Posted in Accountable Care

The Road From Volume-To-Value: The Pivotal Role of Population Health

By Fred Goldstein, MS and Gregg Masters, MPH

Two macro trends are converging to further season and ultimately catalyze the transformation of the American healthcare enterprise: the predominant fee-for-service model that fuels the provider ecosystem (hospitals, health systems, medical groups, IPAs, ACOs, or managed physician networks, etc.) and their ‘partner’ financing plans, payors or administrators.

Ecosystem incumbents include national or regional commercial health insurers (payors), third party administrators (TPAs) that enable self-funding options for smaller employers unable to access the administrative services only (ASO) market, and the historically volatile ‘individual’ market.  And, no discussion of markets would be complete without considering the wide range of public sector initiatives including Medicare (Medicare Advantage and Accountable Care Organizations or ACOs) and Medicaid’s outsourcing to contract with managed healthcare organizations.

These two trends, seemingly at odds with one another, are on a collision course… and the health of our nation hangs in the balance. The burning platform regarding fee-for-service is commonly seen as driving a seemingly insatiable appetite for ‘more’, giving rise to widespread conversation and supportive health policy advocating ‘value based’ healthcare with an emphasis on qualityoutcomes and affordability.

The roadmap to achieving wholesale transformation of our system to focus on health is perhaps best reflected in the emerging science and practice of population health management.

Population health management depends on  business and service delivery provider/financing sector partnerships to achieve a sustainable healthcare ecosystem that enables the ‘triple aim’. Yet, the results of early population health management initiatives nationally are generally mixed, particularly when they neglect to consider the contextual social determinants specific to the target population and community.

In order to achieve that holy grail of improved health outcomes, we must have a clear understanding of the needs and available resources as well as a coordinated plan that includes all the relevant stakeholders.

To avoid the metaphoric outcome once opined by an Eastern Airlines (RIP) pilot emerging from the cockpit to announce to his passengers:

‘well folks, the good news is we’re making great time, the bad news is we have no idea where we’re going…’

The rest is legion for those who recall the death of legacy carrier Eastern.

Finding A True North – Grounding the Science and Best Practices of Population Health Management

The promise of managing populations efficiently and effectively, leading to a healthier overall America is something that just makes sense, whether the push is from the government, payers or providers. Where can one explore the myriad pieces of the population health puzzle to find out what’s working?  Fortunately, the upcoming Eighteenth Population Health Colloquium, March 19-21 in Philadelphia, Pennsylvania can provide some answers.

This conference, chaired by David Nash, MD, MBA, Founding Dean of the College of Population Health at Jefferson, the first such institution in the country, provides the opportunity to hear from and network with some of the biggest names and companies in the field.

Whatever your area of interest — policy, data and analytics, program design and development, provider-based programs and ACOs, payer-based programs, value-based care and contracting, social determinants of health, technologies or even personalized medicine — .  Dr. Nash and his team are bringing together world class leaders and in a right-sized setting that supports interactions with speakers and networking with other attendees.

If you haven’t been to this conference before, now is the time, as health and healthcare system and communities at large are turning to population health.  Be part of this transformation by attending the Colloquium!

For an invitation to the 18th Population Health Colloquium David Nash, MD, MBA, Dean of the Jefferson College of Population Health provides an overview of what to expect (click image).

For the 3rd year in a row Health Innovation Media will be on the ground interviewing keynote speakers, conference organizers, select sponsors and exhibitors committed to supporting the emerging population health focused economy.

Follow the Colloquium via @pophealthconf. The digital dashboard accessible via #phc18 including newsworthy tweets associated with the Colloquium.

For more information or to register, click here.

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This post is sponsored by the Jefferson College of Population Health

 

 

 

 

 

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Posted in Accountable Care, ACO, Triple Aim

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

by Gregg A. Masters, MPH

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

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

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

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

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

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

From the Whitepaper:

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

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

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

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

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

ACOs Fudging the Numbers?

by Gregg A. Masters, MPH

I came across this piece on the Healthcare Blog penned by Kip Sullivan, Esq, critiquing this article posted in Health Affairs last May ‘Bending The Spending Curve By Altering Care Delivery Patterns: The Role Of Care Management Within A Pioneer ACO‘. Sullivan raises valid points as the the legitimacy of claiming or inferring statistically insignificant results as a meaningful contribution of the subject ACO (a Partners Health sponsored venture) to ‘bending the cost curve’.

