Accountable Care, ACO, Affordable Care Act

The Evolution of ACOs

by Gregg A. Masters, MPH


Recently the accountable care industry’s leading ‘skin in the game‘ PPMC 2.0 aka ACOcor equivalent (think PhyCor, MedPartners, FPA Medical, et al) of our time – though Aledade’s model is anything like the pyramid scheme of the PPMC (physician practice management companies) of the 1990s, reviewed the Center for Medicare and Medicaid Services (CMS) recent Notice of Proposed Rule Making (NPRM): CMS Proposes “Pathways to Success,” an Overhaul of Medicare’s ACO Program‘. 

Below are key take-aways from the presentation. The entire webinar is accessible free upon registration here

I will post the Q & A thread that Farzad Mostashari, MD, CEO and Travis Broome, VP, Health Policy, respectively Aledade shared on twitter as well.

Meanwhile, here’s the gist of their analysis and message:

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Accountable Care, ACO, Triple Aim

ACOs in the Medicare Shared Savings Program (MSSP): Is There a Fix?

by Gregg A. Masters, MPH

The Center for Healthcare Quality and Payment Reform just released ‘How to Fix the Medicare Shared Savings Program‘ with lead author and long term managed health care industry veteran Harold D. Miller, its President and CEO. 

Some six (6) years into the Affordable Care Act (ACA) provisions specific to Accountable Care Organizations (ACOs) the results remain mixed at best, and like the serial tweaks made to the Medicare Advantage Program, now covering some 30% of Medicare beneficiaries, the underlying ACO structural characteristics and enabling health policy regulations remain ‘on the come‘ for this still nascent and evolving delivery system model.

For the many critics of ACOs as a form of an ‘HMO lite‘ in the fee-for-services Medicare market, with none of the channeling characteristics commonly associated with HMOs, this comes as no surprise.

In this just released report, Harold Miller weighs in on the fix he sees essential for the program to achieve it’s cost containment and quality improvement objectives.  The executive summary is posted below and the full report is available here.

Executive summary:

Rather than generating savings as expected, the Medicare Shared Savings Program (MSSP) has created losses for the Medicare program for four years in a row.

Calculations by the Centers for Medicare and Medicaid Services (CMS) appear to show that ACOs with downside risk produce higher savings than the “upside-only” ACOs. However, Medicare actually spends more per beneficiary in the downside risk ACOs than in other ACOs, with no difference in quality. Moreover, ACOs that have moved to the downside risk tracks have saved less after doing so.

The risk adjustment and benchmarking formulas used by CMS can penalize ACOs that serve higher-need patients and patients living in rural areas. The greater savings attributed to downside risk ACOs may have more to do with differences in the types of patients they see than differences in the way they deliver care.

Concerns about the problems with the risk adjustment and benchmarking methodologies in the MSSP have made many ACOs unwilling to enter the downside risk tracks. Requiring all ACOs to move to downside risk could force successful ACOs to leave the program, thereby reducing Medicare savings and harming the quality of care for millions of beneficiaries.

There are other options for modifying the Medicare Shared Savings Program in order to increase Medicare savings, including dropping ACOs from the program if they fail to achieve savings after two consecutive years, reducing shared savings payments for ACOs that incur losses before achieving savings, reducing the shared savings rate below 50% for Track 1 ACOs, and/or enabling ACOs to take accountability for the specific types of services they can control rather than placing them at risk for
total Medicare spending.

Neither shared savings nor shared risk payment models solve the fundamental problems in the fee-for-service payment system. As a result, it is unlikely the MSSP will ever result in significant savings or improvements in quality, and it has the potential to harm patients by rewarding providers that withhold necessary services.

Instead of continuing to modify the Medicare Shared Savings Program, CMS should focus on implementing Patient-Centered Alternative Payment Models that provide the resources physicians, hospitals, and other providers need to successfully address their patients’ healthcare needs while holding the providers accountable for those aspects of spending and quality they can control.

