Accountable Care, ACO

On Lessons NOT Learned from Managed Healthcare v1.0 and Beyond

by Gregg A. Masters, MPH

First in a series of lessons NOT learned tweets to be enhanced and re-posted to @ACOwatch.

In the 80s Sanford C. Bernstein analyst Kenneth Abramowitz predicted for-profit hospital systems would dominate the market by 2000. One of the strategy ‘diversification arrows‘ in the quiver of hospital system executives was to enter the insurance market via managed care strategies of various strains. During this consideration phase, my then employer American Medical International (AMI) elected (against my counsel) to build its own insurance company dubbed ‘AMICARE’ vs. creatively ‘parter’ with the insurance sector. /1

Editors Note: See: ‘SuperMeds Hoping to Reshape System‘ by colleague Michael Millenson.

/2 Context: Abramowitz predicted the relative competitive under-performance of 501c3 hospitals & thus their parents. Too clunky and with the wrong governance structure they’d be swarmed by their more nimble for profit operators with easier access to the capital markets required to support a full range of acute care services.

/3 Hospital Corporation of America (HCA) (follow @HCAhealthcare), National Medical Enterprises (NME)  & AMI (merged into @tenethealth) dominated the emerging for-profit sector. Humana was actively repositioning itself from a hospital owner/operator into a health insurance company with a robust portfolio of managed care products.

From major academic medical centers (see: ‘Corporate Takeover of Teaching Hospitals‘) to regional non-profits, c-suite strategists were aggressively courting their engagement given bond debt service coverage requirement concerns amidst an uncertain future.

/4 While all major systems where looking into ‘integration model 1.0’ (recently and cleverly rebranded as ‘pay-vidor’) the mission critical decision in board rooms was: ‘do we make, buy or lease’ the infrastructure? Some sensibly chose the ‘payor neutral’ route, while others built brands.

/5 As then ‘director health system development’ @ AMI California, and previously serving as founding member of Preferred Health Network (PHN) now portfolio company @UnitedHealthGrp post Pacificare acquisition, I counseled AMI to NOT build AMICARE, but partner with the ecosystem as a payor neutral aligned, managed delivery system.

/6 The theory was don’t compete with insurance companies but learn to partner and co-brand local market products from PPO to HMO to POS and ‘OWAs’ (other weird arrangements). Furthermore hospital operations & insurance company cultures were ‘oil and water’ and would not mix. More later (think pre @texashealth formation where Presbyterian Healthcare and Harris Methodist Health Services merged and the health plan leadership where shown the door while DFW market dominant Harris Methodist Health plan was shopped to Pacificare).

/7 Rather than ‘risk’ the payor neutral, lack of vertical integration control (the lessons forged at PHN) and what I advocated at AMI, most majors’ (including 501c3s) with some local market (operations & branding) variations chose to ‘build’ vs. partner. #wrong #move 

/8 I digress. On the branding thing (another wrongly reasoned corporate brand extension decision), what’s wrong with the pictures above? At AMI I advocated that the product/service is the local market asset (a co-branded insurance product) and NOT an extension of corporate nameplate!

/9 I reasoned hospitals serve as ‘hubs’ of community trust (not too mention economic engines and potential integrators of the then dominant independent practice of medicine) & thus the assets to brand & market locally. A sensibly if not delicately calibrated blending of corporate vs. local market identity is more likely to create the goodwill & trust to build upon. Again I was over-ruled by corporate marketing gurus shopping a corporate branded nameplate. For example, all AMI hospital names were preceded by AMI, e.g., AMI Tarzana Regional Medical Center, AMI Irvine Medical Center, etc. 

/10 There’s much more to the story here. This is just an install in the hospital/insurance dance we’ve witnessed in the 80s-00’s playing out today and in some respects completely oblivious to painful lessons of the past (think NorthWell Health’s strategic entry and rapid exit from provider sponsored health plan ownership due to massive losses).There’s a similar story on hospital/health system side (both branding and strategy), to be elaborated in a separate post. 

