FEEL­ING THE HEAT

With the num­ber of Medi­care ACOS more than dou­bling, the pres­sure is mount­ing on providers and the CMS to per­form

Modern Healthcare - - FRONT PAGE - Me­lanie Evans —with Rich Daly

The Fam­i­lyCare Med­i­cal Group in Syra­cuse, N. Y., con­sid­ered but re­jected Medi­care’s ac­count­able care ini­tia­tive be­cause of a lack of needed cap­i­tal. The doc­tors were then ap­proached by an in­sur­ance com­pany with an in­ter­est in ac­count­able care and the in­for­ma­tion tech­nol­ogy re­sources the doc­tors needed. A deal was made.

Doc­tors will in­vest time, but not the sig­nif­i­cant cash needed for hard­ware, soft­ware and staffing to man­age med­i­cal care for 12,000 se­niors en­rolled in Medi­care, said Dr. David Page, med­i­cal di­rec­tor of the Ac­count­able Care Coali­tion of Syra­cuse, one of Medi­care’s lat­est ACOs. “We’re a bunch of pri­mary-care doc­tors,” said Page, who founded the 65physi­cian prac­tice. “We don’t have that cap­i­tal float­ing around.”

Medi­care’s launch of ac­count­able care has proved pop­u­lar, at­tract­ing small and ru­ral providers along with the large, well-funded med­i­cal groups and health sys­tems con­sid­ered best po­si­tioned to form ACOs.

The ven­ture has mush­roomed since Jan­uary, to the sat­is­fac­tion of fed­eral of­fi­cials who said the growth proved naysay­ers wrong.

The Syra­cuse ACO was one of 89 new ones named last week. “And I think, con­trary to some fears that were ex­pressed last year, we have a very strong pro­gram that ex­ceeds our goals that we had for the first year,” Jonathan Blum, prin­ci­pal deputy ad­min­is­tra­tor and di­rec­tor of the Cen­ter for Medi­care, told re­porters.

But it has come with some snags, in­clud­ing de­lays for data that providers deem cru­cial to suc­cess. Doc­tors and hos­pi­tals found other data un­nec­es­sar­ily cum­ber­some and lob­bied the CMS for a fix.

And as hun­dreds more or­ga­ni­za­tions are expected to ap­ply for the next round of con­tracts, it’s still too early to know whether the ones in the pro­gram are de­liv­er­ing bet­ter care at lower costs, as the gov­ern­ment in­tends, and whether they will be com­pen­sated for their trou­ble.

“Ev­ery­body needs to be pa­tient,” Page said, “the physi­cians, the pa­tients and Medi­care. This is a big ex­per­i­ment.” Doc­tors need time to change how they do their jobs. “I just hope that ev­ery­body’s got the in­testi- nal for­ti­tude so that we can change at a pace that we can ac­com­mo­date,” Page said, and that will re­quire Medi­care to set re­al­is­tic goals and pro­vide ed­u­ca­tion.

“If they don’t nur­ture us prop­erly and al­low us to ma­ture at a rate we can ma­ture at, then we’ll fail,” he said.

Roughly six months ago, Medi­care reached its first con­tracts for ac­count­able care. Medi­care agreed to give hos­pi­tals and doc­tors a cut if providers saved money on treat­ing se­niors and si­mul­ta­ne­ously hit qual­ity tar­gets.

Thirty-two or­ga­ni­za­tions agreed to the deal in Jan­uary un­der the CMS In­no­va­tion Cen­ter’s Pi­o­neer ACO model, join­ing a half dozen med­i­cal groups that first tested the pay­ment model.

Since then, the num­ber of Medi­care ac­count­able care con­tracts has in­creased four-fold. An­other 27 or­ga­ni­za­tions fol­lowed in April un­der the shared sav­ings pro­gram cre­ated by the Pa­tient Pro­tec­tion and Af­ford­able Care Act.

The agency had sig­nif­i­cantly re­vised the fi­nal rules to make the pro­gram more at­trac­tive af­ter sharp criticism of an early pro­posal (Oct. 24, 2011, p. 6). Last week, 89 ACOs be­came the lat­est to sign shared sav­ings con­tracts—in­clud­ing the Syra­cuse ACO—and Blum said 400 more have ex­pressed in­ter­est in con­tracts for next year. “We are build­ing a pro­gram that is strong and is grow­ing quickly,” he told re­porters last week.

Medi­care’s lat­est ac­count­able care con­tracts cap­tured a cross sec­tion of the na­tion’s health­care op­er­a­tors, in­clud­ing some that rely on part­ners to clear away ob­sta­cles to en­try.

Univer­sal Amer­i­can, a pub­licly traded Medi­care Ad­van­tage and sup­ple­men­tal in­sur­ance provider, owns a stake in one out of ev­ery 10 Medi­care ACOs. That in­cludes the Syra­cuse ACO and Es­sen­tial Care Part­ners, an ACO com­posed of 14 fed­er­ally qual­i­fied

health cen­ters across Texas.

Es­sen­tial Care Part­ners would not yet be an ACO un­der con­tract with Medi­care with­out its cor­po­rate part­ner’s data an­a­lyt­ics ca­pa­bil­i­ties, said Jose Ca­ma­cho, ex­ec­u­tive di­rec­tor of the Texas As­so­ci­a­tion of Community Health Cen­ters and board chair­man of Es­sen­tial Care Part­ners. “Not this quickly,” he said.

