Posted in Accountable Care, ACO, Affordable Care Act

Center for Medicare and Medicaid Services Releases Accountable Care Organization Performance Results

by Gregg A. Masters, MPH

Friday, October 27th, the Center for Medicare and Medicaid Services (CMS) released details for participating Accountable Care Organizations (ACOs) in the Medicare Shared Savings Program (MSSP) for the 2016 performance year.  For reporting ACO results view the entire report here.

The National Association of ACOs (NAACOs) weighed in below:

The new results demonstrate the value of a premier Medicare alternative payment model and include a higher rate (56 percent)* of MSSP ACOs generating savings than ever before and an almost equal proportion as last year of ACOs that earned shared savings (31 percent).

This public update follows previously posted results for Pioneer ACOs, the Next Generation ACO cohort and the Comprehensive End Stage Renal Disease ACO (ESRD) care model here.

In table form, the results are summarized below:

All in, participating ACOs generated $843 million in gross program savings with a modest net savings of $78.6 million for Medicare in 2016, in addition to material gains in quality scores for aligned ACO Medicare beneficiaries.

While Clif Gaus, NAACOS CEO notes:

These results show the growing success of ACOs, which is a positive trend that should not be ignored. A lot has been accomplished in a relatively short amount of time, and ACOs are on the front line of redesigning healthcare delivery. This is a moment to celebrate them and their hard work.

The ACO ‘Jury’ Is Still Is Out

Given the range of models, risk assumed or gain sharing distributed operating results in a program that some still see as fundamentally ill equipped in a predominant fee-for-services market to materially change physician and beneficiary behavior – and thus enable the elusive ‘triple aim‘ – many in the health policy area including select ACO operators remain convinced to maximize impact the ACO model will ultimately morph into the more robust Medicare Advantage operating platform.

Perhaps the ‘stealth play’ in the mix is the potential upside of Next Generation ACOs to fully leverage their competitive advantages (3 day SNF waiver, telehealth visits, relaxed supervision requirements for post hospital discharge visits and the move to all inclusive population based payments) can up-level both their game AND improve outcomes at lower per capita costs?

On the next episode of This Week in Accountable Care, our very special guest is former Acting Administrator of CMS Andy Slavitt, now Senior Advisor to the Bipartisan Policy Center. Andy was initially part of the ‘fix it dream team‘ that righted the failed launch of Healthcare.Gov, and then presided over the administration of the Affordable Care Act.

Andy is rather familiar with the original intent of the ACA, its many ‘working parts’ and the bumps in the road to perfect the law via provider input, updated rule making and policy refinements.

We’ll get Andy’s take on a range of issues from the political environment to conflicting health policy guidance including broad brush advice to ACO operators.

Join National ACO co-founders Andre Berger, MD and Alex Foxman, MD as we engage this visionary and accomplished entrepreneur turned public service official in critical dialogue impacting the transformation of our industry from its fee-for-services roots to a new model based on a value and patient centricity.

 

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Posted in Accountable Care, ACO, Affordable Care Act, Triple Aim

ACOs Fudging the Numbers?

by Gregg A. Masters, MPH

I came across this piece on the Healthcare Blog penned by Kip Sullivan, Esq, critiquing this article posted in Health Affairs last May ‘Bending The Spending Curve By Altering Care Delivery Patterns: The Role Of Care Management Within A Pioneer ACO‘. Sullivan raises valid points as the the legitimacy of claiming or inferring statistically insignificant results as a meaningful contribution of the subject ACO (a Partners Health sponsored venture) to ‘bending the cost curve’.

Sullivan un-bundles his argument effectively and raises issues for the industry writ large – including participating ACOs, their sponsors, the regulatory crew at both CMS and CMMI – and even the health policy press covering the sector.

I post the first few paragraphs of the piece below, for full reference the entire article on the Healthcare Blog is accessible via On the Ethics of Accountable Care Research‘.

  • Is it ethical for health policy researchers to claim that a Medicare ACO reduced “spending” by 2 percent if the reduction was not statistically significant?
  • Is it ethical for them to do so if they made no effort to measure the cost to the ACO of generating the alleged 2 percent savings nor the cost to Medicare of giving half the savings to the ACO?
  • Does it matter that the researchers work for the flagship hospital within the ACO that was the subject of their study?
  • Does it matter that the ACO and the flagship hospital are part of a huge hospital-clinic chain that claims its numerous acquisitions over the last quarter-century constitute not mere empire-building but rather “clinical integration” that will lower costs, and the paper lends credence to that argument? 
  • Is it ethical for editors to publish such a paper? Is it ethical to do so with a title on the cover that shouts, “How one ACO bent the cost curve”?

