Tag: change

Accountable Care, ACO, Affordable Care Act, Triple Aim

ACOs Fudging the Numbers?

Admin

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‘!

 

 

Advertisements
Accountable Care, ACO, Affordable Care Act

POTUS: The De Facto Health Wonk-in-Chief of the US?

Admin

by Gregg A. Masters, MPH

United States Health Care Reform

 

Love him or hate him President Barack Obama continues to demonstrate depth, insight, tenacity and a firm grip on the state of the U.S. Healthcare ecosystem dysfunction (and remedies) well beyond his formal training as a Constitutional scholar. Now as arguably one of the most legislatively accomplished President’s in U.S. history, particularly in light of the catastrophic train wreck he inherited from his predecessor and fueled by the nonstop ‘hell no‘ chorus of his disingenuous (often health policy clueless) political opposition he weighs in to set the record straight and for legacy purposes.

On July 11, 2016, JAMA released ‘United States Health Care Reform: Progress to Date and Next Steps‘ a rather scholarly construed unbundling of the state of healthcare then and now (pre and post ACA implementation). As a rather complex piece of legislation with many moving parts, and staggered implementation timelines (some as a result of political accommodation, some merely in tune with operational and prevailing healthcare delivery and financing legacy inertia) he steps up and in classic barrister narrative fashion lays out his case, and simultaneously calls out the next steps to remedy the U.S. healthcare conundrum.

POTUS aka ‘Health Wonk-in-Chief‘ Barack Obama concludes:

Policy makers should build on progress made by the Affordable Care Act by continuing to implement the Health Insurance Marketplaces and delivery system reform, increasing federal financial assistance for Marketplace enrollees, introducing a public plan option in areas lacking individual market competition, and taking actions to reduce prescription drug costs. Although partisanship and special interest opposition remain, experience with the Affordable Care Act demonstrates that positive change is achievable on some of the nation’s most complex challenges.

I strongly encourage you to click on and read the entire piece. It is well worth your time and wholly consistent with the ‘accountable care’ narrative (the subject of this blog) driving Medicare ACOs, their commercial derivatives and large portions of the moving parts of the ACA including the entire spectrum of ‘value based’ healthcare initiatives.

For this piece, I want to focus on four areas of the ‘next steps‘ called out by POTUS, namely: the ‘Health Insurance Marketplaces’, associated ‘delivery system reform’, AND the introduction of ‘a public plan option in areas lacking individual market competition, and finally ‘taking actions to reduce prescription drug costs’.

Health insurance marketplaces

So much of the ACA oppositional cheerleading liked to stress the ‘buying across state lines‘, and ‘malpractice reform‘ as ‘freedom and choice‘ enabled solutions to the health insurance quagmire. Never mind the rampant marketing, churn, double digit premium increases, retrospective rescissions or opportunistic denial rates, coverage limits and lifetime caps so endemic in the space. Not to mention ‘mini-meds‘ or ‘junk insurance’ so prevalent in the market before some baseline notions of what constitutes ‘insurance‘ in the face of typical health, illness or accident challenges one may experience in life. Here again, coverage baselines and the need for consistency to shop, compare and ultimately purchase real health insurance seemed like too much regulatory over-reach in a market where choice absent basic ground rules somehow seemed like a more attractive solution – at least to the often clueless opposition. The entire over-reach narrative was wrapped up, sold and bought as a ‘Government controlled healthcare takeover‘ per the vacuous talking points proffered by ACA oppositional research.

Google Image Result for http___1.bp.blogspot.com_-FCS-xwHjt8Q_TksRz3PW4CI_AAAAAAAAATo_aR9LEeQ57bU_s1600_medicare-keep-your-hands-off-my-medicare.jpg

 

Yet, the value proposition of an ‘insurance market place‘ whether Federally run, ‘facilitated’ or state delegated exchange option makes total sense if a transparent consumer market is to emerge from the chaos that is principally the individual market (non employer sponsored health insurance), though the group, or self funded ASO market ain’t much to cheer about either. Yet such a model was/is a proven way (witness the explosive growth of private exchanges) to introduce orderly competition in an otherwise opaque industry.

