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!

Posted in Accountable Care, ACO, population health, Triple Aim

The Transformation Continues – PopHealth Week’s Focus in July

by Fred Goldstein

The role of Primary Care Providers is changing and much of this is for the better. With the Triple Aim of improving the patient experience, improving the health of populations and reducing per capita costs; along with new payment methodologies, quality measures, organizational structures, and the like, primary care providers are being asked to to play an expanded role in the healthcare system; but what is that role and how can they ensure success?

PopHealthWeek-logo-TWTTR-sq (2)During the month of July PopHealth Week will focus on Primary Care and Population Health, interviewing primary care providers and thought leaders who have developed innovative new ways to practice. We’ll explore patient centered medical homes, capitated contracts, team based care, meeting patients needs, are the incentives in ACOs large enough to change behavior, and where these trend setters believe primary care is headed.

Join PopHealth Week for the following shows:

July 1, 12 PM ET/9 AM PT

Roy Hinman, MD, Island Doctors @Island_Doctors. To listen to the broadcast click here

Roy H. Hinman, II, M.D. is the founder of Island Doctors which employs more than 50 people within 14 offices in Florida stretching from Jacksonville to Interlachen and New Smyrna Beach. They also manage a network of 32 affiliate providers throughout these six counties and around the Orlando area. Their mission is to promote health improvement to each and every patient that walks through their doors.

The practice focuses on improving their patients’ health and participates in numerous community events and health fairs including holding Diabetes Awareness Seminars several times per year. Island Doctors want each patient to achieve optimal health status through education, meal planning, exercise, smoking cessation and cholesterol management.

Dr. Hinman opened his first family practice office in 1991 on Anastasia Island in St. Augustine, Florida.

July 8th,12 PM ET/9AM PTStanding Up the ACO

Rushika Fernandopulle, MD, Iorahealth @IoraHealth

Dr. Fernandopulle is the founder and CEO of Iora Health, an innovative primary care practice that offers Team-based care that puts the patient first, a payment system based on care, not billing codes and technology built around people, not process.

July 15th, 3 PM ET/12 Noon PT 

<Tentative not yet confirmed>

Jay Lee, MD MPH aka @FamilyDocWonk 

Dr. Lee is board certified in family medicine. After leaving Stanford University with a degree in Human Biology, Dr. Lee worked for a non-governmental organization in rural northern El Salvador providing clinical support for local physicians and organizing public health projects before returning stateside for medical school at the University of Southern California and family medicine residency training at Long Beach Memorial. Prior to re-joining MemorialCare Medical Group he worked at community health centers in southern California and Boston, where he earned a Masters in Public Health at Harvard University.

Dr. Lee was recently honored and elected to the 2016 term as President of the California Academy of Family Physicians aka @cafp_familydocs

July 22, 3 PM ET/12 Noon PT 

Paul Grundy, MD Global Director of Healthcare Transformation IBM, President PCPCC and Ambassador Healthcare Denmark

Dr. Grundy, known as the “Godfather” of the Patient Centered Medical Home is one of the leading thinkers in the transformation of Primary Care and is the Founding President of the Patient-Centered Primary Care Collaborative (PCPCC).

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Fred Goldstein is the President/CEO of Accountable Health, LLC, and the co-founder of PopHealth Week. This post originally appeared here

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

‘Fear and Trembling’ or Simply ‘Lonely in’ Seattle?

By Gregg A. Masters, MPH

The old is new again…

I’ve been writing and tweeting about this theme for some time now. It was aptly offered as contextual insight via Nicole Bradberry of MZI Healthcare /Orange Solutions and CEO of the Florida Association of ACOs.

Many have similarly echoed this ‘deja vu’ theme when discussing the roll-out of ACOs including functional similarities and key differentiators with HMOs and previous managed care initiatives circa the 1980 – 2000 vintage.

