Accountable Care, ACO, Affordable Care Act, population health

Another Milestone Marker in Favor of the ACO Model?

by Gregg A. Masters, MPH

I awoke this morning to an email from a PR rep who supports outbound news for one of the emerging ACO management companies enabling physician led participation in the Medicare Shared Savings Program (MSSP) aka Aledade (@AledadeACO).

I then copy, pasted and tweeted the headline: ‘Aledade Creating New Medicare Accountable Care Organizations in Seven States.

I usually ignore ‘PRs’, yet this announcAledade newsement is material as it lends support via a growing body of evidence on the viability of the ACO model and its enabling ‘consciousness’ if not ‘sentiment shift’ in the prevailing market narrative.

While some still slam the ACA – and by proxy it’s ACO ‘workhorse’ – via relentless yet ‘diminishing returnsimpact of the ‘government takeover‘ fear mongering fueled by strategically sourced oppositional research, there is a building steady body of evidence supporting both the model and the broader context of efficacy of the competitive dynamics the ACA has unleashed on the stewards of our at risk (some say collapsing) healthcare economy.

Ergo my tweet:

Aledade news tweet

Ever since the Senate Finance Committee took up the debate and relentless series of ‘amendments‘ proffered by the ‘Rs’ trying to ‘improve‘ the proposed legislation that eventually emerged as the Patient Protection and Affordable Care Act (I NEVER use the pejorative term ‘Obamacare’), I’ve been a voice in the narrative of trying to get the facts of competitive market dynamics into the post political conversation around reforming our complex healthcare economy.

This is no easy task as the complexity of both the political process and objective reporting of how legislation becomes law including its contextual historical narrative is addressed in ‘A Legislative History of the Affordable Care Act: How Legislative Procedure Shapes Legislative History.

A challenge recognized upfront via admittedly ‘apolitical’ or ideologically agnostic ‘law librarians’ (yeah, you know those agenda driven bullies):

“Using the health care legislation passed in 2010 as a model to show how legislative procedure shapes legislative history, this article posits that legislative procedure has changed, making the traditional model of the legislative process used by law librarians and other researchers insufficient to capture the history of modern legislation. To prove this point, it follows the process through which the health care legislation was created and describes the information resources generated. The article concludes by listing resources that will give law librarians and other researchers a grounding in modern legislative procedure and help them navigate the difficulties presented by modern lawmaking.”

Since social media was starting to pick up in 2009 – 2010 time-frame, and given the angst associated with the public’s consumption of the ACA, I started ACO Watch and latter the hashtag #healthreform to track tweets associated with ACA consideration.

None-the-less, 5 years later the disinformation campaign persists though some of the pieces of the ACA are starting to show some promise of the law’s original intent. ACOs often referred to as a flawed model, perhaps an ACO lite if you will or too little too late to make a difference, the emerging datasets (both government and private market tea leaves) are building a case that the law is working.

Tomorrow on PopHealth Week, join my colleague, co-host and co-founder Fred Goldstein as we chat with Aledade Founder and CEO Farzard Mostashari, MD. This month we’re conducting a series on Population Health and ACOs talking to leadership from each ACO type: physician led, hospital sponsored and health plan enabled.

Listen here! We’re live 12 Noon Pacific/3 PM Eastern, and on demand thereafter.

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Accountable Care, ACO, Affordable Care Act

Three Reasons Your ACO Will Likely Fail

by Gregg A. Masters, MPH

I’ve seen this before, and many times at that, see: 6 Reasons Your ACO Will Fail (A Series), Any One Will Do.

While some continue to debate and attempt to repeal the Affordable Care Act, the underlying market dynamics on which the vision of ‘Accountable Care‘, the triple aim or a sustainable healthcare ecosystem has risen continues to spawn innovation and remains remarkably intact.