If you’ve ever run a health plan, built a managed care organization or contracted for hospital, physician, ancillary and pharmaceutical services (I presided over several employer sponsored health plan initiatives, MSOs, PHOs and IPAs tackling both capitated and discounted fee for service plan launch and operational issues in for-profit, voluntary and academic health systems) you will know that prudent (empowered, informed, etc.) purchasing of health insurance options requires clear apples-to-apples covered services comparisons, exclusions and non-covered item disclosures coupled with understandable pricing transparency and the cost sharing burden associated with your election. Absent this comprehensive clarity, listing guidance and/or requirements that an exchange imposes to ‘qualify’ eligible participants as candidates to choose from is virtually impossible. Standing up the infrastructure (people,  process, culture, etc.) to enable informed choice requires such an exchange environment whether public, private or some combination thereof to transparently market their services to the consuming public.

Delivery system reform

This is clearly the ACA’s ‘achilles heel‘ as there ain’t much there, there other than aggregate ‘on the come‘ efforts to tip toe into the waters of ‘clinical integration‘, measured risk assumption and a range of payment reforms collectively recognizing fee-for-service (i.e., do more to earn more) medicine as a burning platform. The most tangible form of this commitment is represented by Secretary Burwell’s call to migrate increasing shares of Medicare beneficiaries (including me, as I turn 65 in August and have elected Kaiser Permanente Senior Plan in San Diego) into Medicare Advantage, ACOs and a broadly cast series of ‘value based‘ healthcare arrangements by certain dates.

Standing Up the ACOFor the most part, ACA focused on insurance market place reforms. While delivery system reform was principally invested in ‘nascent’ ACOs (which are mutating as we speak amidst some 5 and 1/2 years of operating experience under the Medicare Shared Savings Program (one I like to call ‘HMO-lite’ which incidentally and inevitably is morphing into its more traditional gatekeeper HMO predecessor vs. the retrospective attribution methodology that undermines successful ACO risk assumption performance).

Additional delivery system reform was to come from pilots, demonstrations and other ‘innovations’ the Center for Medicare and Medicaid Services (CMS) funded via the Center for Medicare and Medicaid Innovation (CMMI) – who’s budget the Republican controlled Congress is determined to cut.  Here, I might add at the ACO Summit circa 2012 one of the most seasoned and successful risk savvy players I had the opportunity to work for and with in Dallas, Texas Richard Merkin, MD, the founder and owner of Heritage Medical Systems and Heritage Provider Network described as the ‘hidden jewel’ in the ACA.

As much as we’ve progressed into ‘managed care‘ whether discounted, bundled, case rates, per diems or global or partial per member per month (PMPM) capitation or percent of premium the majority (estimated at 80-90%) of healthcare payments are still of the fee for services variety. Back in the 80s when American Medical International (AMI) retained me to develop and preside over their managed care strategy for the California Region’s 19 hospitals I elected ‘Director of Health System Development‘ vs. Regional Director of Managed Care as a title, since I saw the strategic imperative of building and operating a hospital system as a partnership with payors, health plans and employer groups, in order to create value. Since ‘payors’ (as a group) were our customers to grow market share we needed ‘dots on the map‘ to effectively service their employees, members or insureds. That vision and strategy collapsed before taking root since quarterly earnings per share incentives of the hospital CEOs precluded the longer term strategy of acquisitions and divestitures consistent with a dots on the map game-plan could take hold.

Today, many years later health systems are ‘getting [payor/provider partnership] religion’ at least rhetorically, yet the prevailing provider/payor mindset remains ‘your revenues are my expenses‘ – not much progress! So don’t hold your breath on material delivery system reform other than the equivalent of re-arranging furniture on the deck of the Titanic while the ship sinks. Mergers, acquisitions, the ‘death of independent‘ medicine and rise of mega institutionally led health systems more or less ‘clinically integrated‘ notwithstanding.

A public plan option in areas lacking individual market competition

While POTUS stresses the individual market as the target ‘book of business‘ most at risk and dysfunctional absent effective reform the need for a ‘public option‘ across the board (group, self funded/ASO, fully insured, etc) is rather compelling, in my view. The recent failures of the ACA enabled ‘CO-OPs‘ notwithstanding (i.e., startup insurance companies or health plans rarely if ever achieve profitability in such a short timeline given the threshold need for ‘the law of large numbers‘ for actuarial credibility and the inherent volatility of the underwriting profit/loss cycle) do nothing to undermine the argument and need for a public option writ large.