One such old is new again effort is ‘direct contracting’, where the employer deals directly with the provider community without a health plan as third party intermediary. An army of TPAs (third party administrators) stepped up to offer ‘administrative services only’ (ASO) typically to larger employers who self fund their benefit plans to carve out the middleman, i.e., Aetna, United, the Blues, etc., and exercise greater flexibility with their provider community. Seeing the handwriting on the wall, many traditional insurance carriers promptly positioned themselves to compete in the TPA space via acquisition or internal accommodations.

I suppose the novelty and efficacy of direct contracting (vs. traditionally orchestrated health plan based managed care) was somewhat muted by the overall failure of the managed care industry writ large to effectively restrain the rapacious appetite of a volume fueled delivery system; see: ‘Direct Contracting: Why It Hasn’t Grown’.   

Fast forward a decade plus and we read about innovation in the Seattle market where competing health systems have internally launched ACOs and in turn are direct contracting with Boeing, see: ‘Seattle Health Systems Launch New Accountable Care Organizations for Employer’.

While the cited ‘InterStudy’ report (the think tank founded by progenitor of the ‘SuperMed’ concept and the acknowledged father of HMOs Paul Ellwood, MD) is behind a pay-wall, the report highlights are as follows [Note: for details on Boeing direct contracting see: ‘Narrow Networks in Today’s Health Care Climate]:

  • Aviation giant Boeing is the first large employer in the market to sign on for both ACO networks, which will be offered to non-union members and select unionized employees. Other employers are expected to contract with the health systems prior to January 2015.
  • The UW Medicine Accountable Care Network features a mix of hospitals within the Seattle market and in surrounding communities. The network includes Seattle Children’s Hospital and Seattle Cancer Care Alliance, both of which were left off the networks for most health insurance exchange policies.
  • The state’s exchange plans prominently featured narrow networks. After outcry from affected stakeholders, state Insurance Commissioner Mike Kreidler introduced new regulations requiring the submission of provider networks for approval, and the networks must include adequate access to specialists and community care providers. Insurers warn the regulations could lead to higher premiums, while hospitals argue that the new rule does not goes far enough to protect consumers.

Comments from report author include:

  • “The introduction of direct-contract ACOs in the Seattle market is surprising, as the market has only begun fully embracing ACOs in the last year. Traditionally, Seattle health systems have shied away from bearing risk, so the market is now entering into a more advanced model of care. Franciscan Health, which was not included in a direct-contract ACO network, may feel pressure to form one to remain competitive in the market.”
  • “Boeing’s willingness to offer the new ACOs, as well as its traditional health plans, allows employees to select the coverage and network they prefer. UW Medicine may have a bigger draw as its ACO network includes providers that have been excluded from insurance networks.”

Meanwhile, per ‘Employer Direct Contracting‘ via Knowledge Source:

According to a recent National Business Group on Health survey, 11% of the large employers are using direct contracting with designated surgical centers of excellence or patient-centered medical homes. Such direct contracting is likely to increase because another roughly 20% of such employers are considering such provider agreements.

Large employers are using reference pricing, where self-insured companies offer to pay only the median price in certain geographic areas for some medical services and require employees to pay the difference at more expensive providers.

So yes, the old is new again. The question is: will it or can it be different this time? Or will we witness another round of ‘me too’ cookie cutter strategies followed by a risk push-back bloodbath, and ‘return to core operations’ by health systems who can’t manage risk, or the acquired physician practices they are so busy swallowing or health plans who can’t manage delivery systems.

Perhaps more on point with the headline of the post is: Will the health plan and institutional health system communities and their advocacy partners respond in kind to another Søren Kierkegaard ‘fear and trembling’ moment with wisdom and clarity? Or will the collective industry ignore the lessons learned from prior well intended but misguided strategic initiative?  

Times have indeed changed, and the horse is out of the barn. Healthcare reform and its required re-engineering is no longer contained behind the closed doors of board rooms of health systems or health plans. Achieving the triple aim is a ‘all hands on deck’ responsibility of all stakeholders in the healthcare ecosystem. But people are people, so we shall see!