/11 Concluding thread as follows. So what happened to those systems who elected the ‘build’ option? Massive losses & write-downs were reported with d/c operations posted to the balance sheets of public companies’. The gamble of assuming ‘insurance risk‘ was repelled as if the plague. Health plan or health insurance division employees were looked upon with suspicion. Welcome to FFS maximization era which reigned supreme until the recent round of re-engagement with managing the burden of the total costs of care (think triple aim) envisioned by various risk transfer provisions in the Affordable Care Act (ACA), where Accountable Care Organizations (ACOs) serve as the principal – but not exclusive – workhorse.

Comments:

Hey @VinceKuraitis, please checkout thread 1 – 11 below. Would love your thoughts and commentary. c #ACOchat #phychat #hcldr #JPM19 @jpenso1 @DonCrane @Farzad_MD @bobkocher @DrShlain @sgschade @davidmuntz @RejuvalifeBH @NACOMSO @NicoleBradberry @drnic1

Gregg Masters MPH @2healthguru

Replying to @2healthguru @jpenso1 and 10 others 

Vince Kuraitis @VinceKuraitis

Nice thread. On point.

IMO the jury is back — high probability of failure/$$ loss. (Most) hospitals do not have expertise, culture, patience, scale to become successful health plans.

Newer model of hospital/health plan JV MUCH more promising, e.g., Aetna + Inova.

John Moore @john_chilmark

Replying to @VinceKuraitis @2healthguru and 11 others

It may be promising Vince but we’ve been studying this for several years and still dumbfounded by the shear amount of distrust between provider and payer.

Requires a degree of transparency that few are willing to abide

 

Advertisements
Accountable Care, health innovation challenges, HealthIT, population health

On the ‘N of 1’ As a Standard for ‘Accountable Care’

by Gregg A. Masters, MPH

When I penned the post, ‘CTE on the Accountable Care Agenda? Junior Seau it’s latest victim?‘ in 2012 my intention was to draw a circle around seemingly unrelated events now finding increasing conversational gravity in the emerging ‘population health‘ zeitgeist where social determinants of health are valued as strategic grist for the mill of health systems and especially their ‘integrated‘ bretheren’s leadership.

It was also my hope that the commentary might generate some sober conversation in the healthcare social media, healthtech and healthIT social media communities. Much to my dismay, there was none.

The causes of this silo-ed, episodic, ‘we’re not concerned with life or health related events that occur beyond the walls of our cathedrals of medicine‘ sick care focus are well known and documented. Though mitigated somewhat by select provisions in the Affordable Care Act with emphasis on transitions of care, avoidance of 30 day re-admissions and continuum of care coordination particularly in the long term, post acute care (LTPAC) space, it’s mostly ‘modified” business as usual in U.S. Healthcare operations.

Oft referred to as the ‘burning [fee for services] platform‘ now clearly in the crosshairs of regulators, health industry leadership, payors, employers and even patients as the source of the problem, everyone is now focused on ‘value based healthcare‘ as the ecosystem’s likely successor footprint.

Yet, we do have a long way to go.

Case in Point

As someone who’s been in the belly of the beast of the ‘healthcare borg’ dating back to the mid 70s, I have witnessed and been to more or less degrees both a strategist (‘disruptor’) and implementation principal to successor waves of ‘innovation’ – ALL intended to tame the rapacious appetite of our ‘do more to earn more‘ healthcare financing and delivery ecosystem.

Decades later the bottomline is we’ve failed, writ large and collectively as an industry. The healthcare spend run rate as a percentage of GDP (then 8%) is now approaching 18-20%., where one out of every five dollars spent in the U.S. finds its way into the coffers of the silo-ed sick-care system we’ve collectively co-created. And while the change or re-engineering imperative was then limited and contained behind mostly closed door board rooms of health systems, health plans and large self funded employers or multiple employer trusts, today that ‘conversation’ is top of mind for our nation. Then, only corporation’s and government’s financial stability were ‘at risk’, today it’s entire nation states at peril.

So clearly something must be done. It must be bold (all inclusive), truly innovative and impactful. No mere tweaks at the margin will do and this may be the last hurrah for a public/private partnership to succeed before the Government has to intervene and solve the problem from the ‘top down’.

