High Hurdles: Leaders of Patient Care Organizations Participating in Medicare’s ACO Programs are Pushing Ahead Into the New Healthcare

With 368 Medicare Shared Savings Program (MSSP) accountable care organizations (ACOs) nationwide, and, according to recent estimates, well over 500 ACOs of some kind, including an ever-expanding group of collaborative arrangements between private health insurers and provider groups, the ACO concept is moving inexorably forward in U.S. healthcare. Indeed, even some of the challenges inherent in the shift to the ACO delivery-and-payment model—such as the announcement a year ago that seven of the Pioneer Medicare Shared Savings Program (MSSP) participant entities were shifting to regular MSSP status after failing to produce the level of cost savings expected of them under the terms of the Pioneer MSSP program, and two were leaving the MSSP program altogether—are leading to intensified work to ramp up ACO cost savings and outcomes gains.

(A Leavitt Partners analysis published in the Health Affairs blog in June found that “The Pioneer program generated $147 million in total savings [in 2012], with approximately $76 million in savings returned to ACOs. Of the original 32 Pioneer ACOs, 12 shared in savings, while 19 did not share in savings or losses. Only one ACO shared in losses.” Meanwhile, as that same analysis found, “Of the 114 MSSP ACOs”—the non-Pioneer ACOs—“54 kept costs below budget benchmarks and 29 of those saved more than 2 percent, thus qualifying for shared savings.”)

In fact, the ACO development work taking place these days is accelerating in the context of significant gains in ACO reach across the U.S. According to a study released in April by the New York-based Oliver Wyman consulting firm, “More than two-thirds of the U.S. population now live in localities served by accountable care organizations and more than 40 percent live in areas served by two or more.” Specifically, the Oliver Wyman researchers found that 67 percent of the U.S. population lives in a primary care service area with at least one ACO, compared to 45 percent in September 2013. That analysis was commissioned by the Department of Health and Human Services. The same report cited 368 Medicare ACOs nationwide as of April, and 522 ACOs of some kind, according to the Oliver Wyman estimate.

Still, though the Oliver Wyman report read as bullish overall (and the federal Centers for Medicare and Medicaid Services was able to report a total cost savings among all MSSP ACOs of $380 million in the first year of the program in 2012, $126 million over targeted savings),  it did note a number of challenges, particularly on the strategic IT side of things. Its authors noted that, “As healthcare providers experiment with new ways to deliver care, their IT systems have a hard time keeping up: traditional systems can’t support coordinated care, they do a poor job of maintaining relationships with patients, and they don’t even supply the basic data needed to manage a contract based on value.” Further, the report noted that, in an ideal world, ACOs would simply compel every participant entity (physician, physician group, hospital, etc.) involved in the same ACO to adopt the same core electronic health record (EHR); but the authors immediately conceded that such an approach would be “expensive, disruptive, and nearly impossible to achieve in a disseminated organization.” So what are the leaders of ACOs, both Medicare MSSP entities, and private ACOs, doing to overcome the broad strategic and IT-strategic challenges inherent in the shift to this new model of care delivery and payment?

Diverse efforts towards the same broad goals

ACO leaders interviewed for this story all agree on one thing: creating, developing, sustaining, and expanding accountable care organization models of all types is a very challenging and complex undertaking. At the same time, all are optimistic about the long-term prospects. Among the organizations making significant gains:

• The Northridge, Calif.-based Heritage Medical Systems is operating one of the nation’s largest Pioneer MSSP ACOs, with about 90,000 members, called the Heritage Pioneer ACO. That ACO, reports president Mark Wagar, was one of two ACOs that generated 40 percent of the savings documented in 2013 in the Pioneer MSSP program (the other was the Montefiore Pioneer ACO in New York City). What’s more, Wagar notes, the Heritage Pioneer ACO is composed primarily of independent (non-salaried) physicians in California, Arizona, and New York, making that achievement even more noteworthy.
• In Massachusetts, the Brighton-based Mount Auburn Cambridge Independent Practice Association (MACIPA), with over 500 physicians practicing in 10 communities, is also a Pioneer MSSP, reports Barbara Spivak, M.D., MACIPA’s president. The organization is making headway, she says, and moving forward under the banner of improving care through better care coordination.
• In New York state, the 300-plus-physician, 17-location Crystal Run Health Care is participating as a regular MSSP, uniting its doctors and other clinicians as they strategize around getting ahead of the curve in value-based healthcare on behalf of its patients in Orange, Sullivan, Rockland, and Westchester counties in New York state, reports Gregory Spencer, M.D., the multispecialty medical group’s CMO and CMIO.
• In the Boston metro area, the Steward Health Care System is participating in the Pioneer MSSP program as Steward Health Care Network, reports Dominique Morgan-Solomon, the ACO’s vice president of population health. Steward Health Care Network has worked through the initial issues around attribution, and is moving ahead on numerous fronts, particularly in terms of data analytics around population health, Morgan-Solomon says.
• Meanwhile, the St. Louis-based Ascension Health, the largest not-for-profit health system in the U.S., has chosen to create Mission Point Health Partners, a Medicare MSSP ACO caring for more than 100,000 members across middle Tennessee, says Jason Dinger, president and CEO of the Nashville-based Mission Point Health Partners. The focus there has been ramping up quickly around data analytics to identify the ACO members in need of the most intensive medical interventions and care coordination.