I’ll go one step further and say ultimately our worshipping of ‘pluralism‘ in healthcare delivery and finance will ultimately give way to a ‘Medicare E‘ version as in Medicare for everyone. If public/private partnerships and business models could successfully manage clinical risk and meet the health and healthcare needs of their constituents we would have solved the problem in the 80s and 90s. Who remembers the ‘Harry and Louise‘ narrative battles (‘if the Government choses, we lose‘) on the Clinton Health Security Act aka ‘HillaryCare‘? So perhaps we’ll get there once we exhaust every other option to avoid ‘single payor‘?

Actions to reduce prescription drug costs

This seems to me the segment the easiest to resolve. Here I’d empower Medicare to negotiate direct and on behalf of it’s entire pool of beneficiaries, rather than dilute the market power via a tapestry of variably (under) performing ‘PDPs’. The political compromise that birthed Medicare Part D (the Prescription Drug Plan) materially undermines the market power of the ‘law of large numbers’ to extract best price from vendors, suppliers or providers of services. This make NO sense, and we’re paying the price! Here, politicos assured Medicare could NOT intervene with such market clout instead they routed the business upside to a pool private participants.

Add to this macro market efficiency undermining the challenges of orphan or rare disease market segments and the egregious and unaccountable pricing practices most recently popularized by ‘bad boy’ Martin Shkreli of Turning Pharma and more recently Valeant‘s abusive pricing admissions.

Yes, specialty pharma is at risk and a major source of heartburn for AHIP and it’s employer allies, yet PHRMA has a point. The drug discovery and commercialization process/pathways to market are unpredictable and fraught will high failure rates. Coupled with the long development runways and high costs, but absent a ‘ceiling’ or ‘pricing accountability framework’ pharma’s management credo will remain ‘whatever the market can bear‘ strategy lest ProPublica‘s (et al) investigational journalism (see their guide to investigating non-profit health systems) marshals sufficient public attention and shame forces reconsideration or retraction of Pharma’s lazy over-reliance on raising ‘P’ (Price) vs. the more complex market challenge of driving ‘U’ (units via share gains) becomes their duty and ultimate measure and basis of ‘success’.

So thanks BO! Despite all odds, you (and Max Baucus et al) pulled it off. And yes, it’s only a beginning and there’s lots of work to do. In the words of then Acting CMS Administrator, Don Berwick, who was wrongly blocked (by you know who) for permanent appointment [I paraphrase below]:

This will require no less than an all hands of deck, full court press to make happen [i.e., the triple aim].

 

Accountable Care, Affordable Care Act, health innovation challenges, public health

‘Non-Profit IDNs’: Where’s Da Beef?

Admin

By Gregg A. Masters, MPH

I have followed this narrative for quite some time albeit inside the industry contained debate of whether so-called ‘non-profit’ [501(c)3] hospitals or their parent systems (really more aptly characterized as “tax exempt”) actually earn this financial advantage via material ‘returns’ to the communities they serve.

NASI_Goldsmith studyAs can be expected you have the party line of the American Hospital Association (AHA) a trade group of predominantly non-profit members vs. that of it’s for-profit brethren The Federation of American Hospitals (FAH). You can guess which side of the argument each of them favor.

Now thanks to a recently published landmark study ‘Integrated Delivery Networks: In Search of Benefits and Market Effects’ by Healthcare Futurist Jeff Goldsmith, PhD et al, of the 501(c)3 cast of characters in the related but more often than not distinctly different ‘IDN culture’ we extend that line of inquiry into what has been a somewhat conversational ‘safe harbor of sorts’ – not any longer?

The Executive Summary notes both the rationale and basis to study the market ‘incident to’ a more focused pricing (via asset concentrations) power line of inquiry:

In January 2014, the National Academy of Social Insurance commissioned a study of the performance of Integrated Delivery Networks (IDNs), incident to its Study Panel on Pricing Power in Health Care Markets. The premise of this analysis was that any examination of the role that hospitals play in health care cost growth is complicated by the fact that in most large markets, the significant hospitals are part of larger, multi-divisional health enterprises. In these markets, hospitals may be part of horizontally integrated hospital systems operating multiple hospitals; vertically integrated health services networks that include physicians, post-acute services and/or health plans; or fully integrated provider systems inside a health plan (e.g. with no other source of income than premiums) like Kaiser Permanente. The latter two models are collectively labeled IDNs.

