Nor­ton's ACO: One-year checkup

Nor­ton Health­care, Hu­mana al­ready see­ing re­sults in first year of pi­lot project

Modern Healthcare - - Front Page -

One year into an ac­count­able care or­ga­ni­za­tion, Nor­ton Health­care and Hu­mana of­fi­cials can point to re­sults—which is more than any­one ex­pected at the out­set.

As hos­pi­tals, med­i­cal groups and com­mer­cial in­sur­ers grap­ple with how to launch an ac­count­able care net­work and Medi­care of­fi­cials de­bate fi­nal rules for ACO shared-in­cen­tive pay­ments, Nor­ton, which owns four Ken­tucky hos­pi­tals, and in­surer Hu­mana have a year’s worth of re­sults from a lim­ited pi­lot.

So far, their test has pro­duced mi­nor sav­ings and more pro­nounced gains for some qual­ity mea­sures.

“That was not our goal for the first year,” says Dr. Thomas James III, cor­po­rate med­i­cal di­rec­tor of na­tional net­work op­er­a­tions for Hu­mana, who says of­fi­cials ex­pected new strate­gies adopted dur­ing the first year would need time be­fore pro­duc­ing re­sults.

Can­cer screen­ing, rou­tine di­a­betes tests and med­i­ca­tion mon­i­tor­ing all showed im­prove­ment dur­ing the first year of the pi­lot, which in­cluded 10,000 pa­tients (all em­ploy­ees of Nor­ton and Hu­mana) and more than 300 doc­tors, in­clud­ing roughly 200 pri­mary-care, 29 med­i­cal spe­cial­ists and 89 sur­gi­cal spe­cial­ists.

“We did bet­ter than what we ex­pected,” says James, a prac­tic­ing physi­cian who works at Nor­ton hos­pi­tals on week­ends.

Nor­ton and Hu­mana got a jump-start on ac­count­able care from pol­icy ex­perts at the Dart­mouth In­sti­tute for Health Pol­icy & Clin­i­cal Prac­tice and the Brook­ings In­sti­tu­tion’s En­gel­berg Cen­ter for Health Care Re­form.

The Ken­tucky ACO is one of five lo­ca­tions in­cluded in a closely watched Dart­mouthBrook­ings pi­lot of ac­count­able care.

On­go­ing qual­ity ef­forts, height­ened at­ten­tion to ac­count­able care qual­ity mea­sures and ac­cess to new data from Hu­mana helped im­prove per­for­mance dur­ing the first year, says Dr. Steven Hester, Nor­ton’s se­nior vice pres­i­dent and chief med­i­cal of­fi­cer.

For ex­am­ple, Hu­mana’s claims data presents a more com­pre­hen­sive view of doc­tors’ pre- scrib­ing pat­terns and can help iden­tify doc­tors who could switch to gener­ics from brand-name drugs to lower costs, he says.

Nor­ton also hired two care co­or­di­na­tors for pri­mary-care pa­tients and is ex­pected to hire three more. The health sys­tem’s em­ployed doc- tors did not en­ter into ac­count­able care con­tracts, but al­ready re­ceive in­cen­tive pay­ments tied to qual­ity per­for­mance and in­for­ma­tion tech­nol­ogy use, Hester says. Bonuses in­clude in­cen­tives that vary each year as qual­ity pri­or­i­ties change; Nor­ton of­fi­cials in­cluded na­tion­ally rec­og­nized qual­ity mea­sures se­lected by Dart­mouth and Brook­ings for the pi­lot last year, he says.

More di­a­betic pa­tients were tested for blood su­gar con­trol and choles­terol man­age­ment in the first year of the ac­count­able care group. Blood su­gar test­ing in­creased to 93.4% of di­a­betic pa­tients from 87.7% for the base­line year, and choles­terol man­age­ment tests climbed to 91.8% of di­a­bet­ics from 83.9%.

Fewer Nor­ton pa­tients re­ceived an imag­ing study dur­ing the first 28 days after be­ing di­ag­nosed with lower back pain. Imag­ing is un­nec­es­sary for most back-pain pa­tients, a com­mon rea­son for doc­tor’s vis­its, and was one tar­get to im­prove qual­ity and lower health­care costs.

Nor­ton re­ported imag­ing use dropped to 56.3% for newly di­ag­nosed back-pain pa­tients dur­ing the first year com­pared with 65.2% in the base­line year.

Among other qual­ity gains: Breast can­cer screen­ing in­creased, as did cer­vi­cal can­cer screen­ing, though marginally, Nor­ton’s firstyear fig­ures show. Also im­proved was med­i­ca­tion mon­i­tor­ing for pa­tients with longterm pre­scrip­tions.

