Posted in Accountable Care, ACO, Triple Aim

Leavitt Partners Weigh in on Medicare, APMs and Provider Readiness for Pivot

by Gregg A. Masters, MPH

It’s been busy since our re-launch at This Week in Accountable Care primarily due to the heavy lifting support from National ACO co-founders, Andre Berger MD, CEO, and Alex Foxman, MD, President and Chief Medical Officer, respectively.

While I moderate the series, Drs. Berger and Foxman serve as co-hosts and subject matter experts as we engage thought leaders and best-in-class ACO operators in focused conversation around local or regional market challenges including headwinds, tailwinds, lessons learned and emerging best practices.

Recently we’ve chatted with top national talent including: Don Crane, CEO, of CAPG, Hal Sadowy, the IPA Association of America, Jay Parkinson, MD, Founder and CEO of Sherpaa Health and author, consultant and futurist Ian Morrison.

Our all-star line-up continues in October with David Muhlestein, PhD, JD, Chief Research Officer, Leavitt Partners on Tuesday October 3rd, Farzad Mostashari, MD, Founder & CEO of Aledade on October 17th, and the rock-star advocate to fix the Affordable Care Act and former Acting Administrator of the Centers for Medicare and Medicaid Administration (CMS), Andy Slavitt on October 31st.

For our chat with David Muhlestein, PhD, JD, Leavitt Partners, Chief Research Officer you may want to read: Medicare Alternative Payment Models: Not Every Provider Has a Path Forward.

An informative Whitepaper that lays out the range of challenges most health systems, IDNs, physicians whether in groups or not face in the pivot to a value based (alternative payment models – APMs).

From the Whitepaper:

The Centers for Medicare and Medicaid Services (CMS) has shown significant support for the development of Alternative Payment Models (APMs).

CMS’ development and testing of 45 payment models has led to the adoption of similar models by other payers. Initial reports indicate that APMs could be key to producing the health care delivery reform necessary to decrease health care costs and increase delivery quality.

However, these models are only available to select provider types, and some providers, such as emergency physicians and audiologists, have no Medicare APMs in which they can participate. To realize the full benefits of APMs, additional collaboration between CMS leadership and providers is needed to develop new models for providers who do not currently have access to them.

Be sure to join us October 3rd at 5PM Pacific/8PM Eastern for a conversation with David Muhlestein on This Week in Accountable Care with Andre Berger, MD and Alex Foxman, MD. co-founders of National ACO.

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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, health innovation challenges, health insurance reform, MSSP, Triple Aim

The Next Generation ACO: Accelerating the Transformation from Volume to Value

In January 2015, then Secretary of Health and Human Services (HHS), Sylvia Burwell outlined ‘Federal policy‘ and for the first time put a measurable stake in the ground to scale the pivot from fee-for-service to value based healthcare with concrete milestones and an associated timeline. The policy outlined seemingly scalable goals via linking 30% of traditional fee-for-service Medicare payments to quality or value through ‘alternative payment models‘ (APMs) including Patient Centered Medical Homes (PCMHs), ACOs or ‘bundled payment arrangements‘ (BPHCI) year end 2016, scaled up to 50% of payments year end 2018. For details see: ‘HHS Sets Specific Targets and Timelines for Alternative Payment Models and Value-Based Payment‘.

Now fast forward to 2017. First introduced in 2016 we’re approaching the start date of a ‘new and improved‘ ACO tagged the ‘next generation ACO model‘ now embracing an ‘all in population based payment‘ (AIPBP) option that ZERO’s out fee-for-service payments.

Between ACO operating results, significant provider community feedback via several Notice of Proposed Regulations‘ (NPRMs) and what some may say is simple commonsense, this latest iteration of the Next Generation ACO model is looking more and more like their predecessor risk bearing operators in the 80s and 90s.

As CMS notes:

Building upon experience from the Pioneer ACO Model and the Medicare Shared Savings Program (Shared Savings Program), the Next Generation ACO Model offers a new opportunity in accountable care—one that sets predictable financial targets, enables providers and beneficiaries greater opportunities to coordinate care, and aims to attain the highest quality standards of care.

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.

The Bottom Line

We (i.e., ACO industry operators, associated management companies’ including venture financiers, CMS and supplier stakeholders) are tweaking the ACO formula via a range of models that materially engage the provider AND payor communities as co-creators of a sustainable healthcare ecosystem embracing value and outcomes as the ‘dependent variable’.

With the uncertainty surrounding the future of the ACA and it’s likely ‘Trumpcare’ or ‘RyanCare’ replacement options, some argue ACOs are in an unspoken ‘safe harbor’ of sorts. Yet, much detail remains to be added before that picture is functionally revealed. Here at ACO Watch we’re proceeding on the assumption that ACOs or the accountable care industry collectively, are not likely to disappear anytime soon. So we’re posting some resources below:

For a deep dive into the AIPBP option CMS is hosting an Open Door Forum: Next Generation ACO Model – Overview of Population-Based Payments on Tuesday, April 11, 2017 from 4:00PM – 5:00 P.M. EDT.