Univer­sal Amer­i­can will re­ceive a share of any sav­ings bonus that doc­tors earn by hold­ing down costs, said Robert Waegelein, co-pres­i­dent and chief fi­nan­cial of­fi­cer for Univer­sal Amer­i­can. The com­pany ex­pects to ap­ply for the next round of Medi­care ACOs. “We’re very bullish on this op­por­tu­nity,” he said.

Among the new­est Medi­care ACOs, one out of four are groups of fewer than 100 doc­tors and do not in­clude a hospi­tal in the for­mal net­work. One out of 10 ACOs have more than 1,000 doc­tors that have for­mally part­nered with hos­pi­tals.

In an in­ter­view, Blum said there is no limit to the num­ber of ACOs the agency can ap­prove from each round of ap­pli­ca­tions. “I am con­fi­dent we have the re­sources in place to sup­port the in­ter­est,” he said.

Sup­port and feed­back about what does and does not work will be nec­es­sary for ACOs to suc­ceed, Page said. Now, the Syra­cuse ACO’s doc­tors are wait­ing for data from the CMS. The med­i­cal group must also adapt its elec­tronic health record to re­port new mea­sures to Medi­care, Page said. And doc­tors will need to talk with area hos­pi­tals not in­cluded in the ACO for help co­or­di­nat­ing care as pa­tients en­ter and exit the hospi­tal.

Medi­care of­fi­cials re­ceived feed­back from ACOs that be­gan April 1 af­ter providers strug­gled to use data that iden­ti­fied pa­tients for whom doc­tors would be ac­count­able.

ACOs agree to man­age med­i­cal care for a spe­cific group of pa­tients iden­ti­fied by which doc­tors they visit. Medi­care agreed to send providers a list of the pa­tients up­front but then failed to iden­tify which pa­tients visit which doc­tors.

“It’s been an in­ter­est­ing cou­ple of months,” said Dr. Morey Menacker, a pri­mary-care doc­tor in Para­mus, N.J., and pres­i­dent of the Hack­en­sack Al­liance ACO, which en­tered into an April 1 ac­count­able care con­tract with Medi­care. Frus­trated com­ments from ACOs prompted the CMS to try again with bet­ter re­sults.

That’s not the only data hic­cup Medi­care ACOs have ex­pe­ri­enced.

Mar­i­lyn Taven­ner, act­ing ad­min­is­tra­tor for the CMS, said in June that the first wave of Medi­care ACOs faced data de­lays that prompted the agency to work to stream­line clin­i­cal data ac­cess, Mod­ern Health­care re­ported. “While we have a will­ing­ness to share data, it’s not al­ways as sim­ple as we had hoped,” she said.

The CMS will re­view ACO per­for­mance mea­sures, such as hos­pi­tal­iza­tion and the cost of care, quar­terly and an­nu­ally for progress, Taven­ner said. The agency will also even­tu­ally re­lease per­for­mance mea­sures pub­licly. Last week, the CMS re­leased a pro­posed rule that sug­gested post­ing 2013 ACO per­for­mance data on its con­sumer web­site Physi­cian Com­pare.

Blum con­firmed “kinks” in the agency’s data dis­tri­bu­tion and providers’ abil­ity to ac­cept and use the in­for­ma­tion. He said the agency pre­vi­ously re­leased data an­nu­ally and had to over­come some hur­dles to stream data to ACOs each month. He said the process had im­proved.

John Friend, ex­ec­u­tive di­rec­tor of the Ari­zona Con­nected Care board, an April ACO that in­cludes the Tuc­son Med­i­cal Cen­ter, three fed­er­ally qual­i­fied health cen­ters plus 150 doc­tors, said par­tic­i­pants have worked with the best in­ten­tions to ad­dress early tech­nol­ogy snags.

All par­tic­i­pants share the de­sire for a health sys­tem driven by use­ful data and met­rics, but providers and pay­ers still lack all the nec­es­sary com­po­nents, he said. “Not ev­ery­thing’s in place.” Medi­care is grap­pling with how to trans­mit data that is use­ful and timely. And providers are strug­gling to, for the first time, for­mat, store and use that data, he said.

Ac­cess to fed­eral data to help doc­tors mon­i­tor care de­liv­ery, qual­ity and costs fac­tored sig­nif­i­cantly into ProMed­ica Physi­cian Group’s de­ci­sion to ap­ply to Medi­care’s ac­count­able care ef­fort, said Dr. Julie Tome, di­rec­tor of ProMed­ica’s ACO. The 250-doc­tor group in Toledo, Ohio, be­came a Medi­care ACO on July 1.

Suc­cess for doc­tors and hos­pi­tals hinges in part with Medi­care’s abil­ity to pro­vide timely data, said Dr. Si­mon Prince, pres­i­dent and CEO of Bea­con Health Part­ners. The Man­has­set, N.Y.-based net­work ap­plied to be­come a Medi­care ACO on July 1 with­out any con­crete ex­am­ples that Medi­care could de­liver.

“We re­ally didn’t have much to go on,” he said. The ap­pli­ca­tion was ac­cepted. “It’s sort of

need.”<< a leap of faith that we’ll get the data we

TAKE­AWAY: rapid growth The of Medi­care ACOS is test­ing the re­sources of the par­tic­i­pants and the CMS.

Ac­cess to fed­eral data fac­tored sig­nif­i­cantly into ProMed­ica Physi­cian Group’s de­ci­sion to ap­ply to Medi­care’s ac­count­able care ef­fort, says Dr. Julie Tome, left, with nurse Beth DeAr­mond.

Source: CMS

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