Twitter Dialogue on ACO Results Reported

Today on twitter there was a representative exchange from both sides of the ACO narrative which I’m posting below for context:

MANas8U's avatar

True! Yet innovation is not cheap + anything even moderately at scale in Medicare/Medicaid is definitely not cheap. Questions while innovating: What did we learn? How can we inform our future efforts? @policywonk1

danmunro's avatar

I would argue that the evidence is already in b/c the trajectory we’re on is easy to see – and forecast. Just labeling newer efforts of ‘cost containment’ as ‘innovation’ is like rearranging (in this case expensive) deck chairs.

danmunro's avatar

But that may be the same hymnal in title only: HC Reformation I don’t think #FFS is “an addiction” that needs #ACO or #VBP rehab and the evidence that #FFS works reasonably well around the world is compelling. We don’t need single-payer, but we absolutely need single-pricing.

A Sampling of ACO Leadership on the Center for Healthcare Quality and Payment Reform Report and Associated Remedies

Our Nation’s move from volume to value based care will not occur in one day. Transformation of our complex, misaligned and disjointed healthcare system will take the hard/smart work, dedication, risk and financial support from key stakeholders, including the largest being CMS. Transition to risk based/value based care is not an option, it is a necessity not only to save but successfully advance the US Health Care system. It is easier to point out problems, than to roll up our collective sleeves and develop innovative and outside the box solutions.  – Alex Foxman, MD, FACP, CMO, President and Co-Founder National ACO, LLC

The state of Florida is a great example of ACOs having success.  I believe this is true because we already have a vibrant managed care market.  Medicare Advantage makes a lot of people money but has not proved it has saved any.  It has only served to risk adjust a population for higher revenues.  ACOs, as originally designed, may only be ‘transitional’ but they are an important step toward shifting from volume to value payment models. We should expect the models will continue to evolve.  This shift is a jog not a sprint. The goal and focus should be on the “shift” not which model and flavor is the stepping stone along the way. – Nicole Bradberry, CEO and Chair of Board, Florida Association of ACOs 

ACOs in Florida reduced expense by $365,809,069, earned shared savings payments of $178,447,886 with a net benefit to the Medicare trust fund of $187,361,183. MSSP is working in Florida! We’re concerned that the success of the MSSP is being evaluated based aggregate ACO performance which includes ACOs who are not putting forth adequate effort. I know of at least 7 ACOs that have 2 or less employees. That’s not enough effort to make ANY business model work! Unfortunately their results are tabulated with others and cause the program to be inaccurately evaluated. We look forward to the required transition to downside risk as it will require those without much commitment to drop out. If you drop the minimum effort ACOs, we expect the aggregate ACO results will look different. This is PY 2016 data… –  David Klebonis, Chief Operating Officer, Palm Beach Accountable Care Organization & Chief Operating Officer, South Florida Accountable Care Organization 

One definition of literal fantasy requires only that we accept a single non-reality, after which the rest of the story becomes quite plausible. If that be the case, Mr. Miller has written a Best Seller. His entire analysis assumes that the CMS “Shared Savings” formulas reflect reality, when those of us that have really crunched the numbers know this is far from the truth.

Intentionally or not, CMS has built significant savings for the Trust Fund into the benchmark methodologies for both MSSP and NextGen. These range from the actuarial fallacies inherent in continuous attribution, successful ACO market share effects on the “Benchmark”, National Efficiency ratios that divert Benchmark dollars from high attribution areas to low attribution areas, risk score caps, automatic “discounts” and much, much more.

Still, it seems that our Florida ACOs consistently overcome the increasing headwinds and succeed. Additionally, CMS recognizes the problems in their own Benchmarking models and has tweaked these year after year, including the latest Proposed Rule submitted by MSSP to OMB earlier this month. I fear Mr. Miller is whistling past the graveyard on this one.

For a glimpse into a few of the methodology problems, see ‘Regional Benchmarking or Regional Bonus? Sustainability in the Medicare Shared Savings Program‘. – Richard J. Lucibella, CEO, Accountable Care Options

 

A Continued Search for Answers and Business Models

Further context sourced from the Florida Association of ACOs annual conference last year was provided by Aledade co-founder and CEO and former National Coordinator for Health Information Technology at the Office of the National Coordinator Farzad Mostashari, MD here.