Yet ACO’s are the workhorse in the mix of this triple aim enabling ACA magic and will remain so (until and unless the Medicare Advantage special interests prevail in their advocacy of an ‘end-run’ from ACOs direct to ‘MA’s’ aka global risk bearing HMOs).

But back to my premise…

Reason One Your ACO Will Likely Fail

The first impulse is to put ‘form’ (vs. function or culture) at the top of the agenda. I like to call this the ‘O,G & E‘ (organization, governance and equity) card. Just vision a typical process which plays out over and over again. An entity (usually a hospital or hospital system with access to capital) retains ‘advisers’ presumptively qualified to educate and guide local leadership into focused consideration of a ‘journey’ away from if not antagonistic to their core operations and culture.

First up are the lawyers, then accountants and consultants who address the business risk profile, regulatory environment, competitive landscape and outline structural models or options of organizing and participating in this new line of business consistent the mission, objectives and tax status of the ‘host’ enterprise.

Right from the outset the focus becomes the form of the organization and not it’s vision nor underlying or enabling culture per se. While these considerations may be part of the mix, breathing life into this sensitivity and operational awareness is usually seen in the designation of one or more hospital or health system friendly physicians to represent the balance (ergo interests) of the medical staff tribe. We’ve seen this in PHO formation, or the underlying management services organizations (MSOs), JV’s, etc., to support their operations. But make no mistake the ‘deliverable’ is a timeline, top down, check the box type strategy where the meter is running and things need get done whether they’re layered on quicksand or ‘terra firma’ so to speak.

Reason Two Your ACO Will Likely Fail

It’s about the right kind of ‘leadership’. More often than not the DNA guiding these conversations and shortlist of implementation decisions are principally healthcare leadership typically sourced from ‘institutional’ (hospital, health system or more recently IDN circles) vs. physician leaders who ‘see the [arbitrage] light‘, i.e., principally those trained in leadership (whether at the level of MBA’s or a scheduled participation via off-site Estes Park like medical staff/administration co-management team building efforts), have historically participated in managed care v1.0 et sequelae, AND actively value the transformation imperative under consideration.

Add this to the fact that the most appropriate physician leaders in this volume-to-value transformation are primary care physicians, yet the true power brokers in the institutional setting are the cash cow volume based specialties including cardiology, orthopedics, and neurosurgery, and fill in the blank proceduralists. PCPs have for the most part been carved out of inpatient culture and stay relatively focused on the ambulatory or outpatient side of medicine. A trend that began a while ago as the credentialing process assured a growing economic turf war as to who got to do what in the hospital, and was sealed by the industry move to the ‘hospitalist’ as the go-to inpatient specialist.

Reason Three Your ACO Will likely Fail

Rick Scott the former CEO of the disgraced Columbia/HCA hospital system (and now sitting Governor of the State of Florida) who earned that system a record $1.7 billion fine and with whom I routinely and vehemently disagree with, best framed the volume-to-value shift as follows:rick scott quote

While this quote may be another carefully crafted (some may say devious) calculus as Scott continues to oppose the ACA and Medicaid expansion in the ‘Sunshine State’ (see: ‘Gov. Rick Scott officially convenes commission on hospital spending‘ ), it none-the-less accurately reflects why institutional leadership will neither proactively nor aggressively pursue a revenue cannibalization strategy. Disruption as he noted must come from ‘outside’, however in this case outside comes in the form of hospital asset untethered ACOs driven by prudent resource allocation, access and quality in their service area.

Until hospitals become ‘cost centers‘ (as in Kaiser Permanente) vs. the traditional revenue plays they’ve no doubt perfected while hospital based care drives the cost of healthcare UP, this is mostly rhetoric to buy time and sometimes exit packages of oft overcompensated senior executives both in the 501(c)3 sector as well as their more transparent though similarly for-profit oriented health system operators.

