Leaving the Pioneer ACO Program Successful, Atrius Health Gets Ready for its Next Accountable Care Test

When the Centers for Medicare & Medicare Services (CMS) unveiled its Next Generation ACO program in January 2016, accountable care organizations (ACOs) that were in either of the government’s other two ACO models—the Pioneer ACO model and the Medicare Shared Savings Program (MSSP) model—had a leg up, as the newer model was built on many of the accountable care concepts and principles as the elder two initiatives.

As such, for ACOs like Newton, Mass.-based Atrius Health that were in the Pioneer model, which expired at the end of 2016, the federal ACO options going forward in 2017 were either MSSP or Next Gen. For Atrius Health, only one of six Pioneer ACOs to generate shared savings in 2015, the Next Gen model was the right move, since, as Emily Brower, the organization’s vice president of population health puts it, Next Gen “is most like the Pioneer [program], as it included and was built around many of the things that worked in that model.” Brower also notes that the Next Gen model is located in the Center for Medicare & Medicaid Innovation (CMMI), “where we had developed some good collaborative relationships with the team, and that we felt the center would help shape other models going forward. So this was the right path for us,” she says.

Atrius Health, whose participating Pioneer ACO clinicians serve more than 25,000 Medicare beneficiaries in the central and eastern parts of Massachusetts, achieved a 95 percent quality score from CMS and saved Medicare $6.8 million compared to its target, returning $4.4 million in savings to the organization in 2015. When CMS announced the launch of the Next Gen ACO model in 2016, it initially had 21 participants—15 of those which came from either the Pioneer or MSSP models—but then the agency started accepting applications for 2017 participants, and it was announced early on this year that Atrius Health was officially accepted. CMS recently said that the number of 2017 Next Gen ACO participants is 45; the federal agency also announced that 2018 Next Gen participants will qualify as Advanced Alternative Payment Models (APMs) under the Quality Payment Program within the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

Emily Brower

Brower notes that having Next Gen count as a qualified advanced APM was something that attracted Atrius Health, but she adds that being in the MSSP model also would have qualified, as she understands it. “Participating in an ACO model does mean that we can check the box for [the Quality Payment Program] and not have to do two separate processes,” she says. But she adds that a possible complication could occur when an organization has to do a secondary process for the providers that joined the ACO after the list of participants was submitted to CMS. She explains: “CMS is working with us so we could add additional providers to the APM list during the year, and I believe that will happen.” [Upon follow-up, Brower confirmed Atrius Health provider additions will be included in its NextGen ACO for MACRA purposes.] “That will limit the number of providers that an organization will have to do supplemental or MIPS [Merit-Based Incentive Payment System] reporting for. But there will always be some providers who you have a gap for, as we hire people all year long.”

Challenges Ahead

For the Next Gen model, as CMS said at the time of the initiative’s launch, “Participants will have the opportunity to take on higher levels of financial risk—up to 100 percent risk—than ACOs in current initiatives. While they are at greater financial risk they also have a greater opportunity to share in more of the Model’s savings through better care coordination and care management.”

Rather than a substantial roadblock, Brower sees this as a great opportunity for Atrius Health. “Eighty percent of our revenue is in full risk. So this model is more like what we do elsewhere. And it gives us more of a 1:1 correlation in terms of the effort we’re putting in and the reward gained,” she says. “So rather than a dollar you save going through a process where a piece goes here and a piece there, and you share that with CMS, [for this model], CMS takes a discount of their savings off the top and then 100 percent of the risk or reward lies with the ACO against that discounted benchmark. That’s more typical of the other payer contracts we have, so that works for us,” Brower attests.

As for the keys for success in Next Gen, it comes down to the same goals that Atrius Health has always had—to improve outcomes for patients at a more affordable cost. “That remains the same, and is true for any of the ACO models,” Brower says, adding that what’s different about Next Gen is that there is an opportunity for what are called “benefit enhancements.” She says the very first of those was developed in the Pioneer model, and that was a waiver for the three-day hospitalization rule for a skilled nursing facility (SNF), with the intent to save money on hospitalizations by having “patients admitted to a SNF directly from their home, a doctor’s office, or if they have fewer than three consecutive inpatient days in the hospital,” according to CMS. As such, that enhancement afforded Atrius Health a lot more flexibility to treat patients appropriately for what they need without having to send them to a hospital when it’s not needed, but rather getting them into rehab on day one, says Brower. “So that was called a waiver in Pioneer, or a benefit enhancement in Next Gen, and there will be a few more of those waivers coming down the pike,” she says.

Another benefit enhancement example is around telehealth, Brower notes. With this flexibility, Atrius Health will be able to give its patients immediate access to telehealth, she says. “What CMS has done is allow some flexibility in the Medicare telehealth benefit, so Atrius Health can now participate in that, which is great for us and great for our patients.” Indeed, according to CMS, the telehealth expansion waiver “has an expanded benefit allowing beneficiaries who are associated with a Next Generation ACO to receive telehealth services from their doctor from their homes, regardless of geographic location.” This is in contrast to normal Medicare policies which only cover limited telehealth services.

Needless to say, Brower is bullish on Atrius Health’s outlook for success in the Next Gen ACO model. Despite the organization’s strong performance in the Pioneer program, 20 of the 32 original participants of that model eventually dropped out. But Brower advises folks to dig deeper into the reasons why they left. “Different models work better for different groups, for a whole variety of reasons, sometimes having to do with where you are geographically and what the Medicare fee schedule is in that region. Or sometimes it has to do with the makeup of the healthcare market in that region, [depending] on if there are mostly teaching hospitals or community hospitals there. I don’t think of it as someone dropping out, but rather choosing the model that works best for them,” she says.

Brower adds that she knows groups that may have started in Pioneer and didn’t change models because things weren’t working per se, but rather for other reasons. “I know some who have switched models and were getting incredible quality results around managing patients with chronic disease, avoiding unnecessary hospitalizations, so good stuff around quality, but the way the budget is created is a little different in those three [federal] programs. You have to understand it to understand which will be most beneficial for your ACO,” she says.

Brower feels that the despite the rumblings from some that ACOs have not produced great results to date, multiple ACO iterations on improving prior models represent a shift in how the healthcare delivery system feels they can better deliver care to their patients. “I see that as a very market responsiveness approach to care, and that sits right in the sweet spot of an administration that is looking to put more decisions being made about care in the hands of the delivery systems.” She adds, “We have a physician leader who’s heading HHS [Health and Human Services], and I think this would be very attractive to him.”

What’s more, Brower says that while federal ACOs may not be getting the “shared savings” that some look for, the media should not be focusing on the dollars as much as the quality that ACOs are delivering on. “Are they decreasing unnecessary and disruptive care? Are they providing more coordinated care? Are they helping patients manage multiple chronic illnesses? And in all of that literature, it’s been a home run. A lot of that skepticism is focused on the wrong numbers,” she says.