Enter the Triple Aim, Value Based Healthcare and the Population Health Mandate

There is non-stop discussion at meetings, conferences, webinars and expositions on the subject of a structural and scaleable pivot of ‘U.S. Healthcare Inc.’, from it’s Fee For Services (FFS) roots and incentives to a successor, sustainable version. Perhaps best framed by Don Berwick and the Institute Healthcare Improvement (IHI) as the ‘triple aim’, the charge to healthcare industry leadership is for a better experience of care, with better outcomes at lower per capita costs.

This ambitious tasking rightly shifts the focus of health system leadership from that which is customarily provided within the walls of the acute – and now subacute – delivery system operating units, to the ‘upstream‘ arguably ‘roots’ of the social determinants of health as discerned by proactive risk stratification coupled with outreach to defined populations.

Technology As Enabler?

Concurrent with the pre-occupation on value based healthcare and emerging focus on population health management, we’ve been discussing and evidencing the value of ‘mhealth’ or ‘digital health‘ apps, platforms and technologies to nest inside current clinical workflows (and beyond?) and fuel delivery of the triple aim. Yet, closing in on a decade later (the iPhone launched in 2007) there is sparse and limited evidence of the salutary benefit of digital health apps to make a dent in the aggregate quality, cost and access challenges we face as an industry.

Whether we’re in collective denial, have all drunk the ‘kool-aid’ thinking this time will be different or simply point to some evidence based believe or faith that technology can serve the greater good of the triple aim’s goals, the expectations and stakes are high – very high in fact. Much talk about contributions from AI, Big Data, Gamification, VR, the Internet of Things and even the Internet of Medical Things, all get woven into often lofty forward looking tech-speak and even policy solutions of how we’re going to make this happen. Yet is this warranted?

A Long Way to Go

A recent experience of mine suggests much work remains ahead. As indicated in the Junior Seau (RIP) post there is a grand canyon divide between the ad copy and rhetoric of population health initiatives and current healthcare operations and financing.

In November I moved to South Lake Tahoe for the ski season. I am 65, in general good health and reasonably active (I surf in San Diego) and recently qualified for Medicare and chose to enroll (i.e., assign my benefits) to a private sector alternative operating under Part C as the ‘Medicare Advantage’ (NOTE: which is a misnomer, since it isn’t Medicare but rather a private and in some markets ‘enhanced version’ when when the health plan is profitable) program organized by Kaiser Permanente in San Diego California. Kaiser Permanente (KP) is a trophy IDS (integrated delivery system) and is often and rightfully acknowledged as ‘best in class‘ in their approach to the organization, delivery and financing of healthcare services. I agree, and thus elected to enroll via their ‘Senior Health Plan‘.

KP has made enormous investments in HealthIT having adapted EPIC to serve their regions’ individual operating units. KP has also embraced technology and innovation via their Garfield Innovation Center and present with a well staffed and focused social media enterprise that seems linked to its member services group.

The Event

On Friday, I headed up to the summit at Heavenly Mountain with my girlfriend Lori. Upon exiting the Gondola and traversing up to the Ski lift to the Summit I started to feel light headed, stopped, looked up and collapsed backwards. According to Lori:

‘your eyes rolled up, your face went pale and you looked expressionless. I was alarmed.’

None-the-less, determined to get to the top for the first run of the season I elected to proceed and we entered the lift to the Summit. On the way up, we had cross winds gusting between 20-30 MPH. The temperature hovered in the low 20s to teens and the air was thin and dry.

I was wearing a ski dickey and found it difficult to speak and breath. Clearly this was not normal. Yet, we exited (9500 foot elevation) and began our decent down to Tamarack Lodge. Midway through the run I stopped, began to feel light headed and very dizzy. Gasping for air, I leaned onto my poles and then everything went dark. I collapsed again.

Lori took charge, summoned the ski patrol via a passing skier. Ski Patrol arrived, placed me on oxygen, suggested I was experiencing altitude sickness and STRONGLY recommended immediate descent to the Heavenly Center for hydration and rest (65oo foot elevation).