So don’t hold your breath until the Kaiser Permanente model becomes the defacto clinical integration and financing standard in the U.S., but do watch what former ONC Director for Health Information Technology evangelist turn healthcare disruptor and entrepreneur at Aledade (a physician led ACO management company (MSO) – see ‘Waiting For ACOcor) Farzad Mostashari MD is up to. That Venrock and Bob Kocher in particular are rallying behind this model says a lot to me.

Bottom Line

Your ACO will fail if it’s of the institutionally led, top down, corporate check the box variety, and not imbued with the full court press commitment (so eloquently espoused by Don Berwick) of the required culture of health values to achieve the triple aim. Your ACO’s DNA must truly be truly disruptive from the bottoms up AND willing to can·ni·bal·ize  traditional hospital cash cow revenue streams.

That’s a lot to ask. Building that bridge in a quarterly earnings per share mindset maybe a bridge too far. Just ask Greg Samitt, see; Eating Glass?’: A DaVita Healthcare Partners Hiccup or Impending Physician Integration ImplosionHe tried to bring that bridge forged at Dean Clinic (scaled movement from production to value) at Healthcare Partners (Da Vita) but for reasons unclear to me was prematurely asked to leave.

For some of my experience on this journey, see ‘Some Context and Perspective on Standing Up The ACO‘.

Accountable Care, ACO, Affordable Care Act

Farzad Mostashari MD Unbundles the ‘Healthcare Borg’ at Engage

By Gregg A. Masters, MPH

I have been following the career of Dr. Mostshari since his tenure at ONC as Director of the Office of the National Coordinator for Health Information Technology.

Upon learning of his launch of the startup ACO management company Aledade, we posted some thoughts here and here.

Yesterday at MedCity Media’s ‘ENGAGE’ conference in Bethesda, Maryland he literally tutored the in-person audience as well as many others following the feed via Google Hangouts, or the twitter stream tagged #mcENGAGE. Mostashari illuminated both the burning platform nature of the ‘business as usual’ through a prism of ‘good for doc’, ‘good for patient’, ‘good for society’, as well as probable indicia of the likely solutions. This is a masterful performance by a physician executive turned entrepreneur worthy of widespread distribution. Apparently there’s quite a bit more to Mostshari than EHR adoption and the national e-connectivity backbone.

Enjoy!

Accountable Care, ACO, Affordable Care Act, HealthIT

Catching Up with Farzad Mostashari, MD: An Aledade Preview at HiMSS 2014?

By Gregg A. Masters, MPH

The HealthInnovation Media footprint was again on the ground at Health Information Management Systems Society (HIMSS) 2014 in Orlando, Florida. One of the privileges I enjoy as producer and creator of all digital content generated is I get to tag interesting people to put in front of the camera including suitable hosts for each interview segment.

In this shoot we meet with former Director of the Office of the National Coordinator for HealthIT and now Founder and CEO of ACO management company Aledade, Farzad Mostashari, MD.

The interview was masterfully handled by industry veteran and colleague Neil Versel.

Enjoy!

Accountable Care, ACO, Affordable Care Act

Meet Aledade An ACO Management Company Putting Docs at the Head of The Table

By Gregg A Masters, MPH

farzad mostashari MDWhen Farzad Mostashari, MD not too long ago sported a Federal business card his principal mission was to stimulate and evangelize the adoption of electronic health records (EHR) in his capacity as the lead official for the Office of the National Coordinator for HealthIT (ONC). This important market transformational role was enabled by the American Recovery and Reinvestment Act (ARRA), and in particular the provisions to ‘HITECH‘, the Health Information Technology for Economic and Clinical Health Act signed into law on February 17, 2009:

‘to promote the adoption and meaningful use of health information technology.’

Amidst ‘silo-ed medicine’ the enabling role of health information technology and specifically EHRs to the care management, care coordination and generally the principal upside of the ‘managed care’ vision has been recognized for quite some time. In fact, ‘clinical integration‘, i.e., a network wide EHR platform, shared by independent physicians who were otherwise competitors in a specific market (absent legal integration) was one of the exceptions if not ‘safe harbors’ to antitrust vulnerability.  In other words, a ‘shared healthIT spine’ of sorts allowed physicians to collaborate with each other without getting ‘married’ – if you will.