Weigh In

So what do you think? Please offer your thoughts in the comments section. This is a dialogue well worth a broader exchange as our industry evolves perhaps even ‘pivots’ from it’s near term PCMH or ACO roots to a the valued based healthcare model – one that many refer to as a ‘Rorschach test’ of sorts – where any projection of what constitutes a value based model will do.
Please feel free to post any resources that support your take and we’ll happily include via our social reach. If any of you are inspired to author a guest post with references of citations, we’re happy to include at ACO Watch.

 

Accountable Care

In Pursuit of the Triple Aim: Can Population Health Management Lead the Way?

By Fred Goldstein, MS and Gregg Masters, MPH

Every sector in health care is under pressure to articulate and implement a viable population health initiative that delivers on the triple aim of better health, better quality at a better cost.

Despite a significant investment of resources, we have only achieved ‘mixed results’ to date, and so the industry remains in a continuous learning mode. Although we’ve taken away some insights, we still have a long way to go.

Recently on Pophealth Week, we chatted with the ‘Dean’ of Population Health who spearheaded and continues to steward the nation’s first freestanding College of Population Health at Jefferson University in Philadelphia. David Nash, MD, MBA weighed in on the industry’s evolution — including best practices to emulate —and what near term challenges we are likely to face.

To listen to Dr. Nash’s take, click here, and for additional context checkout The Road From Volume-To-Value: The Pivotal Role of Population Health.

If you’ve worked in this space – at the strategy or operational level — you know that it can be truly daunting to implement a population health program. This can lead some organizations to shy away from attempting meaningful programs, perhaps even into a copycat ‘me too’ effort. Given the inevitable drive to value-based care, it is a strategic imperative to understand how to build and implement population health initiatives that work.

In its simplest framework, one can think of a population health program in terms of the following components as articulated by the Population Health Alliance Outcomes Guidelines Report Volume 6,  2015.

The steps of the Population Health Framework as shown in the image above include:

  • Identify the population
  • Assess the person for risk(s)
  • Stratify the person into risk levels to target for various interventions
  • Engage the person in a program
  • Intervene with specific services and resources and
  • Measure the process and outcome results

These results are then fed back into the system and the process continued all seeking to improve the overall health of the population.

In Search of Answers

One forum many look to for best practices and key insights is the Population Health Colloquium, now in its 18th year with the Jefferson College of Population Health as academic partner. Scanning this year’s Agenda, one can find presentations in each of the elements above.

Data and Analytics are the essential ingredients of any population health program with intent to identify individuals, assess them for various risks or conditions, stratify them to ensure appropriate levels of intervention and measure a program’s success.

Within the area of assessment, we are moving to an ‘N of 1’ approach given the advances in precision medicine and genomics. This exciting area will be covered at the conference in the mini summit entitled Personalized Medicine, Machine Learning and Genomics: a Clinical Approach to Employer Population Health and Wellbeing.

Payment models and the move to value-based care are among the key levers. Although there have been more than a few stops and starts along the way with the change in administration at the federal level, employers are rapidly embracing these approaches.  There are a number of presentations on this topic, including Journey to Value-Based Care — Experience and Expectations, Accountable Care Atlas: Mapping a Path to Value-Based Care and a Mini Summit ACOs at an Inflection Point: Where the Movement is Headed and Why Some Succeed While Others Don’t.

In the Intervention area, there are presentations covering ‘On the Ground: Population Health initiatives’… and we can’t forget about the patients — they, too, have a strong role to play in these efforts. The Mini Summit, Improving Patient Care and Provider Experience through Population Health Management, is timely and informative.

Community-based programs have become all the rage as we better understand the impact on your health based on where and how you live.  A breakout track entitled Population Health in the Community includes discussions on life expectancy gaps in Chicago; Rural and Urban Issues; and primary care and behavioral health that will address some of the approaches.

The program will feature a session on designing and implementing population health, and of course there will be some incredible keynotes and small panel discussions. The program includes a discussion with two former HHS Secretaries, Tommy Thompson and Michael Leavitt, and baseball great Darryl Strawberry will discuss addiction, a critical issue we are now facing with the opioid crisis.