For those pondering their 2018 ACO participation options, CMS‘s Center for Medicare and Medicaid Innovation (CMMI) issued an RFA (request for applications) and activated the application portal here.  

Finally to complete the picture CMS is hosting a series of open forums to provide an overview into the Next Generation ACO model offering information on the required letter of intent and on-boarding process in general on these dates as follows:

  • March 14 from 4 – 5 pm ET — Application Overview and Participating Provider Lists
  • March 28 from 3 – 4 pm ET — Benefit Enhancements Overview
  • April 11 from 4 – 5 pm ET — Overview of Population-Based Payments & All-Inclusive Population-Based Payments;and
  • April 15 — Deep Dive: Completing Your Next Generation ACO Model Participant List

For the complete list of available CMS ACO resources, click here.

And finally for those who desire an overview of the ACO theater, check out the dated but informative: ‘Accountable Care Organization (ACO) 101: A Brief Course by Neil Kirschner, Ph.D. Director, Regulatory and Insurer Affairs, American College of Physicians (ACP).

 

 

 

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

FLAACOs 3rd Annual Fall Conference: A Retrospective

by Gregg A. Masters, MPH

This is the second year I’ve ventured to Orlando to cover the Florida Associations of ACOs (@FLAACOs) Annual gathering.

According to the website, the FLAACOs mission is:

…to provide members a vehicle to collaborate, ensuring that each healthcare organization grows and thrives. The Florida-based association aligns goals to shift physician incentives and improve health-care outcomes across the state.

FLAACOs provides a voice for the accountable care marketplace and its participating providers, payers, and individual physicians.

The goal of FLAACOs is to provide advocacy and support to all Florida accountable care organizations so that together they can become the health-care models of the future.

To many most of the managed care ‘smarts’ and thus ‘risk savvy sophistication’ typically resides in and ‘metastasizes‘ from California to other parts of the U.S. One example being the re-branding and re-positioning for growth ofCAPG formerly known as the California Association of Physician Groups who represents, advocates for and up-levels clinical risk management assumption core competencies for medical groups and ACOs nationwide. Yet, Florida is a Medicare Shared Savings Program (MSSP) hotbed market and judging from the results returned by Florida ACOs there’s a fair amount of savvy infrastructure in the ‘Sunshine state’ particularly as represented by the member ACOs participating in FLAACOs.

For more information on the conference you might review the agenda, faculty and sponsors.

For those who missed this informative conference, some of the highlights include:

flaacos_fields_keynoteA keynote presentation by Robert W. Fields, MD, Medical Director, Mission Health Partners ACO, titled ‘Key Drivers For Population Health: Redefining the Art of Medicine ‘. Our interview with Dr. Fields courtesy of Fred Goldstein is available here.

flaacos_lerer_keynoteFor the second year in a row René Lerer, MD,  President, GuideWell the parent company of a number of subsidiary companies’ including Florida Blue provided a comprehensive update detailing the dynamics of a changing ‘Payer Landscape’ given the instability of many if not all of the provisions of the ACA ‘at risk‘ under the impending Trump Administration. Prior equally informative interviews with Dr. Lerer are available here and here.

A timely panel presentation on ‘How Reimbursement Will Be Tied to Value (MACRA, MIPS, AAPM)‘ was facilitated by Kelly Conroy, Senior Advisor, Aledade, with panelists Dan Duncanson, CEO, Southeastern Integrated Medical, and Ethan Chernin, COO, BayCare Physician Partners.

Finally an extremely informative and insightful interview was offered by Mike Barrett, Sr. VP, Southeast Universal American/Collaborative Health Systems here.

An overview of FLAACOs the organization and its goals including a recap of the conference was offered by Nicole Bradberry, CEO via Fred Goldstein here.

The complete schedule and available presentation decks are here.

Posted in Accountable Care, population health, Triple Aim

Blab the Blockchain: Healthcare Implications?

by Gregg A. Masters, MPH

blockchain blab screen grab

Yesterday, April 27th 2016 I joined twitter colleagues and principal co-moderators and my ‘go-to Blab experts James Legan, MD (@jimmie_vanagon) and Charles “Chuck” Webster, MD (@wareflo) for a ‘Blab‘ on ‘blockchain implications in the heathcare space (both delivery and finance).

Our featured expert du jour Jeff Brandt was a no-show, so we winged it with an excellent overview and introduction by Chuck. We’re all learning in this space but one of the potential applications of the emerging technology might be in the granular if not seamless adjudication of complex bundled payments.

During the session many excellent references were included in the chat box. Several resources were mentioned including Smart Contracts, the Consensus 2016 conference, Youbase, and the article posted by Dan Munro on Health Standards, titled ‘Digital health lessons from BART‘.

I have a feeling there will be major application in the healthcare financing and delivery space as we progress into scaled assumption of risk under a value based healthcare incentive structure. Watch and see if you agree with some of the points made in the discussion!

 

Posted in Accountable Care, Affordable Care Act, Triple Aim

Hey, Remember IPAs, PPOs and TPAs?

by Gregg A. Masters, MPHAAPAN 2016 Forum

In a last man standing of sorts in what some may call the legacy and aging infrastructure of the ‘vote with your feet‘ PPO industry including it’s allies in the TPA (Third Party Administrator) space, the American Association of Payors, Administrators and Networks (AAPAN) is holding its 2016 Annual Forum in my former hometown of Dana Point, California at the Ritz Carlton, Laguna Nigel.