Sullivan un-bundles his argument effectively and raises issues for the industry writ large – including participating ACOs, their sponsors, the regulatory crew at both CMS and CMMI – and even the health policy press covering the sector.

I post the first few paragraphs of the piece below, for full reference the entire article on the Healthcare Blog is accessible via On the Ethics of Accountable Care Research‘.

  • Is it ethical for health policy researchers to claim that a Medicare ACO reduced “spending” by 2 percent if the reduction was not statistically significant?
  • Is it ethical for them to do so if they made no effort to measure the cost to the ACO of generating the alleged 2 percent savings nor the cost to Medicare of giving half the savings to the ACO?
  • Does it matter that the researchers work for the flagship hospital within the ACO that was the subject of their study?
  • Does it matter that the ACO and the flagship hospital are part of a huge hospital-clinic chain that claims its numerous acquisitions over the last quarter-century constitute not mere empire-building but rather “clinical integration” that will lower costs, and the paper lends credence to that argument? 
  • Is it ethical for editors to publish such a paper? Is it ethical to do so with a title on the cover that shouts, “How one ACO bent the cost curve”?

These questions were raised by the publication of a paper  by John Hsu et al. about the Pioneer ACO run by Partners HealthCare System, a large Boston hospital-clinic chain, in the May 2017 edition of Health Affairs. Of the eight authors of the paper, all but two teach at Harvard Medical School and all but two are employed by Massachusetts General Hospital (MGH), Partners’ flagship hospital and Harvard’s largest teaching hospital. [1]

Partners has been on a buying and ….

Comment

As someone who’s been in this dance since the mid 70s (PSROs, HSAs, HMOs, IPAs, PPOs, EPOs & all derivative plays) launched into Medicare risk via TEFRA (the Tax Equity and Fiscal Accountability Act) which introduced us to ‘Medicare Choice’ the for-runner of Medicare Advantage, I can say Sullivan’s critique of fully ‘burdening‘ ALL transformational efforts is rarely – if ever – factored into the volume to value pivot ‘investment calculus‘ of the effects of the intervention (in this case a Pioneer ACO) on the national spend.

It should be noted, the entire managed care industry can be assessed a gigantic collective FAIL for that matter as well. Since managed care penetrated ‘mainstream medicine‘ principally via extension of the HMO model typically on an IPA (independent practice association) chassis (vs. group or staff models) with the exception of a brief period in the 90s premiums continue their relentless upward march; while most payors continue to write commercial business only via an enterprise and industry wide cost shifting (risk transfer) charade. The tacit admission that there is no there there in the prevailing health insurance industry zeitgeist. They’ve proven they can NOT manage clinical risk, period.

So Kip, you might want to go a little lighter on those on the front lines trying to tame the ‘rapacious appetite’ of our ‘healthcare borg‘!

 

 

Posted in Accountable Care, ACO, LTPAC

Florida Association of ACOs Partners with Caredove

Sponsored Post:

22 Aug 2017 7:00 AM | Jacksonville, FL

Partnership Broadens Florida Based Organization

The Florida Association of ACOs (FLAACOs), the premier professional organization for Accountable Care Organizations (ACOs) and value based healthcare leaders throughout Florida, announced today a strategic partnership with Caredove, Inc. to provide its Statewide ACO membership with access to Caredove’s advanced, online e-referral platform which focuses on making it easy to transition patient care into home care and community services.  Under the agreement, Caredove will work with FLAACOs and its ACO members to establish and build out trusted networks between its ACO members and the organizations and agencies providing home care and community support services in the communities they serve.

Nicole Bradberry, CEO of FLAACOs, states:

“Our partnership with Caredove shows our continued commitment to bring additional value to our members and to take a leadership role in helping to address those aspects of care needs to help our member’s patients stay healthier in their homes and communities and to avoid costly readmission into the Acute care system”.

 It is anticipated that over 1000 home care and community agencies will be implemented on the platform, serving some 40+ ACOs across the state.  Caredove’s CEO, Jeff Doleweerd, said

“We spent thousands of hours examining how patients access service to different home care and community services. We saw the same problems over and over. Clinicians couldn’t locate helpful services, patients didn’t know what would happen next, intake staff were overwhelmed while triaging referrals, voicemails would pile up, and patients wouldn’t get connected with the care they needed. We created Caredove to solve these problems”. 