Attribution and patient engagement: the first Gordian knot

Wagar, Spivak, Spencer, Morgan-Solomon, and Dinger all agree that the initial challenges facing ACOs on the strategic, operational, and IT fronts are inevitably daunting, but all feel their organizations, all of which have been participating in one of the Medicare programs, either Pioneer or regular MSSP, since sometime in 2012, have been making steady progress.

Importantly says Morgan-Solomon of Steward, “What we learned early on is that about 30-40 percent of our population in the MSSP is changing every year; that’s really significant, and it makes you really think about how you impact ACO members right away. Typically,” she says, “with care management and population health, you’re trying to institute interventions upstream, and that’s challenging. Interestingly,” she says, “while the majority—though not all—of our MSSP ACO members are over 65, one of the things we’ve learned” in participating in the MSSP program is that “while you’d think there would be a lot of differences between the Medicare and commercial populations, we’ve learned that there really haven’t been a lot of differences. So we’ve learned a lot and have been able to institute infrastructure that goes across payers, and the infrastructure has become somewhat payer-agnostic. Because really, the high-risk diabetics are such that all the programs tend to be applicable. And I think the team was a bit surprised by that.” That area of learning came after the initial hurdle of ensuring accurate attribution (making sure that ACO patients were correctly identified), something that every executive interviewed for this article agreed inevitably poses a strong initial challenge.

Among the other core challenges in the strategic IT sphere faced by organizations moving into accountable care: building strong data analytics teams, creating the decision support tools and performance dashboards needed to keep physicians focused on delivering optimized care, optimizing EHRs to support data-gathering and data analysis, and creating data warehousing and health information exchange infrastructures to support data-sharing and analytics activity on a mass scale.

Meanwhile, immediately related to the attribution issue is patient engagement, says Morgan-Solomon. “To begin with, they’re not always sure they belong to us,” she notes. “So you’ll potentially have a beneficiary who has seen one of our providers a few years ago, maybe via a specialist in our network, but their primary care provider is with a different system. So one of the challenges has been, how do you get these beneficiaries engaged? Because in some cases, they haven’t realized they’re attributed to us. And they have to opt in, and they get letters from CMS, but imagine, for populations who may not have caregivers who can explain everything to them, they can actually become very confused about all this. So we’ve had to get pretty creative there.”

Gregory Spencer, M.D.

“The attribution piece is huge,” agrees Crystal Run’s Spencer, “and really, every payer is slightly different, and it might seem simple, but it’s not. And what do you do with people who see a lot of urgent care but don’t really have a regular primary care physician? And by being attributed, you’re saying, well, you might get some sort of PMPM [per member per month] payment, and that’s good, but if you’re now responsible for the outcomes metrics for a patient and you don’t have a relationship with that patient and aren’t able to hit the quality gates, you’ve missed your opportunity for savings.” So, he says, it is vital to get attribution right, and to link successful attribution with successful engagement of all active patients in the ACO.

Should ACOs start treating all their patients in the same way?

Once one begins to get a handle on the attribution/patient engagement issue, the most immediate set of challenges, all those interviewed, is inevitably around data analytics, and around working with claims and clinical data in an analytics context. Dinger and his colleagues at Mission Point have been working with the Washington, D.C.-based Advisory Board Company in that area, leveraging a solution from that organization’s Crimson Analytics suite, one of the many analytics solutions options available on the market now. Speaking of the need to plunge into that area, Dinger says, “One of the most important things we’ve done is that we’ve made significant investments in data analytics and data mining tools,  with the express interest in understanding our population and some of their unique needs. The technology really allows us to find the most people in need, and to discern what kinds of services they need.” One of the key purposes he and his colleagues have invested in an analytics solution for has been for risk assessment; the solution they’ve chosen, he says, “allows us to understand the historical claims that each member has,” and links that data with EHR-derived data on the same patients. “It’s important for us to know how many people have gotten a flu shot or a mammogram, for example,” he says, and to be able to identify gaps in their care management.”

With regard to analytics, Heritage Medical’s Wagar says that he and his colleagues have had a distinct advantage in “having been around in Medicare Advantage for so long. We took systems we had, and then built new ones” for ACO purposes, he says, “but we’ve built them in a way that would apply to all of our populations.” What’s important, he says, is recognizing that “Just because you’re an ACO patient now and want to go to a Medicare Advantage plan or vice versa—we should still be able to work with you and your doctor, in either environment.”

