ACO ‘Wakes Up the Long-Term Care Ecosystem’ With Data
LTC ACO, an accountable care organization for Medicare beneficiaries who reside in long-term care (LTC) facilities, has had success in the Medicare Shared Savings Program. Jason Feuerman, the ACO’s president and CEO, recently spoke with Healthcare Innovation about how the ACO succeeds by “waking up the ecosystem” with data.
During 2021, LTC ACO said it managed more than 8,000 Medicare fee-for-service beneficiaries under the MSSP with annualized Medicare spend of more than $200 million. The ACO generated $28 million in gross savings, ranking it 30th in gross savings among all ACOs.
A subsidiary of Genesis HealthCare, LTC ACO says it works with participating physicians and clinicians to provide better, more coordinated care to the Medicare beneficiaries they treat in the LTC facilities. Prior to joining Genesis HealthCare, Feuerman served as senior vice president and president of the public sector and health plan divisions of ValueOptions Inc. Earlier in his career, he served as president of Bravo Health, a subsidiary of Cigna Inc. and as president of Senior Care Centers of America, a leading provider of adult day health services.
HCI: How did LTC ACO get involved in the MSSP in the first place?
Feuerman: Back in 2015 the thought process was that everyone in this space needed to become an I-SNP (Institutional Special Needs Plans.) Coming out of the Medicare Advantage world, that was not a very interesting line of business to me. But equally as important, being an I-SNP means you're taking on insurance risk. When you take on insurance risk, there's a need for regulatory reserves. The MSSP model, on the other hand, could be entered into without regulatory reserves or the need to build a provider network, without the need to pay claims, and most importantly, without the need to enroll people. If you think about Medicare Advantage, it is about enrolling one person after another, whereas this program operates on a concept called attribution, and that attribution starts with the primary care providers, so I could sign up one doctor and get 50 patients.
We applied in May of 2015 to become a Medicare Shared Savings Program. During that period, I had been given responsibility to manage a physician group that Genesis owned called GPS or Genesis Physician Services that employed about 300 physicians and nurse practitioners at the time. They were primary care clinicians working in long-term care. In order to get into the Medicare Shared Savings Program, you need at least 5,000 Medicare beneficiaries and you need at least three years’ worth of experience with a population. It put us in a very unique position in that we had all the pieces we needed, It created this this breadth and depth that no one else in the country had the ability to do. So we began to fit a square peg into a round hole with regard to the Medicare Shared Savings Program.
HCI: Because everybody else in the program was doing something different?
Feuerman: Everybody else in the program was focusing on a different population and no one wanted this population. We had to advocate for certain changes, which we were successful in doing because once again, we were fitting a square peg in a round hole. We spent a lot of time with CMMI.
HCI: This must have been attractive to them. I mean, they probably wanted this population as part of the MSSP.
Feuerman: When you talk to CMMI, the answer was absolutely yes because of the large-scale dollars that we were dealing with and the impact that it could have on the program and their spending. There was a lot of interest. The problem was that we were a unicorn. We are one out of 500 programs, and there's only so much they could do to help us on certain issues, because of the other 499. They just had to focus their efforts elsewhere, but we were able to advocate for changes in the program from a quality perspective that made sense for this population. It took a few years to get our sea legs under us because of changes happening within CMS and because this wasn't developed for this population. There were bumps along the way. By the time we got into 2019, we began to produce meaningful savings.
As we went into 2020, we went about the process of expanding outside of Genesis facilities. Now, timing couldn't have been any worse because of COVID. We started looking to contract with nursing home companies because that's where the residents lived, and presumably they had relationships with their physicians. One of the things that we quickly figured out, very disappointingly, is they really don't have relationships with their physicians. They don't know who their physicians are, and there's no bond, so there's no way for them to assist in getting those doctors engaged. We had to pivot our strategy to make it physician-centric, meaning we were going after those physician groups that practice primarily in the nursing home industry, and there are many of them out there. We were surprised about just how many mid-size to larger groups there are out there. There were large providers where we could pick up thousands of people with one stroke of the pen.
HCI: If you work with those physicians, do you still have to get cooperation with the nursing home business itself to make this work?
