Transforming a $3.2+ trillion dollar economy where approximately 1 in 5 dollars of GDP finds its way into the healthcare financing and delivery ecosystem is no small challenge. Decades of variably branded health policy initiatives from HMOs and PPOs to their arguably derivative reincarnated ‘brethren’ ACOs all presented with the promise of taming what remains a rather rapacious appetite for ‘more‘ in a complex do more to earn more web of financial incentives.
The most recent addition to this effort was delivered via the Affordable Care Act courtesy of President Obama in March of 2010. Accountable Care Organizations (ACO’s) are defined as follows:
ACOs are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare patients.
The goal of coordinated care 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.
When an ACO succeeds both in delivering high-quality care and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare program. – Centers for Medicare and Medicaid
Meet Dr. Andre Berger
Andre Berger, MD is a busy man committed to move the needle towards the seemingly conflicting goals of the ‘tripe aim’ – better experience of care, with improved outcomes at lower per capita costs.
This multi-board certified physician has a lot on his plate – a busy cosmetic surgery and anti-aging medical practice as well as the chief executive officer of a primary care physician led and governed next generation accountable care organization (ACO) with a successful five year operating history.
I first learned of Dr. Berger as a result of my interest following and reporting on Accountable Care Organizations (ACOs) for ACO Watch. Dr. Berger was listed as the CEO of National ACO admitted to the first class of participating ACOs in the Medicare Shared Savings Program (MSSP) as an advanced payment model. Then I noticed the office for National ACO was headquartered in Beverly Hills, California on the very street I called ‘home’ while serving as Director of Managed Care for American Medical International (now operating as Tenet Healthcare) California Region – I thought to myself what a coincidence! I need to learn more about this enterprising physician and wondered why a surgeon specializing in a direct pay (non 3rd party reimbursed) specialty for often ‘non-covered’ services from a typical group or individual health benefit point of view, be leading such an effort?
This co-mingling of seemingly divergent interests convinced me there is a deeper story to uncover possibly with an important message for physicians, hospitals, and patients given the current instability of our volume driven healthcare delivery and financing model.
Fast forward some four years + later, and I’ve been invited to advise National ACO on their social media presence and to develop a portfolio of digital assets for a growing thought leadership library.
On recent trip from South Lake Tahoe to cover BIO 2017 the global annual go-to gathering of the best and brightest minds in the biotech sector in San Diego, I was invited in to ‘shadow’ Dr. Berger and get a feel for a typical day in his life at the helm of National ACO.
Tuesday 8:30 AM
While Dr. Berger is CEO of National ACO (NACO) a growing enterprise with lean staffing he maintains his clinical practice so balancing workflow is a challenge addressed by having dedicated NACO days, and in office or surgery patient days. Today was an NACO day.
Dr. Berger arrives at the office equipped with briefcase including his accessorized iPhone, MacAir, iPad. AppleWatch, associated peripherals and a series of file folders. What follows is a series back-to-back phone calls, tech-enabled virtual staff meetings and seemingly non-stop text messaging.
The first call is with the Medical Director of NACO’s PET (provider engagement team) and the subject is physician performance (both quality and financial) reviews.
Next up is executive staff meeting with a long list of action items finalizing a progress report due to CMS.
Key themes include overall and regional performance of on annual wellness visits (AWV) and chronic care management (CCM) programs.
Given growth in NACO there’s considerable discussion on staffing needs, particularly acute is recruiting a Director of Care Management given a tight market and low supply of candidates, NACO may need to retain search firm. Finding qualified case managers and care management staffs sound equally challenging.
The ‘mobile physician’ waiver (allowing physician access to patient’s homes to provide transitions of care consults) is delegated to the chief medical officer, NACO plans to deploy in Q3. Will help with CM staffing and population management.
Provider Network Managers to inventory ‘at risk’ patients to put on care managers’ priority screening. Is vendor a reliable source? May need to vet further for accuracy and then prioritize.
Other agenda items included: contracting with nursing homes, hospice providers, reviewing stop loss policy, discussion of ESRD patient mix, and possibility of contracting with key nephrologist or nephrology group(s).
All with intent to ID ‘preferred providers’ and ultimately tag for population based payments.
9:30 AM GOTO Meeting Conference Call (to review performance results)
Reviewing IT vendor dashboard detailing physician performance by ACO, region, etc. Considerable discussion on the need to manually design custom reports and the duty of that burden falling on the physician or whomever is pulling the data have to input the requested parameters.
Further discussion topics include: evidencing completion events for quality metrics reporting, the status of hospital real time ‘ping system‘ alerting ACO physicians of admits, discharges or transfers. It was affirmed that efficacy of the notification program requires two pings: one to admitting physician, the second to NACO medical director.
Considerable discussion on vendor performance and opportunities for workflow improvement.
HR issues (mostly need for additional staff).
Dilution agreement (issues associated with NACO capital raise via PPM to participating physicians, medical groups or IPAs.
10:10 Management Meeting – Agenda
Routine conversation on travel policy and company preference to avoid ‘non refundable’ airline ticket purchases. Recommended leveraging tools available via concierge support services as often as practical.
Balance of meeting agenda deferred to NACO operations manager. On tap is IRR review of ’Project Plan Requirements’.
Define compliance reporting to NGACO Governing Body members. What does this include? In the minutes. All needs to line up with contracting obligations.
Definition of ‘beneficiary representative’ who is this? Definition of ‘Certified Participants’? Quest was submitted by NACO as ‘preferred provider’.
Same (COI) issue for ‘consumer advocate’.
Key issue is defining ‘joint venture’ (JV)? For purposes of disclosure requirements. Are lab vendor relationships a JV? What about PBMs?
Training and Education program need be developed. Need to source CMS requirements NGACOs.
Need project format with due dates and compliance checks.
Letter re: advantages of joining NACO. Details calculations and benefits of affiliation.
Need fine tune the ‘marketing materials’ for physician recruitment and any special considerations for appeal via IPAs.
Physician outreach need stay away from ‘guarantees’, but stipulate shared savings participation on an ongoing performance basis.
Next Generation ACO Deadlines and Calendar: Webinar schedule, voluntary alignment dates, provider risk stratification meeting, the need for executive breakout session to review tier assignment, engagement level and appropriate notice and cure periods. Deadline is 9/29 for removal from NACO panels. Report period 2017 or rolling 12 months.
Recent submission to CMS certified. Break out by physicians, TINs and preferred providers.
Population Based Payment: what’s plan, deadline and status?
PBP Agreements are just now being sent out to target physicians.
Follow-up planned one week post mailing.
Senior staff query: how are we engaging our medical directors to facilitate recruitment and participation PBP program? May need to develop video on PBP program directed to target physicians with outreach via NACO medical directors.
Chronic Care Management program update included number of care plans completed, outbound call volumes, number of patients in program, sorted by minutes to meet marks.
Care Manager recruitment status report.
Revenue pro-forma review, including ‘consent’ status and whether ‘on plan’ or not.
Group recruitment update: Signs two agreements to perfect NACO/Group relationships: TIN affiliation agreement, and group participation agreements.
Channel partner initiative. Vetting potential IPAs for outreach purposes.
When recruiting multiple docs, NACO assists with formation of ‘POD’. How defined? Filing required. Maybe role for regional PODs or eve ’super PODS’.
When they get participation letter, who do they call? No specific name listed. Now only directed to general phone number.
SNF Rollout. Primary scope is 3 day SNF waiver portion. Tracking referrals and performance needs improvement.
Remainder of agenda included: Referral tracking and management vendor options, telehealth update, AWV proposal plan given 27.8% completed 2017 v. 21% in 2016 performance and target at 70-80%.
ACOs that incentivize AWVs show shared savings. Need see ROI on internal vs. outsourced AWVs.
Status of group recruitments in California, Colorado and other regions.
Worked on letter on ’physician recruitment’ upsides of participation.
Review responses to RFP for IT vendor replacement.
Review of marketing and communication efforts including social media activities.
Conference call with IT vendor RFP consultant, with status vendor submission ratings.
Free flowing debrief with Dr. Berger on day’s wide ranging and non-stop series of activities. Included question of whether or not to re-do a previous broadcast of This Week in Accountable Care which experienced some audio quality issues due to the moderator originating the broadcast from BIO International Conventions media center.
Calling it a day, Dr. Berger drops me off at my car.
It’s very clear to me that managing an institutionally ‘untethered’ and physician led ACO – while more agile, if you will – is none-the-less a complex and challenging affair. There are many moving parts and with multiple parties coming into and out of key management decisions – both virtually and ‘IRL” – with all the attendant people and systems’ challenges, keeping focused and moving the enterprise forward takes constant vigilance.
When you add the complexity of the volume-to-value transformational imperative into the successful operation and scaled growth into the enterprise agenda, you begin to get a picture of what Dr. Berger, his physician colleagues and administrative staff face on a daily basis.
When you add the advantages (and associated duty to leverage them in support of the elusive triple aim) afforded by CMS specific to Next Generation Models such as National ACO, that complexity takes on an additional duty of care to manifest the ambitious but worthwhile mission of transforming U.S. Healthcare from a volume driven system to one that materially embraces a value based and outcomes oriented future.
My hat is off to this ambitious physician enterprise!