The development of the initial e-Referral networks in Florida under this agreement will pave the way for additional parties to join the platform.  We’re happy to be working with FLAACOs to bring Caredove to benefit the patients of their ACO members.”

Richard Lucibella, CEO of Accountable Care Options (Boynton Beach Florida) and FLAACOs Board member, is an early adopter on the Caredove platform. 

“As we’ve extended our Chronic Care Management efforts, we’ve gained a better understanding of the extent to which behavioral health and community social services can impact out patients’ health status. We’ve all known this to be an issue, particularly in the Medicare population.  Our CCM teams at Accountable Care Options continue our leadership position here on behalf of our patients, and are excited about the very real promise of the Caredove platform to support and potentially multiply our current efforts.”

“Overall, we’re seeing great interest and excitement about the platform in Florida and elsewhere”, says Jim Atkinson (Chief Growth Officer at Caredove), “and, we are working to expand the network through Community & Public Health groups as well as to bring Payers and Health Systems into the trusted exchange.”

ABOUT FLAACOs                                                                                                 

FLAACOs, also known as the Florida Association of Accountable Care Organization, mission is to provide members a vehicle to collaborate, ensuring that each healthcare organization grows and thrives. The Florida-based association aligns goals to help member ACOs 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 learn more click here.

ABOUT CAREDOVE                                 

Caredove is a healthcare solutions company providing its online platform to make it easy for patients to gain access to home care and community services.  Providers and care coordinators, as well as patients and family caregivers, can Search for geo-available home care and community services, Book appointments and e-referrals directly into those services, and Connect through secure data communication and organization-specific referral and intake workflows.  Caredove is a true healthcare platform that builds trusted webs between Referrers (Providers/Care Coordinators), Service Providers and their mutual patients.   Caredove currently covers over 80 categories of Home Care and Community Services.  On the platform referrals are always free and it’s easy to invite referrers and service providers to the network so there is no impediment to its growth in serving each local community. For more information, click here.

 

Posted in Accountable Care, ACO, Affordable Care Act

What, What? ACOs Not ‘DOA’?

by Gregg A. Masters, MPH

When the Affordable Care Act passed in March of 2010 and the law’s many moving parts analyzed by the ecosystem stakeholders including operators, health wonks and patient advocates many weighed in that ACOs were doomed to fail. They were just too ‘tepid’ to make a material contribution to the volume to value transformational journey. Complaints included little control over patients who ‘voted with their feet’ while ACOs bore the liability of their choices whether in upside only track vs. the downside of exposure of track two, flawed retrospective attribution methodologies and data dumps and reporting lags from CMS all handicapped the proactive management of ‘risk’ assumed by participating ACOs in the Medicare Shared Savings Program (MSSP).

Noted futurist Jeff Goldsmith captured the spirit in Pioneer ACOs: Anatomy Of A ‘Victory’ post in Health Affairs:

With over 17 million Medicare beneficiaries voluntarily choosing MA thus far, and enrollment growing at more than 10 percent annually despite three years of CMS payment reductions in real dollars, it is increasingly clear the future of managed Medicare lies in the MA program, not with directly contracted shared savings models.

Co-incident with the ramp up of the Medicare ACO cohort the private sector jumped on the bandwagon, operating with higher degrees of contractual terms and conditions freedom than promulgated by CMS to participating MSSP’s. Aetna, the Blues, United et al negotiated their version of ‘accountable care’ arrangements with participation IPAs, PHOs, IDNs, health systems, medical groups or physician networks.

Five years later, we have some important data recently reported by Health Affairs that suggests ACOs are far from the neutered enterprises many suggested and while mixed in terms of results reported ACOs have found their place in the managed competition ecosystem and are not likely to disappear any time soon.

The headline at Health Affairs is as follows: Growth Of ACOs And Alternative Payment Models In 2017.

As of the end of the first quarter of 2017, our inventory included 923 active public and private ACOs across the United States, covering more than 32 million lives (Figure 1). The increase of 2.2 million covered lives in the past year means that more than 10 percent of the U.S. population is now covered by an accountable care contract (Note 1).

As the ACO model matures, there is now some turnover, with organizations joining and leaving the model. Since the first quarter of 2016, 138 new ACOs began operation, and 46 ACOs dropped their accountable care contracts, representing a net increase of 92 organizations becoming ACOs, or an 11 percent growth.