The mission of American Association of Payors, Administrators and Networks (AAPAN) notes it provides:

….the platform for the unification of payers, administrators and networks and the ability for a stronger collective public policy voice to enhance the position of each stakeholder as essential to the future of affordable healthcare delivery options centered on patient choice.

According to its subsidiary the American Association of Preferred Provider Organizations (AAPPO) the ‘PPO chassis’ accounts for:

An estimated 200 million Americans, or about 81 percent of all Americans with health care coverage (excluding those receiving military health care), receive their health care services through a PPO delivery system.

A history of managed care As a ‘collaborative association’ on behalf of the PPO industry initially positioned as a complementary (if not an HMO-lite) alternative to the more aggressive gatekeeper HMO option (see history of managed care era in graphic), AAPAN has a track record of success from advocacy, to thought leadership and operating best practices and solutions.

The Association aligns two potentially silo-ed (though synergistic) interests: the American Association of PPOs (AAPPO), the Third Party Administrators Association of America (TPAAA). For an issue brief on valued based healthcare and the need for network standards, see: The Need to Standardize Network Value-Based Purchasing Requirements.

So one might say, though a larger share of the employer based insurance market remains in a PPO type (vs. HMO) benefit plan design their role and industry leadership visibility may have been somewhat muted (if not, absent from the health reform narrative) since the rollout of the Affordable Care Act (ACA) and it’s emphasis on Accountable Care Organizations (ACOs) dominated the reform narrative.

AAPAN intends to raise this profile and remind many in the space that PPOs, TPAs and even IPAs (Independent Practice Associations) have a material and meaningful role to play in enabling the triple aim even if their initiatives aren’t tagged ACOs per se.

The 2016 Forum hashtag is #AAPAN16, and the digital dashboard is here. Do follow the tweetstream for thought leadership insights from key industry executives, entrepreneurs and change agents. See keynotes and sessions here, including Health Innovation Media co-host, Douglas Goldstein aka @eFuturist.

The program schedule is here.

 

Posted in Accountable Care, population health, Triple Aim

ACOs and Population Health: The Value Narrative

by Gregg A. Masters, MPH

Before there was ‘accountable care’, the current full court press towards innovation – whether digital health app, platform or service delivery model, an emerging culture of transformation or the attendant pursuit of the triple aim, not to mention the most recent obsession with ‘retail as cure’ for that which ails healthcare, the best and the brightest minds (both clinical and administrative guided by thoughtful health policy wonks) convened in the grand theater of ‘managed care’ or managed competition.

The model and industry writ large (both public and private sectors), variably expressed as HMO, PPOs and derivative strains of contracting models stimulating the development of IPAs, PHOs, PPMC’s, MSOs and DPOs (direct purchasing organizations) had a run from the mid 70s until its abandonment as the official vehicle to restrain the rising cost and variable quality of healthcare in the late 90s. What followed was somewhat of a meandering decade of incremental tweaks here and there to an otherwise burning platform of fee-for-service healthcare delivery and financing.

In 2015 with healthcare costs now approaching 20% of the U.S. Gross Domestic Product and the viability of the entire U.S. Government at risk to projected costs increases and unfunded liabilities of the Medicare and Medicaid programs (estimated at $64 trillion), business as usual fee-for-service medicine is no longer an option and the many cathedrals of medicine built by ‘do more to earn more’ largesse are clearly at risk in the shifting sands of value based care.

While the ‘value’ v. volume agenda has been around for a while via risk based contracting including case rates, bundled payment and even capitation – both global and professional only versions – their penetration of mainstream medicine was relatively modest – until now. That is if you can believe the growing prevalence and penetration of risk bearing ACOs arrangements, a tapestry of bundled payment participation via Federal programs and a less transparent portfolio of privately negotiated ‘value based arrangements’.

Into this theater steps one of the trophy consulting companies with both wide (global) and deep (extensive client penetration into the health plan, provider and IDN communities) aka Accenture Health (follow via @AccentureHealth).

value based care meklausInto this developing narrative with a ‘value tutorial’ of sorts steps Gerry Meklaus, the Managing Director of Accenture North America for Clinical & Health Management Services. We speak with Gerry Wednesday at 12 Noon Pacific/3PM Eastern at Pophealth Week where my colleague and co-founder Fred Goldstein, President of Accountable Health, LLC will engage Gerry in the value conversation and the many touch points between a value framework for ACOs and population health strategies of provider organizations.

Key terms to un-bundle and digest are the ‘BIG Three’: 1) to ‘improve outcomes’ via emerging best practices, the reduction in variation and effective engagement of the patient in shared decision making, 2) the effective lowering of costs from a ‘total cost of care’ perspective (not just niche wins – if you will), and 3) the well known challenge to de-silo the many silos in the healthcare ecosystem driving fragmentation, redundancy and a less than patient centric experience.

Join us as we gain insight into the challenges and successes in the market to date!