IDNs have very different stated purposes than mere collections of hospitals: to coordinate care across the continuum of health services and to manage population health. IDN advocates claim that these complex enterprises yield both societal benefits and performance advantages over less integrated competitors. The purpose of this analysis is to evaluate the evidence to support these claims.

And now for the less than surprising but wholly unacceptable answer albeit modestly caveatted by the limits of publically available information:

Despite more than 30 years of public policy advocacy on behalf of IDN formation, there is scant evidence in the literature either of measurable societal benefits from IDNs or of any comparative advantage accruing to providers themselves from forming IDNs. We have similarly found no such evidence in our analysis of 15 IDNs. Serious data limitations hamper anyone attempting to evaluate IDN performance based on publicly disclosed information. IDN financial disclosures obscure the operating performance of their hospitals and physician groups.

There does not appear to be a relationship between hospital market concentration and IDN operating profit [emphasis mine]. However, if the performance of the IDN’s flagship hospital is any indicator of overall systemic efficiency, the IDNs’ flagship hospital services appear to be more expensive, both on a cost-per-case and on a total-cost-of-care basis, than the services of its most significant in-market competitor.

This runs counter to the theoretical claim of IDN operating efficiency. Further, the flagship facilities of IDNs operating health plans or having significant capitated revenues are more expensive per case (Medicare case-mix adjusted) than their in-market competitors.

The authors would have greater confidence in these findings if they covered not only multiple years of information but also multiple institutions in the IDN portfolio (e.g. its suburban or rural hospitals, etc.). Further, the central question of whether IDNs have abused their market power in metropolitan markets can only be answered by examining actual service-specific payments to their hospitals by local health plans and by determining the profits generated by their hospital portfolio.

NASI_Goldsmith study_cohortI am struck by the reaction or better yet absence of a reaction in public discourse let alone in health wonk or big data evangelists circles particularly at time when there’s been so much mis-direction and battle fatigue surrounding the endless debate/efforts at repeal of the Affordable Care Act.

Such a profound observation and ‘counter intuitive’ result (i.e., ‘hey, there may not be a there, there insight’) based on frequent accolades and ‘innovation’ recognition extended to such trophy name plates as Kaiser Permanente, Geisinger Health, InterMountain Health and so little public debate (see complete list) causes me to question whether we’re paying attention to what matters?

How can we intelligently debate, discern and buildout the qualities and characteristics of financing and delivery system platform efficacy and business model innovation that delivers on the triple aim and lays a solid foundation for a sustainable healthcare economy if we do not understand their root DNA and the results (“community benefit”) they ostensibly generate?

Anyone?

Accountable Care, ACO, Affordable Care Act, digital health

ACA, Accountable Care and the @HealthcareGov Fiasco

Admin

By Gregg A. Masters, MPH

With the quiet time afforded this ‘Thanks Giving-Kah’, I feel called to express some ‘dis-ease’ with the progress towards our pursuit of the triple aim or sustainable healthcare ecosystem.

healthcareGov cartoon

As if the health reform battle hasn’t been a power partisan exchange from day one. Think again…

If you weren’t paying attention during the run up to the Act’s passage in March of 2010, be reminded that the process was NOT imbued with the goodwill and fair consideration of grounded health policy arguments – both pro and con – to vet what might emerge from our bi-cameral legislative process and stand in the marketplace of ‘workable reform’.

But who among us could have predicted that health information technology performance or more accurately the lack of said ‘e-commerce performance’ might emerge as the likely candidate fulfilling the oppositions’ intent to stand in the way of ‘real’ health insurance for some 75 millions Americans?