From the nominal ACO count basis to the number of lives associated with the aggregate arrangements, this is an impressive tally for such an allegedly ‘anemic‘ model!

Now enter the Next Generation ACO Model. For details, see: Next Generation ACOs: A Deep Dive Series and Meet the Next Generation ACO Cohort.

 

 

 

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Posted in Accountable Care, ACO, Affordable Care Act

Meet the Next Generation ACO Cohort

by Gregg A. Masters, MPH

As announced in ‘Next Generation ACOs: A Deep Dive Serieswe’re launching a multimedia (blog, internet radio, social media and community tweetchats) programming schedule that will focus on the accountable care industry with specific deep dives into select participants in the cohort admitted by the Center for Medicare and Medicaid Innovation.

Next Generation ACO Model

Written versions of those interviews will post on ACO Watch, with audio versions featured on This Week in Accountable Care’ on the BlogTalk Radio and Affiliate Networks.

If you are interested in the Next Generation ACO Model, see: The Next Generation ACO: Accelerating the Transformation from Volume to Value and the CMS Webinar: Next Generation ACO Model – Overview and LOI Information with key webinar dates and application deadlines.

For those interested in learning more about the rather ‘eclectic’ (academic, physician led, hospital system sponsored and venture backed) class of 44 ACOs in the NextGen Cohort, I’ve listed them below: 

We intend to host monthly moderated ‘tweetchats’ to engage the community of stakeholders via #ACOchat and welcome your input on the preference of the participating ACOs you’d like us to profile.

Please post in the comments section.

Cheers!

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*Editor’s Note: This post including This Week in Accountable Care broadcasts, periodic tweetchats via #ACOchat and blog posts in this series) are sponsored by National ACO, a Next Generation ACO. For more information on National ACO, click here.

Posted in Accountable Care, ACO, Affordable Care Act, health reform

Next Generation ACOs: A Deep Dive Series

by Gregg A. Masters, MPH*

Since ACOs arrived in 2012 courtesy of the Section 3022: Medicare shared savings program, under Title III, Subtitle A, Part 3 of the Affordable Care Act (ACA) as the ‘new, new thing’ layered into a complex healthcare ecosystem peppered with more or less successful public/private efforts to restrain healthcare inflation, promote greater patient/member access, provide seamless coordinated care at lower per capita costs with better documented quality (the triple aim), ACOs have booked modest, variable but increasingly scalable impact via sponsored hosts from institutional health systems to physician driven enterprises.

A Brief Timeline

                                The evolution of manage care initiatives

In 1973 President Richard Nixon signed into law the ‘HMO Act‘ officially launching ‘managed care‘ principally via closed ‘staff‘ and ‘group‘ model HMOs catering to niche (vs. ‘mainstream’) segments of key industry stakeholders, i.e., members (patients), employers, participating physicians and hospitals.

In the early to mid 80’s we witnessed the accelerated migration from narrow market penetration to mainstream medicine validation of the HMO model via the emergence of network models typically enabled by then emerging ‘Independent Practice Associations’ (IPAs).

Most IPAs emerged as a loose confederation of participating physicians as many physicians engaged out of a sense of curiosity or defensive hedging to not lose patients. First generation IPA’s featured at best tepid economic bonds, thus alignment of member physicians with the entity ‘leadership‘ (i.e., the Management Services Organization) goals were often ‘incidental considerations’ to many participating physicians. There just wasn’t enough ‘skin in the game‘ or economic integration, i.e., losing a withhold against a fee-for-service schedule just didn’t make that much of a difference from a total compensation point of view.

In the mid 80s principally in California Preferred Provider Organizations (PPOs) emerged and launched the era of discounted fee-for-services contracting for hospital, physician and ancillary services. PPOs were an HMO-lite version as members/beneficiaries voted with their feet within the network based on ‘in network’ benefit plan incentives vs. the closed loop (gatekeeper) HMO model.

In the 90s as mainstream initiatives continued to evolve and mature we witnessed the emergence of Physician/Hospital Organizations (PHOs) more often than not a joint venture between a host hospital (or parent health system) and a member physician organization (typically one or more IPAs or multi-specialty medical groups). PHOs were contracting vehicles and typically supported by an affiliate or owned MSO. Few PHOs entered into full risk arrangements with payors.

For prior comment and context on the evolving market, check out ‘Hey, Remember IPAs, PPOs and TPAs?’