Feuerman: The disappointing answer is no. And the reason that I say disappointing is that our thesis was we have this three-legged stool: the ACO being one leg, the nursing home being another leg and the physician being the third leg, and that everyone would be rowing in the same direction. Don't forget the timing of this. Many nursing homes haven’t been able to recover from COVID, whether it's due to staffing costs or reimbursement issues. We have some groups that engage and participate well with us, but most don't. We share a portion of our savings with the nursing homes if they participate. These folks are really missing out on the opportunity, and we do believe that this all leads to better care and it's a better way to coordinate with all three parties.
HCI: Have others in the long-term care sector followed your lead into value-based care models?
Feuerman: There are several groups who have gotten into it. And we have found that to be beneficial. The first thing you learn in business school is competition drives demand. We thought it was really healthy. The strategic advantage that we have over folks that are currently in the market is we've got experience with this nuanced program. We had these years of experience where we had to figure things out. And it's a list of things that may make all the difference in the world.
HCI: I saw a recent press release that mentioned some new clinical initiatives that you are looking to do, including comprehensive coordinated approaches to advanced care planning and palliative care and medication management. Can you talk about a couple of those things that you want to introduce?
Feuerman: The first thing we needed to do was what I call waking up the ecosystem. What I mean by that is physicians, in general, didn't really know what was happening with their patients in the nursing home environment, and it didn't matter to them what ends up happening with them. If they went on hospice or if they went to the ER, or they went to the hospital, of if they're being skilled appropriately or inappropriately, it didn't impact them at all, and they didn't know anything about it. We had to make them aware. Data has been one of our greatest attributes and resources to make them aware. And the beauty of making them aware is that physicians are smart people and they're data-driven people by nature. You can make them aware that they've got patients who have been on hospice for two years, and because they're sharing in savings, it effectively is costing them money if it's not being appropriately used. So the first thing we did was what wake up the ecosystem with data. I use hospice as an example. After we made them aware of what was going on with end-of-life care, we worked with them on more appropriate use of palliative care. Another thing that we've invested in just recently is an artificial intelligence tool from ClosedLoop. They won an Innovation Award from CMS two years ago. We are in the process of training that model so we can use it for predictive analytics with our providers.
HCI: What kinds of things could it see in the data that might help clinicians respond differently or more quickly?
Feuerman: The first model that we're testing involves using data to help predict the risk of hospitalization in the next three months. When you look at our cost structure, our biggest drivers include hospitalizations and Medicare Part A skilled nursing care. And prior to the public health emergency, in order to get skilled nursing care, you had to have a three-day hospital admission. So if you can get rid of that admission appropriately, you can impact two cost categories. The third biggest cost driver is hospice. We're hoping with this modeling, we can reduce unnecessary hospitalizations and the next model will also help with end-of-life planning, so we can be better at identifying the need for palliative care prior to people just going on to hospice.
HCI: With the end of the public health emergency coming in two weeks, what is the impact going to be on your ACO on nursing homes in general?
Feuerman: With regard to to the ACO, it will have a very positive impact. One of the waivers allows people to be in skilled nursing in Medicare Part A without the need for hospitalization. The reason that CMS had put that in place was to take the burden off the hospitals and appropriately so. We ended up seeing a significant increase in Medicare Part A skilled nursing services, so it's going to help us, but it will theoretically have a negative impact on nursing homes. It's putting them back to where they were at pre-pandemic levels.
HCI: Is LTC ACO looking to scale up and grow?
Feuerman: Yes, we are in about 2,000 nursing homes today dealing with probably 2,500 practitioners. We're able to operate in all 50 states. I think we have lives in 34 states. We're the only ACO in the country that has a national footprint.
HCI: Is there anything else that you would like to see from CMS or CMMI?
Feuerman: The biggest thing we'd like is for there to be a specific program for this population. There are certain measures the simply don't make sense from a quality perspective for this population. There are a number that we've been able to advocate for and they've been remediated, but there are still issues because we're dealing with a different cost structure. As the program evolves, we would like there to be a more specialized focus. That gets back to your earlier question about competitors. Now that we've got other people who will advocate for very similar things, I think the more people we can get to the table, the better.