Seriously HealthIT as the tipping point in the demise of the Act? Who saw that? As noted by a colleague on twitter:

Margalit Gur-Arie ‏@margalitgurarie 20 Nov
@2healthguru Oh yeah If someone said a year ago that Obamacare will fail on account of technology, I would have laughed them out of the room

In the midst of 46 attempts by the Republican controlled House to defund or repeal the ACA, a tapestry of lawsuits filed by AGs in ‘red states’, an unexpected SCOTUS affirmation of the law coupled with ‘discretionary’ state participation in the Medicaid expansion provision, and relentless Tea Party backed efforts to tag the Act as the end of freedom itself and the institutional permanence of ‘big government’ in the lives of all Americans – what most failed to appreciate is the market based nature of the effort. Health reform and the provisions in the Act express macro trends deeply rooted in the connective tissue of provider/payor/patient/consumer marketplace experience, wholly independent of the exquisitely orchestrated though faux political narrative – the crown jewel in the playbook of ‘weapons of mass deception’.

I have been in the ‘managed competition’ side of this business for 3+ decades and often can’t understand the nature of the beast we’ve created. The ‘healthcare conundrum‘ so aptly coined by Atul Gawande quite some time ago is a complex and unwieldy beast I have affectionately tagged the ‘healthcare borg‘ as a reference to the ‘resistance [as in change] is futile’ reference in Star Trek. Yet, many who lack even an undergraduate grasp on the nature of the American sick-care economy are unreasonably certain in their opinions on the nature of the malady and what might pass as proper remedies. Unfortunately, this certainty seems to be rooted in cheerleaders who might be characterized as ‘frequently wrong, but never confused.’

In this absence of anchorage to facts and contextual truths where is one to start in an ideological fueled echolalia of lies, misrepresentations, partial truths architected by armies of K-street funded special interests and their partner PR machines? Unfortunately for the rest of us K-street and the balance of the often morally bankrupt (chase the buck) beltway bandits find gold in them their hills of fueling ‘conflict’ as a contractual or ‘annuity solution’ to their recurrent ‘bill-ability’ concerns.

Let’s be clear. If the ACA were repealed do you think any of the macro trends would slow or reverse? Would Accountable Care be set aside for an ‘unaccountable care’ status quo? How about the movement into value based or performance based payment? Might this be moved to the quicksand of failed ideas while the return to fee for services ‘happy days’ plays on and on? Will selective movement into direct or retainer based medicine somehow disappear as well (note the return to direct practice is merely the reinvention of the HMO only in more micro practice terms)? Or will care management and coordinated care be seen as merely a passing fad with an immediate return to silo based episodic care and unit revenue or pricing maximization? I don’t think so…

None of these granular market tectonics would reverse if the Act were to be defunded, repealed or somehow re-litigated in the court of public opinion or elsewhere.

So let’s place the change or transformational energy impulse where it can best serve us. Since we’ve just recognized the 50th anniversary of the tragic JFK assassination I’m reminded of this bit of timeless wisdom:

‘if you’re NOT part of the solution, you are [part  of] the problem.’

Have you looked in the mirror lately?

Accountable Care, ACO, Affordable Care Act, health reform

ACOs ‘In the News’

Admin

Gregg A. Masters, MPH

heritage masthead

As the drip, drip, drip of the reported collateral fallout – both perceived and actual – of the stalemated resolution of the Federal shutdown makes it way into the American psyche we’re also seeing reports from the front on the success, indifference or failure of the ‘ACO vision’ to successfully pivot the healthcare borg from a fee-for-services (volume) to a fee-for-value paradigm.

Today’s news reports on two entities with which I am somewhat familiar – Texas Health Resources (THR) and Heritage Medical Systems (Heritage Provider Network) both parents respectively of first generation CMMI Pioneer plays. I served as the Vice President for Managed Care and Network Development at THR’s branded affiliate ‘Wellspan Health Network” (including System Health Providers (SHP) and consulting roles to Genesis Physicians Group) pre and post merger of Presbyterian Healthcare Resources and Harris Methodist Health System into THR, while at Heritage Southwest Medical Group, I championed provider network development and management including capitating specialty services for a global risk contracts.

Sourced from: ‘Digging Deeper: Lessons from an ACO Success Story.‘ Texas Health Resources

Perhaps framing the irony surrounding the confused narrative associated with the signature accomplishment of this President against a history of persistent previous legislative failure, the author notes:

We all know that the word “Obamacare” elicits immediate emotion from a good chunk of the American public. Thanks to late night TV host Jimmy Kimmel, and a media poll or two, we know that the words Affordable Care Act (ACA) do not elicit the same kind of emotion.