The Social Stream – More than What I Had for Lunch

Once the fog lifted and I began to feel better, I decided to tweet my experience in the public square and tag my health plan (KP San Diego, the Heavenly Ski Center and my Twitter ‘friends’) to alert them about my experience. For both my twitter colleagues and the Heavenly Center it was an FYI with a Ski Patrol shout out to Nathan (the EMT).

For KP San Diego it was a ‘heads-up’ as in hey, this happened to me today and ‘I think you should know.’ Now I know KP has a patient portal via MyChart and one I’ve been in and out of a few times, in addition to a ‘go to the emergency department‘ when in need advisory. Yet, we’re in the age of population health, risk assessment, prevention and ‘patient generated health data’ (PGHD) including massive investments in ‘listening’ technology for the rich streams of content posted to social networks.

Now add the fact that healthcare is a litigious and thus risk averse environment. Therefore sitting on the sidelines and at best ‘listening’ is probably less risky than realtime or ‘asynchronous’ attempts to ‘intervene’. I’m sure a bevy of corporate lawyers counsel against ill advised engagement outside the normal ‘theater of operations’. Yet, I am old enough to remember when the Darling and Nork cases began to peck away at the immunity from liability traditionally argued by many hospital administrators that ‘we’re just the doctor’s workshop’ and have no control (and by extension no liability) for their actions. Yup, that once was the standard of practice a few decades ago.

The Messaging

Here are the series of tweets posted related to this narrative.

screen-shot-2016-12-19-at-1-35-02-pm

 

screen-shot-2016-12-19-at-1-35-17-pm

screen-shot-2016-12-19-at-1-35-34-pmscreen-shot-2016-12-19-at-1-35-44-pmscreen-shot-2016-12-19-at-1-35-54-pm

The Health Plan’s Response

Several days later… and in ‘async’ fashion KP weighed in via Direct Message on Twitter. I previously tweeted about my inability to reschedule a colonoscopy from a San Diego location to the Sacramento area since I am in South Lake Tahoe for the ski season. I learned that I could NOT opt for a local option as the health plan didn’t operate that way [paraphrased]. The tweets below pertain specifically to the incident on the mountain.

9:19am
@KPMemberService
Hi, Gregg. I noticed your recent tweets and wanted to follow back up with you. If you’ve already sent your email, we have not received it. Can you please resend it? Thank you! ^Jamison

9:49am
Gregg Masters MPH @2healthguru

No point in sending log to you. After DM, spoke to my PCP. She advised I can not schedule colonoscopy in NorCal (Sacramento) w/o changing PCPs. Suggested we delay until I return to Oceanside in April. Really bad form for KP. If true, you are NOT an IDN, but a federation of providers under a common marketing banner with discrete regional accounting, but worse clinical operations. I am VERY disappointed, since I am and have been a fan of KP. I am 65. I’ve been self employed since 2000, and un-insured by choice since. My health plan is my health. If KP is committed to my health, then a simple risk profile of these facts would expedite the colonoscopy as a preventive tool. I shouldn’t have to point this out to my health plan. Then add my fainting on mountain at Heavenly (9500 foot elevation) with minimally hypoxia if not cerebral edema, AND ZERO recognition or comment from @KPsandiego who I tagged [in tweet]. I mean seriously, with the investment made in tech, how can you not leverage proactively on behalf of your members? I am shocked. If this is M-F brand listening tool only and not deployed as adjunctive to KPs clinical risk management surveillance program, you are clearly missing the boat of the PGHD wave that is sweeping the ecosystem under the banner of ‘digital health’ tools. Again, I am a KP fan and believe you need be held to a higher standard given all the accolades received via others in the industry. Please pass this concern in its entirety to both Robert Pearl and Bernard Tyson who I personally hold responsible for these systemic (x2) ‘fails’. I am blogging about this experience (including this response) as a N of 1 example of ‘accountable care’ in the new age of population health contextualized via social [i.e, lifestyles of] determinants of health plan members (including their known risk profiles). Thanks for asking. My concerns go considerably beyond the usual scope of member services, and I do hope you pass on my comments in their entirety to senior leadership. My blog comments will be posted to @ACOwatch as my N of 1 version of ‘accountable care’ to this post: acowatch.me/2012/05/02/cte… Thanks Gregg

@KPMemberService
Thank you for your detailed reply, Gregg. I will definitely make sure to pass along your experience and concerns to our senior management staff. ^Jamison

Much To Do About Nothing or Reflexive Provider vs. Patient Centric Response?