Pi­lot­ing the ex­per­i­ment

In ad­di­tion to the Ken­tucky part­ners, Dart­mouth and Brook­ings se­lected hos­pi­tals and physi­cian groups at four other lo­ca­tions, in Ari­zona, Cal­i­for­nia and Vir­ginia, for the pi­lot of the health pay­ment re­form model. Other lo­ca­tions in­clude the Car­il­ion Clinic, Roanoke, Va.; Tuc­son (Ariz.) Med­i­cal Cen­ter; and two in­de­pen­dent prac­tice as­so­ci­a­tions, Monarch Health­Care, Irvine, Calif., and Health­Care Part­ners, Tor­rance, Calif.

Dart­mouth and Brook­ings se­lected the lo­ca­tions for their ge­o­graphic and op­er­a­tional di­ver­sity.

The Car­il­ion Clinic, the first of the five pi­lot or­ga­ni­za­tions to an­nounce the Dart­mouth-Brook­ings ex­per­i­ment, has strug­gled to find a pri­vate in­surer will­ing to at­tempt shared sav­ings (July 27, 2009, p. 7) and re­mains the only lo­ca­tion yet to be­gin op­er­at­ing an ACO.

Hu­mana joined the pi­lot in 2009 after the in­surer’s for­mer chief ac­tu­ary, John Berko, pub­licly pro­moted the Dart­mouth-Brook­ings ex­per­i­ment, James says. Berko, at the time a mem­ber of the Medi­care Pay­ment Ad­vi­sory Com­mis­sion, also served as a Brook­ings vis­it­ing scholar.

Nor­ton was an ob­vi­ous part­ner, James says, be­cause Hu­mana had worked with the health sys­tem to develop qual­ity re­port­ing be­fore the part­ners’ ac­count­able care ef­forts.

Prepa­ra­tions be­gan well be­fore shared sav­ings be­came pub­lic pol­icy un­der the 2010 Pa­tient Pro­tec­tion and Af­ford­able Care Act.

Months be­fore the Af­ford­able Care Act be­came law, of­fi­cials met for the first time to dis­cuss shared sav­ings be­tween Hu­mana and Nor­ton. In February 2010, the in­surer and health sys­tem be­gan weekly meet­ings. By June

2010, the Ken­tucky ac­count­able care group fi­nal­ized the method to iden­tify pa­tients in­cluded in the ex­per­i­ment. The part­ners signed an agree­ment in Au­gust that year.

Dart­mouth and Brook­ings sup­plied ini­tial qual­ity mea­sures, the for­mula to cal­cu­late po­ten­tial sav­ings and a method for iden­ti­fy­ing pa­tients in­cluded in the pi­lot. Such de­tails have proved con­tentious in draft reg­u­la­tions for Medi­care ac­count­able care. None­the­less, the tem­plates de­lib­er­ately left many el­e­ments for Nor­ton and Hu­mana of­fi­cials to set­tle.

Each test lo­ca­tion was al­lowed to de­cide how to award in­cen­tive pay­ments and divvy up bonuses—or po­ten­tial losses, known among pol­i­cy­mak­ers as “fi­nan­cial risk.” For ex­am­ple, Health­Care Part­ners agreed to fi­nan­cial risk for some qual­ity mea­sures and Monarch agreed to some par­tial cap­i­ta­tion, which re­quires doc­tors to ab­sorb losses if treat­ment costs more than the ne­go­ti­ated cap­i­tated, or lump sum, pay­ment.

Hester says such flex­i­bil­ity is crit­i­cal be­cause the mar­ket­place and re­la­tion­ships be­tween health sys­tems, doc­tors and com­mer­cial in­sur­ers vary across the U.S.

Nor­ton and Hu­mana agreed to share sav­ings be­yond an ini­tial 2% re­duc­tion in costs for pa­tients in­cluded in the pi­lot. Hos­pi­tals and doc­tors would re­ceive 40% of any sav­ings un­der the ar­range­ment and 60% would be re­turned to Nor­ton and Hu­mana for work­ers’ health­care costs. Nor­ton won’t be li­able for losses should health­care costs ac­cel­er­ate in­stead of slow.

Pa­tients en­rolled in the ac­count­able care pi­lot can con­tinue to seek care out­side of Nor­ton, and em­ployee ben­e­fit plans do not in­clude in­cen­tives for pa­tients to re­main within the ACO, James says. In­stead, Nor­ton providers will com­pete on cost, qual­ity and pa­tient sat­is­fac­tion, which the ac­count­able care ef­fort seeks

Nor­ton Health­care’s hos­pi­tals and physi­cians are part of an ACO pi­lot project con­ducted with in­surer Hu­mana.

Newspapers in English

Newspapers from USA

© PressReader. All rights reserved.