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CMS: Accelerated Development Learning Program June 20 & 21, 2011

Day 1: ACO Formation: Leadership and Priority Setting

On Day 1, presentations and discussion will emphasize the importance of understanding patient populations, market environment and the core functions of an ACO as a starting point that will guide ACO formation and provider relationships. The plenary, case studies and team based exercises will show how data and market intelligence can be used to set strategic ACO goals and priorities that bind providers and inform ACO development. Participants will also leave the day 1sessions with an understanding of the other ACO competencies they will need to develop

1:00 – 1:15 | Welcome & Introductions
1:15 – 1:30 | Opening Remarks from CMS

Rich Baron, MD, Group Director, Seamless Care, CMS Center for Innovation

John Blum, Deputy Administrator, Centers for Medicare and Medicaid Services

1:30 – 3:30 | Setting Priorities and Leading ACO Formation

How becoming an ACO changes perspective, priorities, and leadership

John Bertko, F.S.A., M.A.A.A., CMS

Essential questions an ACO needs to ask – and what it takes to answer them

Paul M. Katz, MBA, Chief Executive Officer, Intelligent Healthcare | This session will introduce the two-day program. It will demonstrate the importance of grounding the ACO’s strategy on a solid understanding of the population for which it will be responsible, existing patterns of care and opportunities for improvement in that population, clearly defining the role and responsibility of all participating providers for meeting the needs of the population and achieving strategic goals for improvement, establishing a workable organizational structure, and leading efforts to change the way care is organized, delivered and managed. This session will introduce the notion of a “recipe for success” that reflects an ACO’s understanding of the local market it operates in, the specific goals that it will need to achieve, and the core competencies it both has and needs to develop, given the different starting points of each organization.

3:30 – 3:45 | Break
3:45 – 5:30 | Insights from the Field

Participants will learn from the real-world experience of ACO leaders who have developed and implemented organizations that perform the functions of an ACO. Issues to be addressed include leadership and management functions such as priority setting, decision making, and negotiating provider relationships.

Case Study 1: Building an ACO on the foundation of an Integrated Delivery System (IDS)

Craig Samitt, MD, Chief Executive Officer, Dean Health

Case Study 2: Building an ACO on the foundation of an IPA

Karen van Wagner, PhD, Executive Director, North Texas Specialty Physicians

Case Study 3: Building an ACO on the foundation of a Physician-Hospital Organization (PHO)

Lee Sacks, MD, Chief Executive Officer, Advocate Physician Partners

The 5 Imperatives of Accountable Care

By Jaan Sidorov, MD

In order to manage the financial risks of being “accountable” to a population, provider organizations that want to be ACOs will have to do five things:

1) assess their assigned members’ individual risk (using health risk assessments (HRAs) and predictive modeling,

2) that then segment or stratify the population into three “buckets”: high, medium and low. Then….

3) deploy a full spectrum of communication interventions, including telephone, mail, email and social media, the purpose being to…..

4) recruit patients into the appropriate care pathways that are tailored to the level of risk. Patients at highest risk need case management. Patients at lower levels of risk may require less intense coaching, such as preventive counseling, telephonic reminders and, if available, wellness interventions. Patients with a high level of readiness to change are most likely to benefit. The purpose of all this is to…

5) apply evidence-based medicine and guidelines using shared decision making so that patients can reconcile the the care they need with what they want and, simultaneously, reduce claims expense (an example is here).

And who is responsible for all this you ask?

Many naive policymakers, out-of-touch regulators, inflexible legal experts and physician-leader apparatchiks will tell you the primary doctors will do it. According to this policy-insider elite, giving PCPs electronic records, 10% pay increases and medical home status will unleash the physicians’ hidden lust for becoming accountable. They’ll want to counsel patients in the course of their office visits.

Poppycock, says the DMCB. Docs don’t mind being ultimately responsible, but they have little interest in reviewing, recruiting or educating lists of patients. They’re more than happy to “outsource” that job to case managers. The DMCB thinks of these professionals as the ones who review the lists, oversee recruitment rates, provide counseling services and assure that maximum numbers of patients become engaged in their self care. Plenty of those patients will need an appointment to see a doctor for diagnosis and treatment, and – thanks to a working relationship with their docs – the case managers can make that happen.

In other words, the case managers will be the linchpin to assuming ACO success. Where the rubber hits the road. Where the light shines. Where the action is. Where the return on investment will be achieved.

