marxists on twitter as follows:

[THR] ….wanted to avoid paying a penalty, but was still focusing on ACO efforts. 

Whereas, Jonathan Gluck senior executive and counsel at the Heritage Provider Network notes, we’re:

…all in on the program.

This differential approach to risk is illustrative. Both entities at least in the Texas market have erratic performance. Heritage Southwest Medical Group ultimately declared bankruptcy during the global risk days in the late 90s, while THR returned to it’s hospital roots when the succession leadership vetting was over and the insurance culture of the then CEO of Harris Methodist Health System demurred to the predominant hospital culture of the Presbyterian leadership (aka the Smith v Hawthorne succession dance) by selling the Harris Methodist Health Plan to PacifiCare Health Systems.

It should come as no surprise that a physician organization untethered in any material ‘bricks and sticks’ sense to hospital infrastructure other than a drawer full of partial (at best) risk contracts should embrace the Pioneer model; whereas a hospital system even in partnership with a risk savvy physician organization the likes of ‘NTSP’ aka North Texas Specialty Physicians (_NTSP_), the JV partner in the Pioneer ACO) would step down and recalibrate their pathway options into this value shift.

The jury is out whether institutionally led health systems can re-engineer their culture let alone their asset portfolio to meet the vision quest of the triple aim via ACO intermediaries. If I were a betting man, my money would be on Dick Merkin and Mark Wagar, et al to tame the unrestrained appetite of the often maldistributed, excess capacity and misaligned production based assets.

AHIP Back in the ‘huddle’ and Reminiscent of the ‘GHAA Revolution’?

By Gregg A Masters, MPH

It’s been a very long time since I participated in an AHIP event. In fact for the record I have NEVER been to an AHIP event – that is before this week in DC. I attended, filmed, tweeted, broadcasted from, and now blog about AHIP’s ‘Medicare, Medicaid and Dual Eligible 2013 Program series.AHIP Medicare, Medicaid, Duals DC 2013

As someone who’s guided, counseled and implemented (at times successfully and other times not) some rather large proprietary, non-profit (ah hem, I mean ‘tax exempt’) health systems and their national or regionally branded provider sponsored ‘managed’ (ah hem, I mean ‘discounted’) health plans dating back to the 80s and into the millennium this is awkward if not curious (‘N’ of one?) state of affairs.

AHIP is after all is the ‘go to’ resource for the health plan community and their aligned provider and health system partners.  Yet somehow in my non traditional yet ‘mangled’ healthcare career path I managed somehow to stay outside of that tribe of dedicated and passionate healthcare professionals.

Back then, half of AHIP’s predecessor iteration was known as GHAA – the ‘group health association of America.’ This was an multi-dimensional trade label, as ‘group’ could be seen from an employer’s wholesale purchasing of group health insurance (vs. the ‘individual market)’ perspective but also from the point of it’s constituent member health plans mostly built upon ‘risk savvy’ medical group practice infrastructure – Friendly Hills, Mullikin, Bristol Park, Harriman Jones et al, at least in Southern California – though peer equivalents peppered the national lanscape, ie, Dean, Kelsey Seybold, Scott & White, InterMountain, Park Nicollet, Virgina Mason.

It’s been a while since the vertical integration and rabid consumption of group, IPA, or network model HMOs by national nameplates storming into the managed competition market and away from their indemnity roots (Aetna/US Healthcare, Prudential/PruCare, United HealthGroup, The Equitable/Equicor), but the players back then included the likes of HealthNet, PacifiCare, TakeCare, Maxicare (RIP)’ and many other national startup wannabes ie, Partners/VHA, UniHealth/CareAmerica, HealthPlan of America, HealthCare USA, to name just a few.

Nonetheless, GHAA meetings radiated with excitement and enthusiasm as the disruption vibe of the day was to bring this HMO thing from marginal (a 2nd tier class of docs, hospitals and ‘ancillary providers’ aligned with ‘HMO medicine’) into the mainstream. HMOs other than Kaiser Permanente, Mayo Clinic and the Cleveland Clinic were seen as less than quality ie, ‘cheaper’ medicine. Yes, back then comprehensive HMO benefits where the ‘value play’ in the group health portfolio.

Fast forward to today September 25th 2013. Consider the following: the Affordable Care Act (ACA) though approved by Congress, signed into law by the President and affirmed constitutional by the Supreme Court is a hostage to the antics of the junior Senator from Texas leading a ‘defund ObamaCare’ filibuster of sorts amidst a very real threat of a Federal Government shutdown. [Editor's Note: Consider this the leading edge of wasting taxpayer dollars to pursue a political, not healthcare solution agenda].
AHIP podium signage
Whereas, in the ‘roll up your sleaves and lets get er done’ tribe, less than a mile away at the AHIP meeting a flock of dedicated healthcare professionals and aligned stakeholders from every sector of the healthcare ecosystem [perhaps absent the patients voice?] are ‘huddling’ to share best practices, enterprise models and the technical guidance that can assist the implementation of both the spirit and intent of a very complex and mostly certainly less than ideal law.

Wow what a contrast! That ‘juxtaposition of irony’ did not escape many of the faculty including no less than one warrior of a previous similar battle, the then OMB Director Alice Rivlin, now Co-chair, Bipartisan Policy Center’s Domenici-Rivlin Task Force and Interim Director of Brookings’ Engelberg Center for Health Care Reform who opined:

‘It really is a very strange time to be here in [Washington DC] the most extreme partisan politics in my memory and I’m afraid the most broken that I have seen our democratic process. Healthcare and health insurance are caught right in the middle of this dysfunctional situation……and [in view of the potential Federal Government shutdown] given this ‘disconnect’… you might wonder, have they lost their minds? And the answer is YES!’ – Alice Rivlin

So amidst this self imposed ‘faux’ crisis the title of the blog is to analogize the ‘return’ of AHIP to its original revolutionary roots. Given the scope, range and depth of the Act, making the ACA work is in the words of previous acting director of CMS and champion of ‘the triple aim’ Don Berwick an ‘all hands on deck’ affair. We need each other all rowing in the same direction if ‘we’ are to matter this time.

If not, the party for the public/private hosting of American medicine – both financing and delivery may be over.  It’s certainly debatable whether AHIP ever migrated away from their GHAA roots or not, but this is one observer’s experience in prior team huddles.

A Juxtaposition of DC Irony

By Gregg A. Masters, MPH

It’s Monday in DC and the Capitol is distinctly vibrant albeit with a peculiar though eclectic mix of create vs.  deconstruct energies.

imageSome might say this attitudinal ‘chemical cocktail’ is in part sourced from a mix of ‘doers’, but also a smidge if not even a heaping portion of the just say ‘hell no’ [to Obamacare] crowd. For reference see: the latest effort by the House to derail health reform via a defund the act showdown with the Democratic controlled Senate and the President himself.

Yet amidst this continuing dance of oppositional strategizing we’re at the Renaissance Hotel DC for a series of one might characterize as ACA ‘implementation conferences’. These are principally the health plan doers who are under a mandate to reinvent themselves, and craft a sustainable market role for their members. The AHIP cohort is perhaps most visible via Aetna, Humana, United HealthGroup as well as others, who are intent upon making the best of this complex piece of legislation known as ‘the Affordable Care Act’. This gathering of players has huddled to support each others efforts and identify and share best practices to model as the industry collectively pursues the triple aim or alternatively cast as the coveted sustainable healthcare ecosystem.

One can assume the overwhelming mission of those attending the AHIP Conference trilogy are here to learn about if not advocate for the three pillars associated with the ACA: the tweaking of Medicare from volume to value via ACOs and other innovations, the significant expansion of Medicaid and the rapid expected growth in  ‘Dual Eligible’ population.

For conference schedule click here.

The hashtag for the conference is #AHIPMCMCConf.

An ACO ‘Shell Game?’ Of Arrows, Pioneers & Patsies’

By Gregg A. Masters, MPH

In ‘Pioneers Take Arrows While Settlers’ Get the Land’ I reported in a ‘just the facts ma’am’ fashion the developing narrative as proferred by Modern Healthcare, CMS, and the AMGA as to whether this was to be seen as good news or bad news.

Pioneer with arrow in backRecently the witty industry veteran and futurist  Ian Morrison weighed in via ‘Why Some ACO Pioneers Turned Back, as did Oliver Wyman via ‘The Year of the Pioneers’ and even the health policy braintrust, aka the ‘…aw shucks, we just really want to help Obamacare out’ cheerleading squad at the American Enterprise Institute weighed in via ‘Reforming Medicare integrated care: An alternative to the Obama administration’s accountable care organizations. Whoa can you say bandwidth consumption?

Indeed, rather than parse out each, I will address them separately via individual consideration. I just wanted to get them on the blog before more time passed.

I might add that as far back at June of 2012 at the jointly sponsored CAPG (California Association of Physician Groups) and IHA (Integrated Healthcare Association) ACO Congress word on the streeet had it  ‘all was not well in Pioneer land’. So fresh as some of these insights and realization may claim to be, some of the more chronic challenges have been on the record for quite some time.

You  might enjoy the reading ‘From ‘Unicorns to Multicorns” ACOs Morphing Below Radar’ which followed the ACO Congress.

As some say….

More will be revealed

Leavitt Partners on ACO Growth and Dispersion: An Update

By Gregg A. Masters, MPH

Per Leavitt Partners:

A ‘Growth and Dispersion of Accountable Care Organizations: August 2013 Update.’

The Leavitt Partners Center for Accountable Care Intelligence releases new white paper entitled “Growth and Dispersion of Accountable Care Organizations: August 2013 Update”Growth and Dispersion of ACOs August 2013.Screen shot 2013-08-15 at 12.09.40 PM

Salt Lake City, August 15, 2013 — Drawing from an ongoing study by Leavitt Partners, The Center for Accountable Care Intelligence has released an ‘August 2013 Update’ to the previously acclaimed white paper: Growth and Dispersion of Accountable Care Organizations.

The report details how the growth and proliferation of accountable care initiatives has unabatedly continued over the last twelve months. The broad adoption of accountable care paired with the emergence of preliminary results has provided some clarity to the overall accountable care movement.

Analysis of the current accountable care landscape highlights three significant findings:

The number of accountable care entities is increasing. Leavitt Partners is currently tracking 488 accountable care entities through the end of July 2013, more than double the number from June 2012.

Medicare ACOs are growing faster than non-Medicare ACOs. Medicare ACOs now comprise more than half of all accountable care contracts nationwide.

There are many different models of accountable care. No single model has emerged as most successful and as accountable care expands, we continue to see variety in organization and execution.

About Leavitt Partners

Leavitt Partners is a health care intelligence business. The firm delivers collaborative, high-value intelligence that helps clients transition to new models of care. Through its member-based collaboration called Health Intelligence Partners™ and direct services to clients, the consulting firm provides the best available window to the future of American health care. For more information visit LeavittPartners.com or call (801) 538-5082.