One can argue,  hey dude work within the system, i.e., call/alert KP via member services, enter a note to your PCP in the MyChart portal or head to an Urgent/Emergent Care Center – quit whining.

Yet, am I wrong to think that in an era of ubiquitous, real time and ‘asynchronous’ tech stacks afforded by major social networks where participants are ‘tagged’ as in a ‘headsUP’ fashion, need be viewed solely as a forum for posted images of cats or what’s on the menu today?

When and where do we walk the talk of the upside of digital health tools, the value of patient generated data and the big data and massive analytics engines that routinely data-mine these streams for population health insights and actionable ‘intelligence’?

So maybe this is just too much to expect even from best in class performers – the likes of KP. Maybe the residual ‘resistance ifs futile’ legacy inertia is just too powerful to overcome systemically and we’ll just have to be happy with at best tweaks at the margins.

I for one think we need to up the ante and hold both the providers and financiers accountable to this dysfunctional ecosystem we’re so often powerless to influence or change.

I am committed to make a difference. Where are  you?

 

 

 

ACO, Affordable Care Act, Uncategorized

ACO Onramp: Reading the Pioneer [Exit] Tea Leaves

By Gregg A. Masters, MPH

Whenever someone buys a stock for the most part they make a decision that weighs available public (and sometimes ‘non public’) information and concludes that the company’s value exceeds (currently or shortly will) that which is expressed in the bid/offer price points the day the purchase is executed. Yet, there is always a seller who may more often than not hold the opposite opinion. After all why is he/she selling if the stock price undervalues the company’s enterprise fundamentals?buy sell

Absent the expressed manipulation of a third party intermediary (broker dealer, hedge fund, etc.) this buy vs. sell ‘call’ can reasonably and accurately reflect the aggregate market based ‘tug of war’ between the public perception and actual fundamentals of a company – at least as reflected in it’s stock price or ‘market cap’.

This same tug of war might equally apply to the battle for the ACO narrative at least as it relates to interpreting the reported ‘signals’ of movement inside the accountable care space.  However, instead of stock prices we’re looking at certain metrics including the number of players entering or conversely exiting the accountable care theatre as a proxy for the underlying health or efficacy of the Affordable Care Act – or at least that piece allocated to the provision in the Act specific to ‘accountable care’.ACO growth medicare vs non medicare

Of late the headlines have predictably served up a mixture of news for public consumption and therefore fodder for the talking heads to spin in the media and the ‘credible’ blogosphere writ large to explain to their audience.

If only healthcare where as simple as buy/sell equity transactions on public exchanges (lets not get into ‘dark pools’) mostly immune from ideological spin as to the broader significance of a move up or down in standing, valuation or growth vs. contraction. Unfortunately the health reform space is littered with agenda driven spin to drive an ideological outcome in one way or the other. And we know who the usual suspects are…

Meanwhile, several headline examples meriting interpretation including original source links are posted below. Further, since the launch of Aledade and several other entrepreneurial players (Privia Health) to bolster the vision, leadership, capacity and management infrastructure including the healthIT spine that supports independent physician led participation in the ACO initiatives, we include a recent Commonwealth Fund deep dive titled Profile: Rio Grande Valley ACO Health Providers’ exploring a physician led ACO effort in the Rio Grande Valley of Texas.

Context for the ACO pulse check narrative is perhaps best framed via a JAMA piece titled: The Pioneer Accountable Care Organization Model Improving Quality and Lowering Costs which is instructive on the significance of select Pioneer exits, while a deeper dive into the weeds of ‘Shared Savings in Accountable Care Organizations: How to Determine Fair Distributions (abstract only) addresses a problem most ACOs would aspire to have, i.e., a formula to distribute actual savings generated. 

