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.  

Healthcare Experts Weigh In On ACO’s

By Karen Minich-Pourshadi, for HealthLeaders Media 

If you feel as though just about every week or so something new comes out involving accountable care organizations, you’re not mistaken. The Centers for Medicare & Medicaid Services recently announced two initiatives related to the ACO model: The ACO Pioneer Program and the Advanced Payment Initiative. So, what do these two programs mean for hospitals and health systems? Well that depends on your thoughts on ACOs, and more than a few experts, including the two I spoke with, disagree.

First, the lowdown on the latest programs:

The ACO Pioneer Program: Launching in fall 2011, the ACO Pioneer Program allows 30 organizations, or “Pioneers,” to more rapidly move from a shared savings payment model to a population-based payment model “on a track consistent with, but separate from, the Medicare Shared Savings Program,” according to the CMS Center for Medicare & Medicaid Innovation.

The program is designed to:
  • work in coordination with private payers by aligning provider incentives
  • achieve cost savings for Medicare, employers and patients

For the first two years of the Pioneer program, the payment models being tested are a shared savings payment policy with generally higher levels of shared savings and risk than those currently proposed in the Medicare Shared Savings Program. In the third year of the program, participating ACOs showing specified levels of savings over the first two years will be eligible to move a substantial portion of their payments to a population-based model.

Advanced Payment Initiative: Also launching in the autumn, the….

For complete article, click here.

Karen Minich-Pourshadi is a Senior Editor with HealthLeaders Media. She may be reached at kminich-pourshadi@healthleadersmedia.com.

CMS Announces Request for Applications on ACO ‘Pioneer Program’ and More..

Just off the phone listening to Drs. Berwick, Gilfillan, and Jonathan Blum CMS conference call on ACO’s. According to CMS, the call replay is available ‘for the next two days’, via: 800.837.1935, use code: 68658167, held on 5/17/at 11 1:30 ET. 

We’ve recorded the session and it will be available via ACO Watch: A Mid-Week Review as well [Program note, the audio is not the best, so your first choice is to listen by dialing the phone number above].

To access the filed document with the Office of the Federal Register, click here.

The original press release announcing the three CMS initiatives can be found here.

The CMS announcement is quoted in part below:

Organizations interested in applying to the Pioneer ACO Model must submit a letter of intent on or before June 10, 2011.  Applications must be received on or before July 18, 2011.  The Pioneer ACO Request for Application, the Letter of Intent form and the Application form  may be accessed at http://innovations.cms.gov/areas-of-focus/seamless-and-coordinated-care-models/pioneer-aco.  The Innovation Center will hold an Open Door Forum to review the Pioneer ACO Model Request for Application on June 7, 2011.

More information about the Advance Payment ACO Model can be found at: http://innovations.cms.gov/areas-of-focus/seamless-and-coordinated-care-models/advance-payment/.  The Innovation Center will accept comments on the Advance Payment ACO Model, if submitted prior to June 17, 2011.  Comments should be submitted via email to:  advpayACO@cms.hhs.gov.

Individuals wishing to attend the June Accelerated Development Learning Session in person may register at https://acoregister.rti.org. Registration is on a first come, first served basis.

More information about the Medicare Shared Savings Program can be found at:  http://www.cms.gov/sharedsavingsprogram/.  The Medicare Shared Savings Program proposed rule can be downloaded at: http://edocket.access.gpo.gov/2011/pdf/2011-7880.pdf .  Comments on the proposed rule, which can be submitted electronically to www.regulations.gov, must be received by June 6, 2012.

The ‘ACO Sentiment Index’: A Tipping Point In Sight?

It’s been some 47 days (and counting) since CMS released the Notice of Proposed Rule on Accountable Care Organizations. Initial reaction was somewhat subdued, given its inherent complexity. Yet recently it seems CMS’s likely surviving allies may be patient advocates, Medicare beneficiaries and the patchwork of provider culture associated with Federal program funding, as well as those tethered to or counting on the range of programs empowered by the Center for Medicare and Medicaid Innovation (CMMI).

Most recently that prevailing hedged if not ‘bearish sentiment’ was captured and parsed in a report compiled by HealthLeaders, perhaps best reflected in the lead quote from Chris Van Gorder, President and CEO, Scripps Health:

“Frankly, I was surprised. I thought there would be more carrots, not so much stick.”

Let’s back up a tad and re-set the context for this piece by recalling the ‘ACO Basics’ per recent preso compiled by Navigant, titled: ACO Proposed Regulations: Implications for Payers & Providers. In summary:

  • CMS issued proposed rules for Medicare ACOs on 3/31/11 and is actively soliciting comments until June 6th, 2011.
  • ACO refers to a group of providers and suppliers of services (e.g., hospitals, physicians, suppliers) that will work together to coordinate care for Medicare Part A & B patients.
  • Implementation goal is January 1, 2012 (phase 1) and potentially July 1, 2012 (phase 2).
  • Provider participation is voluntary; 5,000 patients minimum; 3-year contract between ACO & CMS; beneficiaries do not enroll in an ACO per se.
  • CMS still reimburses FFS; CMS also develops benchmark against which ACO performance is measured to assess whether ACO qualifies for additional shared savings or is accountable for shared losses; 2 possible risk arrangement tracks.
  • Extensive patient-centered criteria to demonstrate, i.e., Data reporting capabilities in place, Patient on the governing board, Systems to identify high-risk individuals, Processes for individualized care plans, Mechanisms for coordination of care (e.g., care coordinators) and Electronic exchange,  summary of care in care transitions
Worthy goals and ambitions any reasoned  health care stakeholder would not likely oppose, yet perhaps reflected best by Andy Slavitt, CEO of Ingenix (Editors Note: ‘hedging’ duly noted in the whitespace.)
“In the short-term, the ACO proposed rules will create a framework for the industry to start to transition from silos to a well-coordinated and aligned system.”