These questions were raised by the publication of a paper  by John Hsu et al. about the Pioneer ACO run by Partners HealthCare System, a large Boston hospital-clinic chain, in the May 2017 edition of Health Affairs. Of the eight authors of the paper, all but two teach at Harvard Medical School and all but two are employed by Massachusetts General Hospital (MGH), Partners’ flagship hospital and Harvard’s largest teaching hospital. [1]

Partners has been on a buying and ….

Comment

As someone who’s been in this dance since the mid 70s (PSROs, HSAs, HMOs, IPAs, PPOs, EPOs & all derivative plays) launched into Medicare risk via TEFRA (the Tax Equity and Fiscal Accountability Act) which introduced us to ‘Medicare Choice’ the for-runner of Medicare Advantage, I can say Sullivan’s critique of fully ‘burdening‘ ALL transformational efforts is rarely – if ever – factored into the volume to value pivot ‘investment calculus‘ of the effects of the intervention (in this case a Pioneer ACO) on the national spend.

It should be noted, the entire managed care industry can be assessed a gigantic collective FAIL for that matter as well. Since managed care penetrated ‘mainstream medicine‘ principally via extension of the HMO model typically on an IPA (independent practice association) chassis (vs. group or staff models) with the exception of a brief period in the 90s premiums continue their relentless upward march; while most payors continue to write commercial business only via an enterprise and industry wide cost shifting (risk transfer) charade. The tacit admission that there is no there there in the prevailing health insurance industry zeitgeist. They’ve proven they can NOT manage clinical risk, period.

So Kip, you might want to go a little lighter on those on the front lines trying to tame the ‘rapacious appetite’ of our ‘healthcare borg‘!

 

 

Posted in Accountable Care, ACO, Affordable Care Act, Medicaid ACO

Tufts Health Plan Forms MassHealth Accountable Care Organization Partnership with Four Provider Organizations

Press Release | Watertown, MA | August 18, 2017 

The Massachusetts Executive Office of Health and Human Services (EOHHS) recently announced that Tufts Health Plan has signed contracts to form Medicaid (MassHealth) Accountable Care Organization (ACO) partnerships with four provider organizations:  Atrius HealthBeth Israel Deaconess Care OrganizationCambridge Health Alliance, and Boston Children’s Accountable Care Organization.

The new ACOs feature a value‐based payment structure for providers who had largely been paid fee for service for MassHealth members in the past.  For members, this means the opportunity to receive medical, behavioral, dental and long-term support services in an integrated model of care.  This will improve quality of care, the member experience, and potentially help stabilize Medicaid costs in Massachusetts.

“We support the Commonwealth’s goal of providing integrated health care to MassHealth members that is more efficient and improves their overall health,” said Tom Croswell, president and CEO of Tufts Health Plan.  “We have partnered with four highly-regarded provider groups, all of whom share our vision of what collaboration and highly coordinated care can look like.”

Continued Croswell:  “Tufts Health Plan has an excellent reputation for our collaborative approaches with providers.  We’ve been working with value-based contracts for more than 20+ years, starting in our Medicare Advantage plans.  We know first-hand that working closely with providers on coordinating care results in healthier members.  We’re excited to broaden our success and bring this approach to our Medicaid members.”

MassHealth ACO transformation is a major component in the state’s five-year innovative 1115 Medicaid waiver from the federal government, which allows Massachusetts to restructure the current health care delivery system for 1.9 million MassHealth members.

Tufts Health Plan’s ACO partners are:

  • Atrius Health, which provides high quality, patient-centered and coordinated care to more than 740,000 adult and pediatric patients in eastern and central Massachusetts.
  • Beth Israel Deaconess Care Organization, a value-based physician and hospital network that partners with providers to improve quality of care while effectively managing medical expenses.
  • Boston Children’s Accountable Care Organization is an ACO comprising Boston Children’s Hospital and its affiliated primary and specialty care physicians. Boston Children’s Hospital is the No. 1 ranked Children’s Hospital in the nationand is a 415-bed comprehensive center for pediatric and adolescent health care.
  • Cambridge Health Alliance, an academic community health system committed to providing high quality care in Cambridge, Somerville and Boston’s metro-north communities. CHA has expertise in primary care, specialty care and mental health/substance use services, as well as caring for diverse and complex populations.

 

Editor’s Note: We are in the process in scheduling a Tufts Health Plan executive on an episode of This Week in Accountable Care with Andre Berger, MD and Alex Foxman, CEO and President/CMO of National ACO. Once confirmed we’ll post the details here with a profile of Tufts Health.

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Posted in Affordable Care Act, BCRA 2017

CBO Weighs in on Trumpcare 3.0

by Gregg A. Masters, MPH

The non-partisan Congressional Office weighed in today on the impact of the Better Care Reconciliation of of 2017 as amended and rebranded as the ‘Obamacare Repeal Reconciliation Act’.