The later abstract notes:

Accountable care organizations (ACOs) are playing a major role in health care reform. In the last 2 years alone, Medicare ACOs have proliferated to cover more than 5 million Medicare beneficiaries in more than 360 organizations nationwide.1 In ACOs, individual clinicians (including physicians, physician assistants, and nurse practitioners, among others), group practices, and, in some cases, hospitals contract with payers to be jointly accountable for the health outcomes and expenditures of a defined patient population. By meeting specified quality measures while keeping expenditures below defined benchmarks, ACOs share in the monetary savings generated.

Over at Modern Healthcare, Melanie Evans notes in ‘Medicare’s Pioneer program down to 19 ACOs after three more exit‘: 

Franciscan Alliance in Indianapolis, Genesys PHO in Flint, Mich., and Renaissance Health Network in Wayne, Pa., have exited the program, which is now in its third year.

For further discussion into quality performance measurements checkout ‘Medicare gives first glimpse of ACO quality performance’.

Perhaps the biggest piece of news was wrapped into the announcement of the launch of Vivity Health, see: ‘Reform Update: Will Anthem’s Vivity gain traction among large employers?‘.

This ambitious announcement by Wellpoint spawned the following two tweets today:

.’s ambitious ‘Vivity’ alliance [a response to ] will make merger look like a walk in the park!

Although saw light when it green-lighted as chassis to build out/express MA care delivery innovation.

Finally until job descriptions change reflecting better deployment of professionals working at the ‘top of their license’, as well as non clinical or administrative staff support re-engineered workflows, we’re probably not witnessing the movement of the needle towards the triple aim. In ‘ACOs, other delivery reforms shift job roles at hospitals’ we learn a little more about this continued labor pool tweaking.

ACO, Affordable Care Act, HealthIT, Triple Aim

Are Institutionally Led ACOs ‘DOA’? I Say Heck Yah!

By Gregg A. Masters, MPH

At the end of the [business model and strategic positioning] day, it’s all about the intangible but mission critical ‘C’ word, i.e., culture, and whether two traditionally oppositional styles (physician v. hospital) can mash-up and ‘meaningfully integrate’ (clinically, legally & workflow wise) where previous attempts during the 80s and 90s failed.Are Hospital Led ACOs DOA?

Truth be told, fast forward a couple of decades and that cultural divide has yet to be reconciled a least on average. Granted there are some exceptions (most notably progressive integrated delivery systems who’ve aligned financial incentives but more importantly ‘vision’), and many of the oppositional dinosaurs (physician ‘free agency’ and solo practice are on an accelerated decline) are retiring or otherwise stepping aside. Yet even with the emerging digital natives sporting MD degrees, the cultural divide between clinicians and administrative types (or latter day suits of all stripes), remains a geopolitical land grab just beyond the reach of the individual ‘P’, “H’ and thus ‘O’. Yet, all healthcare is local right, so clearly there are differences based on locality and market considerations.

What’s different today?

Most will say that the difference between PHO 1.0 (for the casual reader or those with a professional event horizon shorter than a decade plus, PHO = a physician/hospital/organization), and the ACO movement spawned by the Affordable Care Act and most visibly iterated as PHO 2.0 roll-ups (since many of the more visible and publically tagged ACO efforts include an ‘H’) nets out to an accessible if not the ‘new and improved’ ubiquitous technology edge, coupled with smarter ‘productivity’ systems to hold docs accountable post acquisition (risk transfer) of practice assets or hiring.

Back when the internet was just getting going circa the 1990s and Jim Clark was pushing the Healtheon vision – an ambitious agenda to virtualize if not harmonize the complex healthcare ecosystem, we did not have the ubiquitous connectivity and prevalence of user friendly devices including mobile and tablets or the enabling bandwidth let alone national coverage.

Reading the ‘tea Leaves’

Yet even in the face of ‘smarter people’, ‘better systems’ and increasingly accessible, ‘robust cloud based services infrastructure’ (IT and otherwise) with attractive price points, is the people challenge any different today? At least two data-points suggest otherwise evidencing the underlying ‘dis-ease’ associated with the implementation complexity of a ‘soft sell’ re-engineering of American healthcare via the aggregate market uptake of ARRA, HITECH and key ACA (ACO) provisions.