Since the passage of the Affordable Care Act (ACA), the ‘urge to merge’ is strong particularly at the hospital or institutional health system level, with many corporate parents acquiring medical practices at a pace unwitnessed during the prior ‘integration generation’ circa the 1980 – 2000 vertical integration and subsequent turbulent unwinding timeline.

Inside the ACA the majority of the ‘chop wood and carry water’ provisions of the anticipated transformation or ‘disruption’ are clearly laid at the doorstep of ACOs and the broader ‘accountable care’ framework it has set into motion via both Government and derivative private sector initiative.

Inside this market shift and not un-noticed by many healthcare ecosystem stakeholders (both pre and post passage of the ACA), many argued for the modulation if not regulation of the institutional ‘integration impulse’. Absent restraint, many provider mergers would amount to de-facto ‘too big to sail’ (i.e., more costly) enterprises via asset concentration for anti-competitive pricing leverage. Against this ‘unintended consequence of the law’ (more costly vs. less) some have stepped  up to lend support to physicians as the principal organizers and aggregators of clinical delivery (if not financing) assets. The theory goes, un-beholden to costly hospital infrastructure, physicians are the ‘free and informed agents’ to competitively purchase and allocate needed clinical assets across the care delivery continuum.Aledade ACO

Clearly the wildcard in this formula is an ’empowered network of physician aggregators.’ Since most physicians are NOT infrastructure nor business savvy per se, a third party enabler to harmonize performance around this ‘triple aim’ (better care, better outcomes, lower costs) fueled vision is essential.  In other words, build and support the crosswalk from volume value where care is not incentivized by unit volume to support incomes and lifestyles but what’s right for the patient.

Enter ‘ACOcor’ (see: ‘Waiting for ACOcor?‘) as in Aledade, the new vision and initiative of Farzad Mostashari, MD and his capital partners at Venrock, specifically ACA advisor Bob Kocher.

Today on ‘This Week in Health Innovation‘ with my co-host Dr. Phil Marshall, we chat with Dr. Mostashari about his vision at Aledade.

 

Accountable Care, ACO, Affordable Care Act

Former ONC Director Farzad Mostashari, MD Launches @AledadeACO

By Gregg A. Masters, MPH

Aledade ACOOn July 8th 2011 I penned a blog post titled: Waiting for ACOcor? pondering the question of whether this time will be different in the managed competition positioning dynamics we’re likely to witness post roll-out of the Affordable Care Act. Afterall, the ‘chassis’ on which to graft if not build an ACO can be found in iterations of prior physician led vehicles including IPAs, medical group Medicare Advantage contractors and even PHOs (Physician Hospital Organizations) where the ‘institutional partner’ (ie, the ‘H’ hospital) serves as a limited partner to the medical group or IPA which operated the PHO as ‘the general’.

Today we learned that the former Director of the Office of the National Coordinator for Health Information Technology, Farzard Mostashari, MD has launched – with an infusion of $4.5 of investment capital from Venrock and Bob Kocher, MD taking the lead – an ‘ACOcor’ of sorts tagged ‘Aledade‘.

Mostahari outlines his rationale and reasoning pathway to this ACO consulting and turnkey management company as follows:

Today, I’m launching a new company, called Aledade.

Aledade partners with independent primary care physicians to make it easy and inexpensive for them to form and join Accountable Care Organizations (ACO) in which doctors are paid to deliver the best care, not the most care.

This is good for patients who will find that their trusted primary care doctors are more available and better informed than ever before. It’s good for doctors who want to practice the best medicine possible, the way they always wanted to. It’s good for businesses and health plans looking for healthcare partners that deliver the highest possible value and outcomes. And it’s good for the country as higher quality, lower cost care will help lessen the strain on our budget and our economy.