Jaan Sidorov, MD, is a thought leader, ‘ blogvocateur’ and the author of over 35 peer-reviewed publications and presenter at 60 health conferences, Dr. Sidorov is a seasoned primary care physician with a working familiarity with health insurance, corporate governance, health service research, disease management and health care quality. Dr. Sidorov also publishes ‘The Disease Management Care Blog which is the original source of this blog post.

ACO’s: If You Build ‘em, Will They Come?

Even the models for health reform hate the new HHS rule.

The Obama Administration is handing out waivers far and wide for its health-care bill, but behind the scenes the bureaucracy is grinding ahead writing new regulations. The latest example is the rule for Accountable Care Organizations that are supposed to be the crown jewel of cost-saving reform. One problem: The draft rule is so awful that even the models for it say they won’t participate.

The theory for ACOs, as they’re known, is that hospitals, primary-care doctors and specialists will work more efficiently in teams, like at the Mayo Clinic and other top U.S. hospitals. ACOs are meant to fix health care’s too-many-cooks predicament. The average senior on Medicare sees two physicians and five specialists, 13 on average for those with chronic illnesses. Most likely, those doctors aren’t coordinating patient care.

This fragmentation is largely an artifact of Medicare’s price control regime: The classic case study is Duke University Hospital, which cut the costs of treating congestive heart failure by 40% but then dumped the integration program because it lost money under Medicare’s fee schedule.

Intelligent liberals now concede this reality but claim that the government merely needs to devise better price controls. By changing the way it pays, Medicare under the ACO rule is effectively mandating a new business model for practicing medicine. The vague cost-control hope is that ACOs will run pilot programs like Duke’s and the successful ones will become best practices. While the program is voluntary for now, the government’s intention is to make it mandatory in the coming years.

But what if they had an ACO revolution and no one showed up? The American Medical Group Association… (read complete article here).

ACO’s, CMS, and ‘Tea Leaves’

Not sure what the latest count is on the comments to the ACO NPRM, see submitted comments on anti-trust enforcement, here, but amidst the range of direct commentary, and downstream banter, the following read is proferred: the stakeholder community (broadly cast) is rather, uh hum, ‘engaged’.

It’s been said, the opposite of love is not hate, but ‘indifference’. Extrapolating here, the fact that every healthcare special interest group from providers, to payers, to their channel partners and/or intermediaries, is now on record either in favor or, or opposed to specific provisions or principles the ACO rule and sequelae, ie., Pioneer Model et al add ons, there is no shortage on conversation on ACO’s. The pro-rule, pro shared governance and patient centered indicators consumer voice is reflected here.

Advantage CMS?

Having listened to, interviewed, and generally followed engaged peeps in the ACO conversation including CMS, my sense is our ‘transformationally inclined’ friends in DC are both encouraged and hopeful with the process. Rather than retrenching or feeling overwhelmed by the level discourse, or perceived need to retool their approach, my sense of their thinking is ‘isn’t it great we have so much engagement in the process?’

Since we’ve been at this ‘bend the cost curve’ and improve quality by minimizing variance and promoting evidence based medicine, via a series of acronyms too lengthy to mention, truth be told, we have collectively failed. The rapacious appetite of the healthcare borg is alive and well. The percent of GDP we consume remains on it’s unsustainable and upward trend.

ACO’s whether in principle or operational terms (yet to be finalized) are here to stay. The transformational imperative is perhaps more acute than ever in the 30 years that I have been engaged in the drama, dating back to the ‘office of alternative delivery systems’ in HCFA.

The time is now. Rather than find ways to point fingers, sit on sidelines or otherwise contribute copy to the ‘naysayer echo machine’, let’s be about the continuing business of transformation. The ‘event horizon’ is in sight, i.e., when GDP hits 20%, the private sector will be kicked out of the sandbox and Government will issue a top down remedy, no doubt anathema to our pluralistic commitment to public/private partnership solutions.

ACO: The Narrative Unfolds (Consumer v. Provider?)

This is an abstract of the article posted on KHN News titled: ‘ACO Defenders Emerge As Comment Period Ends‘. Editors note: now the conversation begins in earnest. The bottom-line question seems to be ‘how much GDP do they need’?

Meanwhile, in other health law implementation news, timing issues related to Department of Health and Human Services regulations are flummoxing some states.

CQ HealthBeat: As ACO Rule Limps Toward Finish Line, More Defenders Emerge

Deadline day arrived Monday for comments on Medicare’s much-abused proposal for accountable care organizations. And supporters of the Obama administration championed its pro-patient provisions in the face of criticism from the health industry. Early industry feedback on the ACO rule focused on the expense and complexity it posed for hospitals, doctors and health organizations interested in teaming up to achieve higher quality, better patient care and lower costs. Many providers were deeply skeptical that they could participate and urged a major rewrite (Norman, 6/6).

Politico Pro: Patient Groups Like ACO Rule

The groups representing patients and consumers have some concerns about the accountable care organization rule — but they are generally much more optimistic about the program than providers have been, according to comments filed with HHS on Monday. One advocate pointed to the new ACO rule as an example of how the current administration is more patient friendly than the past administration (Coughlin, 6/7).

Politico Pro: HHS Regulations Timing Troubles Some States

New Hampshire state Sen. Ray White started off 2011 looking to get a bill moving on a health exchange, but he backed off because HHS regulations for state-run exchanges were not expected until June. While White opposes the Affordable Care Act, he also recognizes that it’s standing law. He did introduce a bill in February 2011 that would have authorized the state to set up the health exchange, curtailing the possibility of the federal government coming in and doing the task (Feder and Kliff, 6/7).

And, from the employer perspective, a survey found… (To read complete article, click here).

This is part of Kaiser Health News’ Daily Report – a summary of health policy coverage from more than 300 news organizations. The full summary of the day’s news can be found here and you can sign up for e-mail subscriptions to the Daily Report here. In addition, our staff of reporters and correspondents file original stories each day, which you can find on our home page.

ASCO Comments on ACO Rule

By Allen S. Lichter, MD, CEO, American Society of Clinical Oncology

Dear Administrator Berwick:

I am pleased to submit these comments on behalf of the America Soceity of Clinical Oncology(ASCO) in response to the recent notice of proposed rulemaking regarding accountable care organizations (ACOs) and the Medicare Shared Savings program (MSSP).1

ASCO is the national organization representing nearly …. (for complete letter submission, click here).

Campaign for Better Care Supports ACO Proposed Rule

By Diana Manos, Senior Editor, Healthcare IT News

Leaders of the Campaign for Better Care (CBC), a broad-based coalition of consumer organizations, said they will comment on the proposed ACO rule on Monday, commending the federal government for putting patients first.

The ACO proposed rule was issued by the Centers for Medicare and Medicaid Services (CMS) on March 31, with a comment period closing June 6.

“The CMS Medicare Shared Savings proposed rule is moving in the right direction,” said CBC officials. “The ACO proposed rule is premised on patient-centered care, patient engagement, a strong foundation of primary care, performance measurement including patient experience, and meaningful stakeholder involvement. These elements are the key to a successful ACO and genuine transformation of our care delivery system overall.”

CBC emphasized that the federal government can’t afford to set the bar too low, when it comes to ACOs.

“Some are concerned about asking too much of ACOs, but we believe these new models must be held to standards that ensure they deliver on the promise of better care, better health, and lower cost,” CBC leaders said. “If the bar is set too low, ACOs will likely fail – either by failing to produce real results through a fundamentally different approach to care, or by creating resistance among patients who are called on to pay for or be part of mediocre attempts at change.”

CBC strongly supports the requirement that ACOs meet eight specific criteria including care coordination, patient engagement and use of patient experience to assess care and guide quality improvement.

“These features are essential for ensuring that patients achieve better outcomes,” said officials. “They are also important for reducing the costs of preventable hospitalizations, medication errors, and duplicative tests and procedures.”

CBC also “strongly supports” the proposal that Medicare beneficiary representatives be included on the governing board, opining that an ACO governing board should be a multi-stakeholder body that operates in the public interest and reflects the community it serves as well those providing care.

[See also: CMS announces new ACO initiatives.]

Beneficiaries and community-based consumer advocates should hold a sufficient number of seats on the governing body to enable them to have meaningful influence on the organization and its operations, CBC leaders said. The group recommends that CMS require 50 percent of the seats on the governing body be held by beneficiaries, community-based consumer advocates and other relevant stakeholders.