According to a Athena Health’s 2012 ‘Physician Sentiment Index‘:

  • 69% believe EHRs can improve patient care, down from 75% the year before.
  • 75% believe achieving Meaningful Use is a burden.
  • 53% believe the Affordable Care Act will be detrimental to patient care, up from 50% the year before.
  • 58% believe most or all of the Affordable Care Act should be repealed, and 26% believe that some elements should be repealed. Only 16% said to keep it as is.
  • 63% believe the shift to Accountable Care Organizations (ACO) will have a negative impact on profitability, up from 48% last year.
  • 54% believe the quality of care will decrease over the next five years.

Add to the mix the following headline: ‘Physician Turnover Hits New High as Demand for Primary Care Increases’, which reveals:

physician turnover reaches the highest rate since the first year data was collected in 2005, and exceeds pre-recession levels. Medical groups reported an average turnover rate of 6.8 percent in 2012, according to the 8th annual Physician Retention Survey from Cejka Search and the American Medical Group Association (AMGA).

The survey also reported turnover of 11.5 percent among advanced practice clinicians (APCs), which includes physician assistants and nurse practitioners.

Also noteworthy is from the report’s ‘Other Key Findings’:

‘Culture is the Top Controllable Turnover Factor: Lack of cultural fit was the third most common reason given for voluntary departures, and the most common factor within the control of a medical practice.’

‘Demand for Care Teams Intensifies: More than three-quarters (76%) of respondents plan to hire more primary care physicians in the next 12 months, 67 percent plan to hire more nurse practitioners and 61 percent plan to hire more physician assistants. Strong teamwork skills will be vital to successful coordinated care.’

Bottom Line

So that ‘primary care sucking sound’ (remember Ross Perot’s NAFTA warning?) mostly to build out and staff ACOs, medical homes and their derivative ‘high value’ networks, are creating an environment where the natives are clearly restless, while the disconnect between industry rhetoric and the on the ground reality of the transformational imperative has never been more acute, nor the stakes so high.

ACOs were purposefully visioned as physician led enterprises, yet as is often the case in healthcare innovation amidst a change resistent ‘just say no’ culture the capital partner steps in to steward if not direct the initiative’s vision of organization, governance and equity (fairness if not capital) issues. Moreover, hospitals (or their parent systems) are the likely source of ‘capital’ – financial, managerial and infrastructure, ergo they step into the void of physician leadership to move the needle albeit in their narrow view of self interest.

Most institutionally led ACOs therefore are dead on arrival unless there are compensating factors which infuse [group practice] physician culture at the center of the enterprise in pursuit of the triple aim, or hedges where hospital executives clearly see their role as transitional enablers and not drivers of a physician seeded transformational process amidst a sea of conflicting incentives, values and workflows.

Uncategorized

Standing Up the ACO: Lessons from South Park?

By Gregg A. Masters, MPH

On Sunday I was chatting with a friend in the biz and the conversation turned to ACOs, wherein he whimsically laughed and then relayed a story from a recent California Medical Association (CMA) sponsored event on health reform, the future of medicine and Accountable Care Organizations, wherein one of the keynote speaker’s (I suspect Mark Smith, MD, of California Health Care Foundation), queried the audience asking for a show of hands:

How many of you watch South Park?

To wit, an estimated 350 out of 500 hands went in the air (South Park is apparently popular with many physicians). The speaker then recounted the gist of the ‘Gnomes underpants’ episode, analogizing their ‘business plan’ to the current state of the art in the accountable care industry at large (for detailed plot, click here).