Their summary notes the coverage impact as follows:

  • The number of people who are uninsured would increase by 17 million in 2018, compared with the number under current law. That number would increase to 27 million in 2020, after the elimination of the ACA’s expansion of eligibility for Medicaid and the elimination of subsidies for insurance purchased through the marketplaces established by the ACA, and then to 32 million in 2026.
  • Average premiums in the non-group market (for individual policies purchased through the marketplaces or directly from insurers) would increase by roughly 25 percent—relative to projections under current law—in 2018. The increase would reach about 50 percent in 2020, and premiums would about double by 2026.

On the fiscal impact the graphic lays it out below:  For a complete CBO report, click here

Posted in Affordable Care Act, health insurance reform, health reform

Senate GOP Health Reform Fail: Many Knew This Day Was Coming

by Gregg A. Masters, MPH

Unlike many in the conversation on social media including the likes of Twitter, Facebook, LinkedIn and blogs such as ACO Watch, I have been active in the health reform exchange of ideas since registering my twitter handle @2healthguru in August of 2008. My participation has been of the ‘sweat equity’ variety vs. those who are compensated for their content, curation or advocacy.

Many of us in the healthcare space (both clinical and administrative) are addicted to the industry and find it difficult if not impossible to exit whether physically or emotionally. Some commit out of a sense of missiongiving back or being of service, while others for the economic upside this vast ecosystem (which I have labeled the healthcare borg resisting any attempt to materially restrain its appetite) affords to exploit low hanging fruit from a fragmented, inefficient and unwieldy financing and delivery system. Many have personally enriched themselves via the frequent churn of asset ownership (hospitals, nursing homes, imaging centers, ambulatory surgery centers, etc.) or via niche solutions with little to no sustainable value followed by quick exits and generous investor returns.

This timing of my entry into social media was co-incident with the deliberative process that ultimately rendered unto the American public what was merged as the Affordable Care Act (ACA),

In the early days of twitter those of us active in the community spoke of the ‘addictive’ nature of twitter engagement, some even referred to this virtual community as ‘the matrix’. Bonds were formed, some of which remain intact to this day.

The ‘Fictional’ Obamacare ‘Disaster’

This morning Donald J, Trump aka the POTUS weighed in on the failed efforts of Senate GOP leadership to advance the Better Care Reconciliation Act of 2017 as amended by Senator Ted Cruz to the Senate floor. He said:

By the way Obamacare isn’t failing, it’s failed

That this man continues to minimally misrepresent and worse intentionally lie to the American public is beyond the capacity for many to comprehend. From the American Academy of Actuaries to the Non-partisan Congressional Budget Office and multiple authorities in the underwriting to delivery space including risk bearing provider organizations and integrated delivery systems the narrative is quite to the contrary.

And where there is evidence of market instability or ‘failure‘ there is explanation including serial GOP initiatives to undermine the Affordable Care Act specifically with respect to ‘qualified health plans‘ (QHPs) listed on State run or Federally Facilitated Marketplaces (FFM) aka ‘Exchanges.’

The ‘death spiral‘ or ‘disaster‘ narrative is principally vested in the following argument:

  • Major health plans and regional players who initially developed individual market product(s), i.e., benefit plans, and associated provider networks including premiums) for these exchanges are withdrawing participation from select markets.
  • Premiums for some QHPs have increased by 100% or more on select exchanges; and
  • In some states and select counties there are no participating health plans with QHPs offered

On the face of this narrative, yes it makes sense. This market instability is unacceptable. No one can celebrate a law who’s principal intent is to expand coverage can applaud the absence of health plan participation at the state or county level.

But let’s peel back the curtain and look at the reasons for this ‘instability‘ claim. From day one of the Obama Administration, the GOP agenda was to make him a ‘one term President‘.

On the ACA given it’s passage was a straight line party vote with no support from GOP even though the health reform consideration process was an open and lengthy affair, Senator McConnell et al’s agenda was to remain the ‘party of no‘ and criticize the very model of health reform they had not long ago proffered as a public/private solution,  See: ‘GOP ACA Myths‘ where I’ve posted links to credible voices and JD Kleinke’s classic: ‘Why There Is No Obamacare Replacement — In One Picture‘. 

The bottomline is any ‘fails’ or under performance of the ACA whether enrollment projections, premium sticker shock, exchange exits or regulatory burdens have been engineered by a relentless series of sabotage efforts from defunding risk corridors, to current (see: This Blame Game Driving Up Health Insurance Costs) threats to not fund the subsidies that make QHP listed plans ‘affordable‘. And let’s not forget the big SCOTUS decision on Medicaid expansion which gave Red State Governors the ‘option’ whether to expand coverage for their citizens.

Karma?