If you are committed to learning more about Population Health, this meeting is a must. It’s an event where you can learn from experts covering the full breadth of population health services and have an opportunity to network. Whether you choose to travel to Philadelphia or attend via live webinar, please plan to join us and stop by to say hello. We’d love to hear all about what you’re doing in this exciting space.

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This post is sponsored by the Jefferson College of Population Health

Accountable Care, ACO, Affordable Care Act

Center for Medicare and Medicaid Services Releases Accountable Care Organization Performance Results

by Gregg A. Masters, MPH

Friday, October 27th, the Center for Medicare and Medicaid Services (CMS) released details for participating Accountable Care Organizations (ACOs) in the Medicare Shared Savings Program (MSSP) for the 2016 performance year.  For reporting ACO results view the entire report here.

The National Association of ACOs (NAACOs) weighed in below:

The new results demonstrate the value of a premier Medicare alternative payment model and include a higher rate (56 percent)* of MSSP ACOs generating savings than ever before and an almost equal proportion as last year of ACOs that earned shared savings (31 percent).

This public update follows previously posted results for Pioneer ACOs, the Next Generation ACO cohort and the Comprehensive End Stage Renal Disease ACO (ESRD) care model here.

In table form, the results are summarized below:

All in, participating ACOs generated $843 million in gross program savings with a modest net savings of $78.6 million for Medicare in 2016, in addition to material gains in quality scores for aligned ACO Medicare beneficiaries.

While Clif Gaus, NAACOS CEO notes:

These results show the growing success of ACOs, which is a positive trend that should not be ignored. A lot has been accomplished in a relatively short amount of time, and ACOs are on the front line of redesigning healthcare delivery. This is a moment to celebrate them and their hard work.

The ACO ‘Jury’ Is Still Is Out

Given the range of models, risk assumed or gain sharing distributed operating results in a program that some still see as fundamentally ill equipped in a predominant fee-for-services market to materially change physician and beneficiary behavior – and thus enable the elusive ‘triple aim‘ – many in the health policy area including select ACO operators remain convinced to maximize impact the ACO model will ultimately morph into the more robust Medicare Advantage operating platform.

Perhaps the ‘stealth play’ in the mix is the potential upside of Next Generation ACOs to fully leverage their competitive advantages (3 day SNF waiver, telehealth visits, relaxed supervision requirements for post hospital discharge visits and the move to all inclusive population based payments) can up-level both their game AND improve outcomes at lower per capita costs?

On the next episode of This Week in Accountable Care, our very special guest is former Acting Administrator of CMS Andy Slavitt, now Senior Advisor to the Bipartisan Policy Center. Andy was initially part of the ‘fix it dream team‘ that righted the failed launch of Healthcare.Gov, and then presided over the administration of the Affordable Care Act.

Andy is rather familiar with the original intent of the ACA, its many ‘working parts’ and the bumps in the road to perfect the law via provider input, updated rule making and policy refinements.

We’ll get Andy’s take on a range of issues from the political environment to conflicting health policy guidance including broad brush advice to ACO operators.

Join National ACO co-founders Andre Berger, MD and Alex Foxman, MD as we engage this visionary and accomplished entrepreneur turned public service official in critical dialogue impacting the transformation of our industry from its fee-for-services roots to a new model based on a value and patient centricity.

 

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‘!

 

 

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.

 

Affordable Care Act, BCRA 2017

CBO Weighs in on Trumpcare 3.0

by Gregg A. Masters, MPH

The non-partisan Congressional Office weighed in today on the impact of the Better Care Reconciliation of of 2017 as amended and rebranded as the ‘Obamacare Repeal Reconciliation Act’.

Their summary notes the coverage impact as follows:

  • The number of people who are uninsured would increase by 17 million in 2018, compared with the number under current law. That number would increase to 27 million in 2020, after the elimination of the ACA’s expansion of eligibility for Medicaid and the elimination of subsidies for insurance purchased through the marketplaces established by the ACA, and then to 32 million in 2026.
  • Average premiums in the non-group market (for individual policies purchased through the marketplaces or directly from insurers) would increase by roughly 25 percent—relative to projections under current law—in 2018. The increase would reach about 50 percent in 2020, and premiums would about double by 2026.

On the fiscal impact the graphic lays it out below:  For a complete CBO report, click here