The apparent resonance of the narrative is the fitting metaphor of a three phased business strategy [absent the mission critical second phase] to effectively profit from the ill gotten underpants gains’. Some say the ‘accountable care’ development and management glide-path is equally clouded by the absence of a similar mission critical body of knowledge and practice bridging theory with mission fulfillment. Clearly the humor lay in the leap of faith (or invisible hand(s) of the market) required, i.e., now that we formed this ACO thing, what is it we need do to make it profitable? Or in South Park terms, that thing in between acquiring stolen property, and projected assumed profit. Perhaps the context or challenge to organizers of ACOs is best reflected in the oft repeated (and variably credited) refrain:

The accountable care organization is like a unicorn, a fantastic creature that is vested with mythical powers. But no one has actually seen one. – Ian Morrison

Does this accurately reflect the state of ‘accountable care’? While the jury may be out, the empirical data is starting to accumulate. We shall see, and starting in Q1 2013 @ACOwatch will present examples from the broad tapestry of the ACO industry including representatives from the Pioneer class, independent physician led ACOs, their hospital centric alternatives, and hybrid ‘accountable care collaborations’ typically associated if not led by a single or multi payor partner(s).

Uncategorized

Hospitals Back in Insurance Biz: Good News or Bad News?

By Gregg A. Masters, MPH

I awoke this morning to read the following headline:

Hospitals Look To Become Insurers, As Well As Providers Of Care

To wit, I ‘tweeted’:

OK, it’s reallly ‘deja vu’ all over again! ‘Hospitals Look To Become Insurers, As Well As Providers Of Care’

For complete original article, click here.

Mind you this is both a context and content appropriate knee jerk thought for those with an event horizon beyond the 24 hours ‘news’ cycle. Yet, upon further consideration, it may not be that simple.

Let me explain. Some of us battle weary ‘pioneers’ (you know, per Elliott Fisher, MD at ACO Summit 2012: ‘pioneers take the arrows, but settlers get the land’ types) who executed the business models associated with HMO, IPA, PPO, POS, and eventually PHO rollouts (including their management companies/MSOs) beginning in earnest in the 80s, morphing into the 90s before crashing at or about the millenium, have seen this dance before.

BREAKING: It failed, and failed miserably, with some exceptions. Lets put aside the mature integrated delivery systems who walked the talk then and continue to model best in class integrated or more recently dubbed ‘accountable care’ for the rest of us and just focus on mainstream medicine and the typical community hospital as epicenter.

Back then the ‘big four’ proprietary (vs. voluntary) hospital systems where: Hospital Corporation of America (HCA), National Medicare Enterprises (NME), and American Medical International (AMI), and Humana. Not to be left out, the nonprofit hospital braintrust eyeing the competitive threat these amassing for profit systems represented, turned to their leading trade group, the Voluntary Hospitals of America (VHA).

Thus, all four drank the strategic ‘kool-aid’ fed in part to them by the best and brightest consultants and entered the insurance space. HCA joint ventured with The Equitable to form ‘Equicor’, NME fielded ‘AVmed’, while AMI really stretched the boundaries of creative thought by branding ‘AMICARE’, while Humana fielded Humana Health Plans. [NOTE: I advised AMI NOT to enter the insurance business with their own branded product, later joining the company once they divested (a $350 million charge to discontinued operations) their ill advised misadventure as Regional Director of Managed Care for 21 California Hospitals.] While VHA partnered with Aetna to form “Partners National Health Plans’ aka ‘PARTNERS’.

Thus, the race was on. Senior hospital executives rarely able to deliver on the upside promise of scale in the hospital business, i.e., better care, lower overhead cost, best management practices via ‘corporate colleges’, group purchasing, reduced clinical variation, and greater accessibility to the populations served, chose to up the ante and leap the grand canyon of the hospital business (one they had yet to materially improve) and enter the unfamiliar and potentially cannibalizing business of insurance.

The record is clear. The group as a whole failed, and failed miserably. What’s changed? And how might we view this ‘extravasation‘ differently? I will explore what might be different this time, and perhaps present another way of framing the value proposition of bridging these two very different different businesses in the next post.

Uncategorized

How Hospitals Can Test the Waters of Accountable Care

By Gregg A. Masters, MPH

Found on the Accountable Care Bulletin.

Hospitals considering accountable care strategies have plenty of options to choose from, but deciding where to begin can be confusing. Joseph Damore, Vice President of Engagement and Delivery for Premier, explores how hospitals can test the waters of accountable care, from engaging staff in wellness to partnering with local employers on population health.