CBC also supports the beneficiaries to seek care outside of an ACO. “Negative experiences with early Medicare+ Choice plans are still fresh in the minds of many, and if beneficiaries believe they are being locked in to a new system without their consent they are likely to reject it out of hand – jeopardizing the potential advantages that ACOs may bring to patients and the health care system,” said officials.

Read complete article, here.

Of ‘…Nattering Nabobs of Negativism…’

By David Harlow

There has been a significant outcry against the proposed ACO regs: everything’s wrong and nothing’s right about them, or so some would have us believe. (The comment period is still open, and CMS is still soliciting input; much of the outcry is a form of posturing and negotiation … not that there’s anything wrong with that.)

Today’s “nattering nabobs of negativism” focus on: the estimated price tag for complying with the regulatory requirements (IT and other infrastructure incuded), the slim chance of success by ACOs in righting the wrongs of decades of bloat in the health care system, the premature pledging of allegiance to an idea only partly proven through the PGP demo, the likelihood of failure due to the whole endeavor’s being tied to FFS reimbursement, on the one hand, and due to exposure of ACOs to downside risk, on the other, the unreasonable reliance on dozens and dozens of quality measures . . . and the list goes on. For further detail, see, e.g., David Dranove’s recent post decrying unproven theories baked into the ACO program (with a link to info on the PGP demo’s results, and differing interpretations of those results; check out the lively discussion in the comments to Dranove’s post on The Health Care Blog), Jeff Goldsmith’s opposition to ACOs as conceived in the ACA (and alternative proposal discussed in the linked post), and Mark Browne’s search for a few good quality measures. (This has been a recurring theme for me as well; I would love to find six or eight meta-measures that predict all others; Mark links to the AHA’s comments on the ACO rule, which are worth a read).

My reaction to the flurry of commentary on the original draft rule… (read complete blog post, here).

David Harlow aka @healthblawg, is the publisher of ‘HealthBlawg. Harlow’s experience in both the public and private sectors over the past twenty years affords him a unique perspective on legal, policy and business issues facing the health care community. Health care providers, vendors and payors of all shapes and sizes rely on him to help them navigate the maze of regulatory and business issues facing them on a daily basis.

ACO Industry Stakeholder ‘Outrage’ | Theatrics or Substance?

By Gregg A. Masters, MPH

Re-framed title: ‘CMS, ACO’s and ‘The Grapes of [special interests] Wrath?’

In the United States of Amnesia (“USA”), we seem to be drawn to a regular if not somewhat addictive ‘blame game’ pastime. Watching the post ACO Notice of Proposed Rule release commentary, and subsequent update by CMS announcing the fast track roll-out options of The Pioneer Program, et al, I am reminded of the

Success has many fathers but failure is an orphan quote.

As a veteran of the managed health care industry dating back to PSRO’s and HSA’s (no, not health savings accounts), I can say we are dangerously close to, if not directly enmeshed in a Shakespearean ‘Much To Do About Nothing’ moment.

I will not line item the pro v. con arguments of the rule’s relative merits or liabilities, nor its subesequent updates (in direct response to active healthcare industry stakeholder input), but outline what seems to me to be the core heartburn of CMS’s ‘over-reeach’ (at least in the eyes of some).

As context my lens includes the comments filed to CMS, many of which are proffered from the point of view of providers/suppliers & channel partners, v. those of us on the consumer or patient experience side.

So bottom-line, other than the excessive cost burden imposed (CMS estimates typical start-up costs to be somewhere in the $1.8 million range), the real issue boils down to putting patients or consumers in the conversation or at the table, via ‘shared governance’ and CMS’s indicia of ‘patient-centeredness’. For an excellent recap by David Harlow at e-patients.net, click here.

Stay with me for a moment, just imagine this scene: a board meeting of a private (v. federally qualified anything) single or multi-specialty medical group, IPA, super IPA, or emerging managed physician network, MSO, etc., convenes for a regular ‘business meeting’. On the agenda are standing considerations: production trends, gross charges, adjustments, net collections, payor mix, utilization, resource management, etc., as well as quality issues, including patient satisfaction, reportable metrics, clinical pathways, as well as market competitive developments, hospital affairs, and the general welfare of the practice or network. But at this meeting something is different. There is now a consumer or patient representative in the conversation as ‘principal’.

Will the conversation be different with a patient ‘in the room’ with theoretical equal standing in the conversation? Have you ever seen how a problem is discussed by professionals when a ‘skin in the game’ participant is in the room, both observing and participating in process? I have, and in my experience the quality, intensity and urgency of problem solving is typically in a fast track if not real time resolution mode.