This only makes sense if you can buy with a straight face the sensibilities of the Tea Party cheerleading line of ‘keep your stinkin’ Government hands off my Medicare’ rant.

Meanwhile, the decisions of these two entities shed light on the underlying motivations likely to be driving in one case the decision to ‘step down’ in the risk ladder (THR) while in the second expressing a warp speed determination to proactively manage the risk exposure and deliver on the triple aim.

The author cites THR’s CIO Ed Marx aka @marxists on twitter as follows:

[THR] ….wanted to avoid paying a penalty, but was still focusing on ACO efforts. 

Whereas, Jonathan Gluck senior executive and counsel at the Heritage Provider Network notes, we’re:

…all in on the program.

This differential approach to risk is illustrative. Both entities at least in the Texas market have erratic performance. Heritage Southwest Medical Group ultimately declared bankruptcy during the global risk days in the late 90s, while THR returned to it’s hospital roots when the succession leadership vetting was over and the insurance culture of the then CEO of Harris Methodist Health System demurred to the predominant hospital culture of the Presbyterian leadership (aka the Smith v Hawthorne succession dance) by selling the Harris Methodist Health Plan to PacifiCare Health Systems.

It should come as no surprise that a physician organization untethered in any material ‘bricks and sticks’ sense to hospital infrastructure other than a drawer full of partial (at best) risk contracts should embrace the Pioneer model; whereas a hospital system even in partnership with a risk savvy physician organization the likes of ‘NTSP’ aka North Texas Specialty Physicians (_NTSP_), the JV partner in the Pioneer ACO) would step down and recalibrate their pathway options into this value shift.

The jury is out whether institutionally led health systems can re-engineer their culture let alone their asset portfolio to meet the vision quest of the triple aim via ACO intermediaries. If I were a betting man, my money would be on Dick Merkin and Mark Wagar, et al to tame the unrestrained appetite of the often maldistributed, excess capacity and misaligned production based assets.

Accountable Care, ACO, Affordable Care Act, health reform

The ACO Innovation Summit

Admin

By Gregg A. Masters, MPH

One of the few ACO gatherings I’ve missed since the birth of the industry (and there have been quite a few since there are ‘experts’ everywhere), but the line-up NEHI put together is well worth a look.

Both Steven Shortell and Molly Coye are definitely change agents on the front lines as is the balance of the faculty. Molly is pulling levers of a major institution with, some might say, an impossible reinvention agenda given its governance complexity and cost efficiency obstacles – unlike many other private institutions similarly challenged, while Shortell has a pulse on the healthcare ecosystem DNA, the macro policy dynamics of managed competition, and the empirics of business or service delivery models that work.

 

Thanks to the organizational initiative of NEHI staff. A bit of a delay (this is raw footage), but fast forward to 9:10 mark for introductory remarks by NEHI President Wendy Everett, ScD. About NEHI:

‘…NEHI is a nonprofit, health policy institute focused on enabling innovation that will improve health care quality and lower health care costs. Working in partnership with members from across the health care system, NEHI brings an objective, collaborative and fresh voice to health policy. We combine the collective vision of our diverse membership and our independent, evidence-based research to move ideas into action.’

As discussed elsewhere the battle at the moment is for the narrative on ACOs and by proxy the Affordable Care Act aka “Obamacare”. For context see: The ACO Narrative: ‘Accountable Care 2.0 is a Journey, Not a Program’ or ‘ObamaCare is Toast’? 

 

Key take-aways from the summit included:

  • ACOs necessitate thinking about “packaged” innovations – the organizational culture, process improvements, and payment models that surround a particular innovation.
  • Bundled payments, global budgets and other new ACO payment innovations are beginning to create the “markets for health” that will move the system from a culture of care to a culture of wellness.
  • In an ACO world, physicians require comparative effectiveness research, real world evidence, and ongoing guidance from industry to achieve improved patient outcomes.
  • ACOs are transforming the research landscape by turning previously unintegrated health systems into research organizations.
  • ACOs have created new opportunities for cross-sector partnerships to share data and enhance the pace of innovation.
ACO, Affordable Care Act, MSSP, Triple Aim

CMS Call: Tips on Submitting Application for Medicare MSSP ACO

Admin

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: