Is Evolent Health the ‘New, New’ Healtheon?

By Gregg A. Masters, MPH

There are parallels worth considering!Evolent Health S1 Filing

But first for those who’s event horizons’ don’t reach back to the Healtheon era (mid to late 1990’s) a little history may help with the construction of this narrative. Perhaps the dots are optimally connected by the talented and best selling author Michael Lewis in his book ‘The New, New Thing‘ (a reader’s digest version of Jim Clark’s impact is here) wherein Lewis profiles Silicon Valley Healtheonculture and the ‘pre-mature’ rise of an ambitious company who intended to ‘fix healthcare’ via technology – Healtheon (the vestiges of which exist today as WebMD and Emdeon). And for those of you history buffs, who want a deeper dive into the story, see ‘What The Heck Is Healtheon?

Dots Connected?

EvolentHealthBoth Evolent Health and Healtheon are (or were) ‘transformation plays’ with an ‘on the come‘ revenue upside tied to the expected (almost inevitable) market restructuring from fee-for-services medicine to an expanding book of ‘alternative payment arrangements’, i.e., capitated or fixed price healthcare (‘generation 1.0′ of bundled payment via case rates, DRGs, global or service tiered per diems, etc., as the concept of ‘valued based’ care had yet to penetrate popular healthcare lexicon).

In sum, the rather over-simplified claim for Healtheon’s upside to Wall Street is paraphrased as follows:

‘[Healtheon] would use the power of computing and the Internet to revolutionize the health-care industry, stripping away its inefficiencies and inequities and streamlining it for the new millennium.’

Here’s the company description lifted from Healtheon’s registration statement in 1995:

Healtheon Company description

Fast forward some 19+/- years later, according to Evolent Health’s S1 filing here’s their story:

We are a market leader and a pioneer in the new era of healthcare delivery and payment, in which leading health systems and physician organizations, which we refer to as providers, are taking on increasing clinical and financial responsibility for the populations they serve. Our purpose-built platform, powered by our technology, proprietary processes and integrated services, enables providers to migrate their economic orientation from fee-for-service, or FFS, reimbursement to payment models that reward high-quality and cost-effective care, or value-based payment models. By partnering with providers to accelerate their path to value-based care, we enable our provider partners to expand their market opportunity, diversify their revenue streams, grow market share and improve the quality of the care they provide.

We consider value-based care to be the necessary convergence of healthcare payment and delivery. We believe the pace of this convergence is accelerating, driven by price pressure in traditional FFS healthcare, a regulatory environment that is incentivizing value-based care models, a rapid expansion of retail insurance driven by the emergence of the health insurance exchanges and innovation in data and technology. We believe providers are positioned to lead this transition to value-based care because of their control over large portions of healthcare delivery costs, their primary position with consumers and their strong local brand.

Today, increasing numbers of providers are adopting value-based strategies, including contracting for capitated arrangements with existing insurance companies, governmental payers or large self-funded employers and managing their own captive health plans. Through value-based care, providers are in the early stages of transforming their role in healthcare as they attempt to defend their existing position and capture a greater portion of the more than $2 trillion in annual health insurance expenditures. While approximately 10% of healthcare payments are paid through value-based care programs today, including through models created by systems like UPMC, Kaiser Permanente and Intermountain Healthcare, it is estimated that this number will grow to over 50% by 2020. There were 120 provider-owned health plans as of 2010 and this number continues to grow. The number of ACOs constructed to manage capitated or value-based arrangements with existing insurance companies or government payers grew to 742 by the end of 2014.

We believe the transformation of the provider business model will require a set of core capabilities, including the ability to aggregate and understand disparate clinical and financial data, standardize and integrate technology into care processes, manage population health and build a financial and administrative infrastructure that capitalizes on the clinical and financial value it delivers. We provide an end-to-end, built-for-purpose, technology-enabled services platform for providers to transition their organization and business model to succeed in value-based payment models. The core elements of our platform include:

• Identifi®, our technology platform;
• an integrated technology, proprietary process and clinical services model;
• long-term, embedded and aligned partnerships with health systems;

So the mission’s of both were similar if not identical in terms of the re-structuring upside. They vision a disruptive technology play layering efficiencies into (if not picking off the low hanging fruit) of a change resistant confederation of legacy healthcare interests inclined towards internecine warfare (dis-organized medicine writ large, but primary care v. specialty care in particular and the grand canyon divide between payors and providers to get beyond the simple calculus of ‘your revenues are my expenses’).

What’s different today?

Times have indeed changed, AND the stakes have risen considerably. From a macro-economic perspective the ‘cost shifting’ shell game is officially over as today it’s about ‘total costs of care’ (the triple aim and the new focus at the level of population health) and not shifting liabilities from ‘my P&L to yours’.

Yet, the fundamental problem of a healthcare non-system incentivized by a ‘do more, earn more’ payment model continues to consume a dis-proportionate share of the national economy despite both public and private sector efforts to restrain its appetite. Yet, I see at least four underlying market considerations belying this otherwise ‘deja vu’ insight.

  1. The presumptive value prop of technology (and its enabling infrastructure) is more prevalent, powerful and affordable today than it was in the 90s.
  2. The share of GDP the healthcare spend accounts for in the 90s hovered in the 9-10% range, whereas today that share is closer to 18% where nearly 1 in 5 dollars spent in the U.S is parked inside a seemingly insatiable healthcare appetite.
  3. The healthcare reform or health system re-design imperative, once contained behind the closed doors of health systems, risk bearing physician entities, corporate board rooms of purchasers or their health plan proxies and even the halls of both State and Federal Government is now ‘out of the barn’.
  4. Anticipating the trend growth (i.e., the impending bankruptcy of the U.S Treasury) in Medicare and Medicaid spending CMS has upped the ante in the value based payment glidepath by targeting 50% of their spend to be channeled via value based payments year end 2018; see: ‘Better Care. Smarter Spending. Healthier People: Paying Providers for Value, Not Volume‘.

This change if not re-invention mandate is a national if not global conversation and quest. In other words, the healthcare spend will sink not just companies, but countries if we do not find a satisfactory path to a sustainable healthcare ecosystem.

So maybe this time things are different (those above and perhaps many others) to make this reach and business model both practical and scalable for at times ‘impatient’ investors.

So ‘Ladies and Gentlemen, start you engines’. And by all means do buckle in, this ride will no doubt be a fun one!

An ACO Update via Leavitt Partners

By Gregg A. Masters, MPH

Just released is the continuing pulse of the accountable care industry (not just ACOs per se) via the consulting firm branded with the imprimatur of a former Secretary of HHS Michael Leavitt who opines from the Red State of Utah on the progress made by market driven initiatives outlined leavitt_acosin the Patient Protection and Affordable Care Act (ACA).

I will add my thoughts to the Leavitt commentary shortly, but the one slide that caught my attention y/e 2014 was the crossover by provider type from physician led to institutionally (hospital system) led ACOs.

One might say that the traditional revenue side vs. cost basis of a hospital group is now at the head of the class of ACO innovation is the wrong form of ‘disruptive leadership’.

Yet, it’s interesting to note that the American Hospital Association (AHA) is a principal partner if not co-sponsor of the report. Might this be a filtering outcome of the ‘fox guarding the hen house‘ or even the aggregate impact (conscious or otherwise) of strategy driven choices by CEOs of U.S. Health Systems?

By way of context, as a long as hospitals maintain their ‘revenue center’ primacy vs, their actual role (in the sustainable healthcare ecosystem food chain) as the true ‘cost centers’ they are – at least in legally, financially and clinically integrated delivery systems or networks (IDNs), how can ‘hospital culture’ be expected to pro-actively cannibalize a bread-and-butter fee-for-services business model in a reimbursement paradigm largely dominated by volume driven incentives even in 2015? Only a disinterested third party (aka physician led ACOs) can re-engineer the needed disruption of maldistributed, asset concentrated overpriced hospital services.

For the complete Leavitt Partners report click here.

ACOs by sponsor type Leavitt Partners

The ‘NexGen ACO': CMS Speaks [again]

By Gregg A. Masters, MPH

At one level you have perhaps the most risk savvy and successful operators in the Medicare Advantage space aka ‘CAPG‘ (the California Association of Physician Groups) closely tethered to it’s less geographically constrained though California domiciled partner IHA as in ‘Integrated Healthcare Association’ explicitly advocating for the preservation of the Medicare Advantage program (MA) aka ‘Part C‘ even though the pre-ACA historical cost to the Medicare Trust fund ‘overfunded’ the program by 114% (estimated in 2014 at 106%) vs. historical FFS program payouts. CAPG’s value prop statement is in part reflected below:

Medicare Advantage is a critical element in the nation’s movement from volume to value in healthcare. With its emphasis on risk-based contracting and clinically integrated care, Medicare Advantage is paving the way for the advancement of coordinated care in every other healthcare program. Medicare Advantage has motivated the deployment of electronic medical records, the expansion of robust quality measurement and reporting, and the movement to team based care, all of which have resulted in better care for seniors. In addition to improving care and quality of life for seniors, this risk-based coordinated care model has the ability to rein in Medicare spending, unlike fee-for-service and its volume-driven incentives.

ACO Next Generation Model

Whereas, under the new if not ‘Deputy’ leadership since the departure of Marilyn Tavenner, former CMS Administrator, Patrick Conway, MD, recently announced the launch of a ‘new and improved’ ACO tagged the next generation ACO – which at some level may be virtually indistinguishable from it’s more mature MA program.

So the question remains, where is this program going and what if any difference will there be between Medicare Advantage and ‘Next Generation of ACOs?’

Quoting from CMS, the initiative details are:

The Next Generation ACO Model is an initiative for ACOs that are experienced in coordinating care for populations of patients. It will allow these provider groups to assume higher levels of financial risk and reward than are available under the current Pioneer Model and Shared Savings Program (MSSP). The goal of the Model is to test whether strong financial incentives for ACOs, coupled with tools to support better patient engagement and care management, can improve health outcomes and lower expenditures for Original Medicare fee-for-service (FFS) beneficiaries.

Included in the Next Generation ACO Model are strong patient protections to ensure that patients have access to and receive high-quality care. Like other Medicare ACO initiatives, this Model will be evaluated on its ability to deliver better care for individuals, better health for populations, and lower growth in expenditures. This is in accordance with the Department of Health and Human Services’ “Better, Smarter, Healthier” approach to improving our nation’s health care and setting clear, measurable goals and a timeline to move the Medicare program — and the health care system at large — toward paying providers based on the quality rather than the quantity of care they provide to patients. In addition, CMS will publicly report the performance of the Next Generation Pioneer ACOs on quality metrics, including patient experience ratings, on its website.

CMS expects approximately 15 to 20 ACOs to participate in the Next Generation ACO Model with representation from a variety of provider organization types and geographic regions. The Model will consist of three initial performance years and two optional one-year extensions. Specific eligibility criteria are outlined in the Request for Applications (PDF).

Clearly this may be an inflection point, or more aptly stated, a convergence of what has been a parallel track (excluding the Pioneer ACO program) between ACOs in the Medicare Shared Savings Program (aka ‘HMO-lite’) and their more risk savvy competitors in the MA space.

For a 2014 analysis of the costs of the Medicare Advantage vs. traditional Medicare program see: ‘Medicare Advantage Program in 2014‘.

As tweeted to me earlier this week by James Hansen, VP of the ACO and MA operator company Lumeris:

‘Next generation ACO, finally a starter or more kissing your cousin?’

No doubt CMS is being responsive to provider (contractor) market input from both the Pioneer program exits as well as the overwhelming election by ACOs to NOT assume downside risk under the current terms of the MSSP.

Like it or not, [ACO/HMO] convergence is coming. Clinical and financial integration including partial or full risk assumption are the business models that will succeed in the pursuit of sustainable healthcare financing and delivery business models. I view this latest CMS announcement as confirmation of this macro directional trend.

 

 

 

 

 

 

Value Based Care: what we can learn from those who succeeded (and failed) in Year 1 of the Medicare Shared Savings Program?

By Randall Williams, MD*

“The definition of insanity is doing the same thing over and over again and expecting different results.” — Albert Einstein

einsteinIf you want to lead your organization to success with value based care, I’d like to help you avoid the mistake of committing organizational insanity. As I’ve written before, all value based contracting will require a different and diligent focus on reducing cost. In order to win, you need a model that will help you do that. But first, there’s a lot to learn from those who succeeded (and failed) in the first year results of the Medicare Shared Savings Program (“MSSP”).

The first year impact of MSSP has received lots of attention in the media. To sum it up:

Only ¼ of all MSSP organizations achieved ANY financial success, as measured by receiving shared savings.

cms_logoThat statistic is concerning and has caused hand-wringing inside and outside the Beltway, but it is not surprising. Why? It’s simple really — most ACOs are still working on basic organizational issues like:

  • integrating their doctors
  • getting CMS claims data into a format that can be analyzed
  • documenting and reporting quality performance metrics

While that work is necessary, it is not at all sufficient. It won’t generate the cost savings required to get to the shared savings bonus opportunity. MSSP organizations, depending a bit on their size, must reduce the total beneficiary cost (Medicare Part A and Part B) by at least 2.5 – 3.5%. Yet few are focusing on doing things differently when it comes to managing their population’s utilization and costs.

Imagine the following scenario:

The average beneficiary in your ACO spends $9,000 per year.

You have 10,000 beneficiaries.

Your savings threshold is 2.8%.

In order to get into the bonus category, you will need to avoid at least $2.5 million a year in medical expenditures. That doesn’t just happen on its own.

Sounds like tough work, you say. Maybe we can’t get there, you say. But some of your peers actually accomplished that in their first year.

Were they simply lucky, perhaps having the “good” fortune of a high starting point to work from? Or might their success be a result of the Medicare reconciliation “Black Box”? Evidence and analysis elsewhere suggests these aren’t the explanations. So what is?

Medicare’s own analysis of the Year One winners (those who got bonuses) gives some important insights to the real answer. From that data, we can see that:

  • Winners saved about 6% per beneficiary overall
  • Winners reduced hospitalizations by 52%, ER visits by 41%, and inpatient costs by 69%
  • Winners achieved a 40% decrease in admissions for heart failure patients and a 25% decrease in admissions for COPD patients
  • Winners dropped hospital readmission rates by 26%

What does this mean to organizational leaders looking to achieve savings bonuses?

  • Get your organization focused on avoidable admissions and readmissions to the hospital
  • Eliminate enough admissions to drive down overall costs by >5%
  • Establish a monthly goal of averted admissions that you can measure and manage over the course of each performance year
  • And whatever else you decide to do, don’t simply assume that doing what you’ve always done will get you different results!

For other useful analysis of MSSP results, I recommend reading insights from the Brookings InstituteMedicare ACOs Continue to Improve Quality, Some Reducing Costs‘. Please feel free to share your thoughts about winning with value based care in the comment section.

***********************

Dr. Williams is the founding Chief Executive Officer of Pharos Innovations. He is responsible for setting the vision and overseeing the execution of Pharos’ mission to transform healthcare through patient engagement in self-care. He has 16 years of executive experience developing chronic care monitoring programs.

The above is a guest post originally published here.

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.