Mark Wagar

Indeed, Wagar’s comments reflect those of Steward’s Morgan-Solomon, around shifting their entire organizations towards thinking about all of their patients—whether ACO-attributed or not—in the same way. “In terms of the clinical intervention,” he says, “in terms of the proactive outreach and gains for a population, we’re applying the same principles of care to all of our patients now. Now in the prepaid population, then the provider system is really empowered [800,000 patients] to use those scarce resources in the most effective way. In ACO care, you still have a foot in the fee-for-service camp, and a foot in the ACO camp.” But, he says, the shift into accountable care inevitably prompts a rethinking of core care delivery and payment models across the board.

Rethinking health plan-provider boundaries

At the vast, 20-plus-hospital University of Pittsburgh Medical Center (UPMC) health system, being an integrated health system that has its own provider-sponsored health plan is making a huge difference in this area, says Steven Shapiro, M.D., the system’s chief medical and scientific officer. At the moment, UPMC is not involved either in any of the Medicare Shared Savings Programs, or in a formal private-payer ACO; but the fact of having its own robust health plan is pushing the system inevitably down the same type of road as organizations that are participating in formal ACOs.

Steven Shapiro, M.D.

Overall, what we’ve got here,” Shapiro says, “is a patient-centered medical home-based model, with an ACO –type structure. Nearly all of our 600 employed primary care physicians are involved in a PMCH-type structure, and then we’ve got virtual arrangements with our independent physicians with our ACO-type structure.” What that set of interconnected relationships inevitably leads to, Shapiro says, is this: “In year one of this work, the biggest issue is culture. The physicians who want to ‘own’ their patients and have access to them immediately, are focusing on keeping those patients out of the hospital and the ED, and are doing the best” in terms of care management. And even though their organization is not participating in an explicit federal ACO, the internal health plan-health system linkage, he notes, means that “Since we can attribute those patients who are the high utilizers, we’re able to move that top five percent who account for almost 50 percent of our costs into care management, where they’re being managed by a specific team that really does a lot of care coordination, and monitors them carefully.” What’s clear, he adds, is that “Though we’re still trying to figure out what an optimal care management team is, it’s clear that there are a lot of structural things we can do to communicate optimally with our patients, and to segregate them by risk, and optimally manage them accordingly.” In fact, he notes, UPMC is developing specialized medical homes for patients at the highest risk in terms of their identified congestive heart failure and COPD (chronic obstructive pulmonary disease).

Many horizons, new opportunities ahead

Working in an ACO context may be challenging, but it can also be rewarding and very stimulating. Such is definitely the case at Crystal Run, where Spencer reports that the learnings coming out of its ACO work are contributing to the organization’s push into new frontiers. In fact, he says, “We have our application into the state of New York to create our own formal health plan, to be called the Crystal Run Health Plan.” If the state of New York approves Crystal Run’s proposal this summer, the health plan would go live in January 2015.

That is quite an ambitious undertaking for a multispecialty medical group, and Spencer acknowledges its rarity. But, he says, “We really felt like we wanted to try to cut out a middleman, to not have a shareholder entity take a large percentage of profits off the table; that instead, we’d prefer to be on the top line of that, and be able to share a bit of the savings directly with purchasers, which would be employers, in our case, and of course, the consumers as plan members. We’ve been on a long journey forward on value-based care already,” he adds, “and we felt that we might as well involve the patient, and kind of do performance risk as well as insurance risk.” He says that “We’re going to be a narrow-network product. The majority of the care would be performed by us.”

In the end, all those interviewed for this article agree that they’re in it for the long run, regardless of what specific developments occur in the Medicare MSSP programs or in private ACO-type arrangements. These healthcare leaders see the future of healthcare in terms of shared risk and responsibility and in terms of value-based care delivery and purchasing, and aren’t afraid of it. They also believe that some of the naysaying coverage of ACO development of late has very much overdrawn. Says Crystal Run’s Spencer, “You know, initially, there had been so much hype around the Medicare Shared Savings Programs for ACOs, with predictions that everybody would save gobs of money. And the concept became so popular that there are now a lot of ACOs in name only. Many people wanted to be ‘modern,’ but weren’t really at the place where they could really manage populations.”

Doing so, he emphasizes, requires a fundamental cultural shift among physicians, other clinicians, and whole organizations, away from a volume-based, fee-for-service-driven mentality, and fully into a care management/population health/value-based mindset. “It’s not easy to get there,” he concludes. “You have to have the mindset of doing only what’s shown to have a positive impact on the patient—the right care and the right time, or stuff that’s shown to be useful. It means looking critically at what you’re doing and delivering just the right care, no more, no less, at the right time and in the right way, and that’s not easy.”