The world of start-ups may not be the usual path for those leaving a senior federal post, but it’s the right decision.

For me, Health IT was never the “ends,” but a “means” to better health and better care, and I continue to believe that better data and technology is the key to a successful transformation of health care. And it is why the attempts to do so now can succeed, where they have failed before.

Empowering doctors on the frontlines of medicine with cutting edge technology that helps them understand and improve the health of all their patients- that is the mission of our new company, and one that has animated my entire career.

During the seven years I spent working for Tom Frieden and Mike Bloomberg in NYC, it was exhilarating to be able to push the frontier in what was possible — to innovate at the edge.

Working with my team, we were able to: invent new statistical methods for outbreak detection , develop new data visualization methods, create visibility into population health down to the neighborhood level, bring decision support and rapid diagnostics to the point of care, automate electronic quality measurement, and implement novel financial incentives and hands-on technical assistance to support care transformation in small independent primary care practices. It was exhilarating.

When I moved to HHS in 2009, the transition to federal service also meant a change in perspective.

As the National Coordinator for Health IT, my key responsibility was now to ensure a minimum national “floor.” We had to push the country as a whole towards a common core set of data and capabilities. We applied creativity and grit to do what needed to be done, using the best tools available to us: encouraging the private sector; organizing and scaling state and local efforts like the inspiring work of the regional extension centers; and — yes — through the blunt instrument of regulations too.

I’m extremely proud of the work we did, and the foundation we put in place. The country is in a massively different place, and the age of data has finally come to healthcare. But in that role, I was also acutely aware of the compromises and incremental half-steps that have to be taken when the goal is to move an entire nation. I was inspired by those that pursued improvement not “compliance” and did not mistake the floor for a ceiling.

I’ve had the good fortune for the past nine months to be ensconced among some truly great thinkers at the Brookings Institution, and to go on a “walkabout” – talking to and visiting with leading practitioners throughout healthcare. I have come away with a rare stereoscopic view of the changes sweeping through health care — the anxiety of those with “one foot on their old business model’s grave and the other foot on their new business model’s banana peel”, mingled with the excitement of those who would disrupt the status quo.

And during this process, I have also found my cause.

It’s to help independent primary care doctors re-design their practices, and re-imagine their future. It’s to put primary care back in control of health care, with 21st century data analytics and technology tools. It’s to support them with people who will stand beside them, with no interests other than theirs in mind. It’s to promote new partnerships built on mutual respect, and business arrangements that will truly reward them for the value that they uniquely can bring- in better care coordination, management of chronic diseases, and preventing disease and suffering. It’s to achieve lower cost through better care and better health.

I believe in this. And this is the mission of our new company. And to realize it, we will be back at the vanguard, helping to lead this transformation in health care that has been underway for years but is quickening and coming faster than ever before.

This is clearly an idea who’s time has come – in fact, it’s been here a while. Yet the white water of health[care] ecosystem reform remains, witness: Universal American: A Sign of Things to Come?  The key strategic question is: can Aledade build upon and leverage the collective experience and insights of the past in the development of independent physician networks (IPAs) or their management companies (MSOs) to put physicians back in control via risk assumption at the population health level? In other words, can they succeed in tapping if not channeling the vital community physician leadership to deliver on the culture as well as the mission critical objectives (i.e., the triple aim) of the ACA levied principally on the ACO community writ large?

Clearly Mostashari’s work in building out the HealthIT infrastructure and population health connectivity that enables the vision if not spine of any ACO or accountable care initiative (better care, better outcomes & lower per capita costs) is mission critical insight. Improvements in healthIT and reach of REC’s (Regional Extension Centers) is one big difference since the ambitious if not technologically ‘pre-mature’ launch of Healtheon and the associated rise and collapse of the PPMC (physician practice management company) industry. [Editor’s Note: For additional PPMC context, see ‘The ‘Medical Aggregators’: Are We Entering Round Deux?’]

This one is worth watching very closely!