So the ‘who knew healthcare was so complex’ remark offered by POTUS earlier this year was pure BS. I buy his ignorance of health policy and the complexity inherent in a cottage industry with a $3+ trillion spend, but what about those GOP ‘health wonks’ engaged in this process – from the ‘Senate Quackers’ (my term), i.e., Tom Coburn and John Barrasso – both politicians playing the doc card during ACA markup in 2009, or even worse one half of the GOP ‘young guns’ now Speaker Ryan who’s a budget [and by declaration health] wonk. What’s their excuse for this ‘surprisingly epic fail’?

This is a HUGE squander of the public trust!  And contrary to POTUS assertions, the GOP now has complete ownership of the chaos they’ve stoked from the beginning to this gross mis-management of the legislative process. It’s laughable that GOP are trying to pin this one on the Democratic party.

My god, wake up GOP. You ‘own’ healthcare. Fix the ACA.

Posted in Accountable Care, ACO, Affordable Care Act

What, What? ACOs Not ‘DOA’?

by Gregg A. Masters, MPH

When the Affordable Care Act passed in March of 2010 and the law’s many moving parts analyzed by the ecosystem stakeholders including operators, health wonks and patient advocates many weighed in that ACOs were doomed to fail. They were just too ‘tepid’ to make a material contribution to the volume to value transformational journey. Complaints included little control over patients who ‘voted with their feet’ while ACOs bore the liability of their choices whether in upside only track vs. the downside of exposure of track two, flawed retrospective attribution methodologies and data dumps and reporting lags from CMS all handicapped the proactive management of ‘risk’ assumed by participating ACOs in the Medicare Shared Savings Program (MSSP).

Noted futurist Jeff Goldsmith captured the spirit in Pioneer ACOs: Anatomy Of A ‘Victory’ post in Health Affairs:

With over 17 million Medicare beneficiaries voluntarily choosing MA thus far, and enrollment growing at more than 10 percent annually despite three years of CMS payment reductions in real dollars, it is increasingly clear the future of managed Medicare lies in the MA program, not with directly contracted shared savings models.

Co-incident with the ramp up of the Medicare ACO cohort the private sector jumped on the bandwagon, operating with higher degrees of contractual terms and conditions freedom than promulgated by CMS to participating MSSP’s. Aetna, the Blues, United et al negotiated their version of ‘accountable care’ arrangements with participation IPAs, PHOs, IDNs, health systems, medical groups or physician networks.

Five years later, we have some important data recently reported by Health Affairs that suggests ACOs are far from the neutered enterprises many suggested and while mixed in terms of results reported ACOs have found their place in the managed competition ecosystem and are not likely to disappear any time soon.

The headline at Health Affairs is as follows: Growth Of ACOs And Alternative Payment Models In 2017.

As of the end of the first quarter of 2017, our inventory included 923 active public and private ACOs across the United States, covering more than 32 million lives (Figure 1). The increase of 2.2 million covered lives in the past year means that more than 10 percent of the U.S. population is now covered by an accountable care contract (Note 1).

As the ACO model matures, there is now some turnover, with organizations joining and leaving the model. Since the first quarter of 2016, 138 new ACOs began operation, and 46 ACOs dropped their accountable care contracts, representing a net increase of 92 organizations becoming ACOs, or an 11 percent growth.

From the nominal ACO count basis to the number of lives associated with the aggregate arrangements, this is an impressive tally for such an allegedly ‘anemic‘ model!

Now enter the Next Generation ACO Model. For details, see: Next Generation ACOs: A Deep Dive Series and Meet the Next Generation ACO Cohort.

 

 

 

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Posted in Accountable Care, ACO, Affordable Care Act

Meet the Next Generation ACO Cohort

by Gregg A. Masters, MPH

As announced in ‘Next Generation ACOs: A Deep Dive Serieswe’re launching a multimedia (blog, internet radio, social media and community tweetchats) programming schedule that will focus on the accountable care industry with specific deep dives into select participants in the cohort admitted by the Center for Medicare and Medicaid Innovation.

Next Generation ACO Model

Written versions of those interviews will post on ACO Watch, with audio versions featured on This Week in Accountable Care’ on the BlogTalk Radio and Affiliate Networks.

If you are interested in the Next Generation ACO Model, see: The Next Generation ACO: Accelerating the Transformation from Volume to Value and the CMS Webinar: Next Generation ACO Model – Overview and LOI Information with key webinar dates and application deadlines.

For those interested in learning more about the rather ‘eclectic’ (academic, physician led, hospital system sponsored and venture backed) class of 44 ACOs in the NextGen Cohort, I’ve listed them below: 

We intend to host monthly moderated ‘tweetchats’ to engage the community of stakeholders via #ACOchat and welcome your input on the preference of the participating ACOs you’d like us to profile.

Please post in the comments section.

Cheers!

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*Editor’s Note: This post including This Week in Accountable Care broadcasts, periodic tweetchats via #ACOchat and blog posts in this series) are sponsored by National ACO, a Next Generation ACO. For more information on National ACO, click here.