Enter the ACO

While an ‘alphabet soup‘ of healthcare cost containment and quality improvement acronyms enshrined themselves into US healthcare delivery and financing lexicon (HMO, IPA, PPO, PHO, MSO, EPO, DPA, OWAs [other weird arrangements]), healthcare consumption of GDP continued it’s relentless upward growth – though somewhat moderated post passage of ACA.

In 2012 27 ACOs officially launched under the terms and provisions of the Medicare Shared Savings Program (MSSP) via a cohort sourced from 18 states serving an estimated 375,000 beneficiaries. Approximately half of the participating ACOs were physician-led, per the Center for Medicare and Medicaid Innovation (CMMI) – the administering agency.

Amidst ‘mixed results‘ considerable provider input to CMMI via open door forums and NPRM comments the ensuing years witnessed many tweaks to the rules associated with both the MSSP and Pioneer programs. In January of 2015 then Secretary of Health and Human Services Sylvia Burwell set goals for migration of payments from volume to valued based arrangements, see: ‘HHS Sets Specific Targets and Timelines for Alternative Payment Models and Value-Based Payment‘:

By the end of 2016, HHS plans to make 30 percent of FFS payments through APMs, such as accountable care organizations (ACOs) and bundled payments, and tie 85 percent of all FFS payments to quality or value. By the end of 2018, HHS intends to pay 50 percent of FFS payments through APMs, and tie 90 percent of FFS payments to quality or value. 

This represents the first time in my 30+ years in healthcare delivery and financing innovation space that the Federal government has explicitly benchmarked industry migration away from its prevailing fee for services DNA.

While many pronounced ACOs as ‘DOA’ (dead on arrival) for many reasons, truth be told they’ve found their way into the managed competition ecosystem and are not going away anytime soon. In fact as is the case with most innovation, the ACO formula has been tweaked both in terms of its Government DNA (MSSP, Pioneer models, etc), and it’s private pay or commercial derivatives.

Meet the ‘Next Generation ACO Model’

The de facto amalgam of much of the lessons learned and serial tweaks imposed since the first class of ACOs launched in 2012 can be found in the Next Generation ACO Model, see: ‘The Next Generation ACO: Accelerating the Transformation from Volume to Value‘.

Per CMS, the model is defined as:

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.

Included in the Next Generation ACO Model are strong patient protections to ensure that patients have access to and receive high-quality care. Like other Medicare ACO initiatives, this Model will be evaluated on its ability to deliver better care for individuals, better health for populations, and lower growth in expenditures. This is in accordance with the Department of Health and Human Services’ “Better, Smarter, Healthier” approach to improving our nation’s health care and setting clear, measurable goals and a timeline to move the Medicare program — and the health care system at large — toward paying providers based on the quality rather than the quantity of care they provide to patients. In addition, CMS will publicly report the performance of the Next Generation Pioneer ACOs on quality metrics, including patient experience ratings, on its website.

A thorough application vetting process by CMS will assure participating ACOs admitted to the ‘NextGen’ cohort will present with the track record and capabilities to assume and manage the risk inherent in the model. Rather than bolt a new model on a legacy fee-for-services platform, CMS is fueling the necessary innovation to achieve the triple aim via a network of risk savvy ACOs.

Next Generations ACOs will deploy three (3) powerful ‘benefit enhancement‘ tools as they re-engineer clinical workflows and the prudent utilization of acute and sub-acute healthcare resources. This includes:

Featuring the ‘NextGen’ ACO Cohort

First up as we cycle through and profile best in class Next Generation ACOs is National ACO, led by industry pioneers and co-founders Andre Berger, MD, CEO and Alex Foxman, MD, FACP, President and Chief Medical Officer who serve as co-hosts of this series.

The series launches May 23, 2017 from 5PM – 5:30 PM Pacific/8PM – 8:30 PM Eastern. You can listen both live or on demand via This Week in Accountable Care.

We’ll discuss the model, their backgrounds and history in managed care and why they were drawn to form National ACO. We’ll close with comments from Alex Fair, CEO of the equity crowd funding platform Medstartr who will detail the recent listing of National ACO.

Join us!

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*Editor’s Note: This post including This Week in Accountable Care broadcasts, periodic tweetchats via #ACOchat and blog posts in this series) are sponsored by National ACO, a Next Generation ACO. For more information on National ACO, click here.