So other than AHIP’s and AHA’s grievances of prospective exclusion from ACO formation, organized medicine’s concern about capital and start-up costs, as well as potential CMS overkill in everything from marketing materials, to indicia of a patient center entity, the real issue seems to be the intention of CMS to get the healthcare industry to ‘walk the talk’ with respect to known solutions to the continued healthcare conundrum.

Just sayin’… so, what did I miss? Any thoughts?

World Congress Leadership Summit on ACO’s: A Recap

By Gary Baldwin, Health Data Management Blogs

I spent two days last week at the World Congress Leadership Summit on Accountable Care Organizations and my mind is just now recovering. As far as speaker quality goes, this conference (which offered concurrent tracks on ICD-10 and Meaningful Use) was top-notch, with dozens of speakers from hospitals, medical groups, payers, and consulting firms. There was a lot to absorb, but a few recurring themes came through. Here are my Top 10 takeaways from the conference:

1. The End of Fee-for-Service Medicine is Near

Although it has not commanded the media attention of the previously reported end of the world, the demise of productivity-based reimbursement models is imminent, with profound implications for physicians and anyone else working in the industry. Just how imminent? Well, no one offered a specific doomsday date and time, but consider this: According to Paul Markovich, executive vice president of Blue Shield California, the annual premium for one of its HMO policies will rise to $39,000 annually by 2020 if medical inflation continues at the current pace. “The status quo is going to kill us,” he said. And that message was repeated by multiple other participants, providers among them.

2. Current Economics are Unsustainable

You may not like the current iteration of the ACO model (a highly criticized set of proposed rules to be sure), but in one form or another, the industry needs to move to so-called “value-based” purchasing, and do it quickly. “We spend more than we need to and we don’t get good results,” noted Scott Sarren, chief medical officer of Blue Cross Blue Shield of Illinois. “If we fail to reduce costs, our only option left is price controls.”

3. Narrow Timeframe Threatens Federal Program

The health reform law mandates that an ACO program must be in place by January 1. HHS is now digesting comments from a disgruntled industry. The consensus at the conference was that the current ACO proposal is so unwieldy—and risky—that there will be few takers, unless the rules of the game are eased considerably. No one said it, but the federal ACO party may prove to be a giant dud, simply because not very many show up. And make no mistake, this is a program that will need widespread participation to make a dent in the expanding Medicare outlays. Gene Lindsey, CEO of Atrius Health, a Boston consortium of five independent group practices, said his organization is taking a wait and see attitude before jumping in.

There will be some takers for the federal plan, however. James Satterfield, a trustee of the Queens County Medical Society, described the organization’s early efforts to participate—primarily due to a sense of urgency among primary care physicians facing growing expenses and dwindling reimbursements. “The illusion of being autonomous is gone,” he noted.

4. The Private Sector Will Move on its Own Accord

Faced with the prospects of coping with a tangled federal ACO plan, many in the industry are forging ahead on their own, creating ACO-like arrangements—at the not so tiny risk of running afoul of anti-trust laws. In that sense, Obama’s health reform law—which put teeth (and money) into the federal ACO effort—may already be working. Blue Shield of California has launched three risk-sharing ventures with providers. “This is the private sector’s last chance to demonstrate affordability,” Markovich said. And the Illinois Blues plan has launched an ACO in Chicago with Advocate Health Care, a large hospital system.

5. The EHR is a Foregone Conclusion

Participating in an ACO of any stripe is all but impossible without an EHR. That message underscored multiple presentations. And while the idea is not shocking, the fact that so many speakers now take for granted the technology that has been resisted for so long is telling. Furthermore, the EHR can work, and work well, even in the complex environment of a large, multi-specialty group practice. With 800 physicians, Atrius is fully implemented on its Epic EHR across some 30 sites. “The EHR allows us to function as one large contracting entity,” noted Lindsey, adding that half of its 700,000 patients are being treated under global payment arrangements.

6. Without the Docs, ACOs Go Nowhere

In the ACO world, all eyes will still be focused on physicians. They may…

For complete article, click here.

Gary Baldwin is the Editorial Director for Health Data Management, and has been covering health care since the early 1990s. Prior to rejoining Health Data Management in 2008, he served as technology editor for HealthLeaders Medi for nearly five years.