The Health Leaders report further notes:

Industry leaders expect the regulations will be modified once CMS hears the volume of concerns during the comment period. And in the meantime, healthcare leaders are trying to do what the federal government wants in the long run, which is to cut costs, become more efficient and streamlined, and make tweaks or even massive changes in their systems to better manage all aspects of care for their patients.

To download and read the complete article, click here.

I may be reading too much into the buzz at the moment, but if you add up the documented concerns of industry leadership (both payor and provider verticals), you basically get the message of an industry saying ‘yes, but’. Yes, we agree with the ends, but at the moment we’re not quite convince by the ‘over-reach’ of the means. It’s perhaps the definition of ‘over-reach’ which seems to vary by camp that may be worthy of separate consideration. More later.

Meanwhile, today at 1:30 PM Eastern, CMS holds another listening session and conference call, more on that in a separate post.

Vince Kuraitis: ‘Is Hospital-Physician Integration Sustainable?’

On the Wednesday May 11th 2011 broadcast, at 11AM Pacific/2PM Eastern, consultant, blogger, noted speaker, and soon to be published author, Vince Kuraitis is my special commentator on the always ‘tender’ subject of physician/hospital alignment. Given the current scramble to position traditionally independent, siloed or discontinuous provider relationships into a coordinated tapestry of ‘accountable care’ if not a ‘per se’ ACO, the question arises: Is the marriage of two often historically troubled allies even possible, or might their be a more suitably aligned partner(s)?

In a recent blog post at e-Care Management Blog several noted thought leaders (including former guest commentator William DeMarco) chime in on the subject, see: ‘Is Hospital-Physician Integration Sustainable?‘

Join us!

Top Pick’s in the ‘ACO Tool Shed’

Since CMS released the NPRM in March 2011, we’ve witnessed a veritable onslaught of client briefings, and analysis pieces on Accountable Care Organizations and the Medicare Shared Savings Program. The ‘buzz’ is intense as we play out the comment period.

There is so much quality information readily available via Twitter, we thought it would be useful to capture and link to some of the more impressive works now available.

Here is our first installment of ‘Top Picks‘:

If you want your briefing, document or presentation considered for publication on ACO Watch, please @reply to @ACOwatch on Twitter.

Editor’s Note on #ACOchat

We missed our #ACOchat today due to other commitments and a full schedule. Our intention is for the ‘TweetChat to run on a weekly basis, with Tuesday at 3PM Eastern/12 Noon Pacific time as the preferred slot on the calendar. Though until we reach some community consensus or affirmation of the day, and time chosen, can remain somewhat flexible until we land of solid ground.

Meanwhile, I’ve been noticing the many resources specific to Accountable Care and ACO’s in particular that are being posted to Twitter almost daily, all of which are adding value to the emerging conversation.

As a reminder, we remain in the 60 day comment period of the notice of proposed rule issued by CMS on March 31st, 2011. Their release has stimulated quite a bit of conversation. For an overview of the Medicare Shared Savings Program, click here. To review the complete published rule and comment online before June 6th, 2011 deadline, click here.

In a separate post, I will list some of the more useful resources found on Twitter in the last week or so.

First ACOchat ‘In The Can’

On Tuesday, April 27th, with the able support and leadership of Mark Browne, MD, aka @consultdoc we experienced the first TweetChat focused on the Accountable Care Organization niche.

Many of our community members joined in and created a rich conversational stream around the three topics (T1, T2 & T3) generated for the moderated conversation, which included:

T1: Will ACO’s ultimately lead to any significant innovations in the world of healthcare?

T2: ACO’s have a large focus on primary care physicians. Will specialists be relegated to the role of ‘best vendor’?

T3: Telehealth is mentioned throughout the law, yet current regs are barriers to effective telemed? Can they be overcome?

For a complete transcript of the hour, click here, for a summary recap, click here (both courtesy of our friends at The Fox Group, LLC).

You may also visit ‘ACO Chat’ for a continuous loop of Tweets during the hour. ACOchat will convene for one hour weekly at 3PM Eastern and 12 Noon Pacific Time. Join us!

ACO Watch: A Mid-Week Review with Michael L. Millenson

On the Thursday, April 28th 2011 program at 11AM Pacific and 2PM Eastern, my guest commentator for an encore appearance is thought leader, author, blogger, lecturer and consultant on health care quality Michael L. Millenson. We’ll discuss his piece: ‘ACO Fairy Tale Faces a Rumpelstiltskin Moment‘ and more.

Millenson is president of Health Quality Advisors LLC, and a nationally recognized expert on improving the quality of American health care. He is the author of the critically acclaimed book, Demanding Medical Excellence: Doctors and Accountability in the Information Age, and he holds an adjunct appointment as the Mervin Shalowitz, M.D. Visiting Scholar at Northwestern University’s Kellogg School of Management.

For more information, click here.

Please join us!