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!

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).


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

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!


Accountable Care, ACO, Triple Aim

Patient Engagement and ACOs: A Timely Union or Cute Ad Copy?

By Gregg A. Masters, MPH

We previously (see: National ACO Patient Engagement Benchmarking Survey) brought attention to a national patient engagement bench-marking survey wherein @ACOwatch collaborated with Dave Chase, et al at Avado to field an instrument.

While at ‘The ACO Must…’ Towards an Operational Definition of ‘Patient Engagement’ we addressed the indica of patient engagement as well as the statutory context of Section 425.112: Required processes and patient-centeredness criteria.

And, the results are in…..well, sort of at least. Very few responses were submitted.  As we discussed on the front end, given the state of the industry at the moment, with high degrees of immaturity including systems, people and workflows, there are too many moving parts, lots of other priorities and likely a dearth of best practices to document and bench-mark.

So the net take away may be this is both a fluid and somewhat opaque segment in the implementation of the Affordable Care Act. Yet successful ACOs are likely to leverage their approach to patient engagement as powerful competitive differentiators in their local and/or regional markets.

ENGAGEIn this relative vacuum of best practices, I will be moderating the ‘Driving Patient Engagement Innovation in an ACO World panel’ at ENGAGE on June 6th, 2013. Joining in the conversation are: Todd Rothenhaus, Chief Medical Officer, athenahealth, Lanie Abbott, Eastern Maine Healthcare Systems and Colin Ward, Executive Director, Greater Baltimore Health Alliance Physicians, LLC.

This will be a fun and informative panel, so please join us.

Accountable Care, ACO, health reform, Triple Aim

The 9 C’s of Accountable Care with Tom Doerr, MD

By Gregg A. Masters, MPH

Collaborative Payer Lumeris mastheadRecently I came across a blog post titled ‘The Nine C’s of Successful Accountable Primary Care Delivery’ by Tom Doerr, MD. I had the additional opportunity to participate in a portion of The Collaborative Payer Model: 5 Lessons for Accountable Care webinar which Dr. Doerr led wherein he unbundled some of the data and conclusions drawn from the Lumeris experience to date. This is a AMAZING session with deep and powerful information for emerging as well as risk savvy medical groups, IPAs or IDNs.

For an archived replay of The Collaborative Payer Model: 5 Lessons for Accountable Care webinar click hereACOwatch: This Week in Accountable Care

Meanwhile, on Wednesday, May 1st, 2013 broadcast of ‘This Week in Accountable Care’ at 12 Noon Pacific and 3PM Eastern, we get a second chance to engage with Dr. Doerr. You can listen live, or via archived replay.

Dr. Doerr is a soft spoken but highly informed physician who’s gained considerable experience under the auspices of Essence Healthcare, a Medicare Advantage organization under contract with the Federal Government, via a range of integrated contracting entities.

Join us!

ACO, Affordable Care Act, MSSP, Triple Aim

CMS Call: Tips on Submitting Application for Medicare MSSP ACO

By Gregg A. Masters, MPH

There are those trying to figure out how to best ‘build out’ if not perfect (as in the Pioneer class) an ACO, while an even larger pool ‘leaning’ in the direction of playing, are focused on the mechanics of the application process. As with the ‘interface model’ that’s kept the Health Information Management Systems Society (HiMSS) afloat (some suggest the lack of inter-operability has a 60% revenue share of HiMSS members), many aligned with the ‘ACO industry’ have focused on the mechanics (and opportunities for ‘structural self assessments) associated with the launch of the Medicare Shared Savings Program application process.Physician Standing Up the ACO

In the support and outreach department CMS has been periodically hosting provider calls, webinars, etc., in the ACO trajectory domain. Still rather early in the ACO roll out game, while local strategy footprints are thrashed out and locally flavored community by geo-political community, the first order of business is to determine whether to submit or not submit the app (NOTE: this is a no brain-er if you are a hospital with even a modest share of Medicare patients, or any medical specialty that interacts with Medicare patients for that matter).

Here are the deets for today’s provider call. If you missed the live call and are reviewing this information retrospectively, the archived replay is noted below:CMS App Clipped

National Provider Call (NPC), Medicare Shared Savings Program Application Process: Tips on Completing a Successful Application. We look forward to your participation.

Time: 1:30 PM – 3:00 PM Eastern Time
Call-in Number:(877) 237-0855 (no ID or passcode is needed)

Important: Conference lines are reserved for those who are registered for today’s NPC. If you know individuals who were unable to register but would like to participate in today’s NPC; please invite them to listen in with you on one registered line.

Slide Presentation:

The location of today’s slide presentation was included in the NPC registration announcement and in your confirmation and previous reminder emails. For those who have not already downloaded the presentation, as well as additional materials for today’s call, you may do so here.

Additional CMS Guidance in Medicare Shared Savings Program ACO Applicants is here.

Other resources include:

ACO, Affordable Care Act, health reform, Triple Aim

First Round of ACO Results Due Soon

By Gregg A. Masters, MPH

Most of us watching and trying to interpret the ACO tea leaves are both challenged yet determined to assimilate a coherent picture of what’s happening at the ‘industry zeitgeist’ level. As noted previously, once you’ve seen one ACO, you seen one ACO.

Since there is ample confusion from the differences between ‘certification’ vs. ‘accreditation’ and the role of public vs. private oversight and engagement in ACO operations, that picture will only be built via a compositRichard Gilfillan MDe of discrete entity and industry reporting – both mandatory and voluntary.

Some of the ‘results’ reported to date at least in the commercial (vs. Medicare ‘MSSP’ sector) have been – well -‘alarmingly successful’ using traditional HMO use metrics of admits/1000, bed days/1000 and ED encounters/1000, see: ACOs, ‘HMO lite’ or ‘DNA of the Transformation’? These results albeit ‘preliminary’ are given contextual significance when one compares the reported experience with the modest savings projections assumed in the MSSP.

Yet official word came last month via Bloomberg in ‘First ACO Results Due This Summer, CMS Official Says’:

The first results of the Pioneer accountable care organization initiative will be available this summer, a Centers for Medicare & Medicaid Services official told Congress March 20.

Richard J. Gilfillan, director of CMS’s Center for Medicare and Medicaid Innovation, told the Senate Finance Committee that CMMI is working on numerous programs that could alter the way health care is delivered, but added results of many of CMMI’s projects may not be known for some time.

A CMS spokesperson told BNA the data to be released this summer will “provide a complete and accurate picture of the first performance year of the Pioneer ACO model.”

Gilfillan at the hearing sought to ease the concerns of senators who want to see quicker results from CMMI in its work to move Medicare from a fee-for-service program to one based on value-based purchasing