The early re­turns on ac­count­able care

Newly minted ACOS grap­ple with al­lo­cat­ing re­sources and ad­just­ing op­er­a­tions to put the the­ory to work

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Sharp Health­Care in San Diego, which formed one of the first Medi­care ac­count­able care or­ga­ni­za­tions, be­gan to comb through lists of se­niors for whom its doc­tors must man­age care and costs only to find a num­ber lacked pri­mary-care physi­cians.

The de­vel­op­ment presents a chal­lenge for the newly cre­ated ACO, which seeks to pro­mote care co­or­di­na­tion, well­ness and dis­ease preven­tion through pri­mary care.

Sharp has started to contact se­niors to per­suade them to se­lect a pri­mary-care doc­tor, but can­not force them to visit. “These pa­tients have choice,” says Ali­son Fleury, se­nior vice pres­i­dent of busi­ness de­vel­op­ment for Sharp and CEO of its ACO. “Pa­tient en­gage­ment is our No. 1 op­por­tu­nity and our No. 1 chal­lenge.”

As ac­count­able care moves from the­ory and pol­icy to prac­tice, hos­pi­tals and doc­tors are grap­pling with new strate­gies and in­vest­ments that they hope will be the most likely to achieve higher qual­ity and lower costs, said re­spon­dents in Mod­ern Health­care’s sec­ond an­nual Ac­count­able Care Or­ga­ni­za­tions Sur­vey. This year’s sur­vey in­cludes 26 ACOs.

Un­der ac­count­able care, hos­pi­tals and doc­tors re­ceive fi­nan­cial in­cen­tives to achieve qual­ity gains and re­duce health­care spend­ing. The pay­ment model has gained a foothold among com­mer­cial in­sur­ers, such as Blue Shield of Cal­i­for­nia—which re­ported re­sults for five ac­count­able care con­tracts to the sur­vey—and Medi­care.

Providers sur­veyed by Mod­ern Health­care re­ported pri­vate and pub­lic ac­count­able care con­tracts, and ex­ec­u­tives say the di­ver­si­fi­ca­tion was a push to move away from tra­di­tional pay­ment to re­im­burse­ment that will cover costs of preven­tion and health pro­mo­tion.

“This isn’t our strat­egy for Medi­care, this is just our strat­egy,” says Dr. Ti­mothy Ferris, med­i­cal di­rec­tor of the Mass Gen­eral Physi­cians Or­ga­ni­za­tion at Bos­ton’s Mas­sachusetts Gen­eral Hospi­tal, of the Part­ners Health­Care Sys­tem ACO.

Ac­count­able care went from a hotly de­bated the­ory to the ba­sis for new com­pa­nies and con­tracts within the past year.

Since Jan­uary, Medi­care has an­nounced nearly 150 ac­count­able care con­tracts and more than 400 or­ga­ni­za­tions have said they will seek to ap­ply for 2013. Medi­care launched its ac­count­able care ini­tia­tive this year un­der a pro­vi­sion for the pay­ment model in the Pa­tient Pro­tec­tion and Af­ford­able Care Act.

Jonathan Blum, prin­ci­pal deputy ad­min­is­tra­tor and di­rec­tor of the Cen­ter for Medi­care, touted the pro­gram’s growth in July as he named the lat­est crop of 89 Medi­care ACOs. He says the de­gree of provider in­ter­est in Medi­care’s ac­count­able care ef­forts, which now cover roughly 2.4 mil­lion se­niors, was sig­nif­i­cant. “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,” he says.

Medi­care’s early pro­pos­als for ac­count­able care met with criticism and damp­ened in­ter­est in the fed­eral ini­tia­tive, but of­fi­cials heav­ily re­vised the fi­nal rules to providers’ ap­proval. Medi­care’s ma­jor changes in­cluded re­duc­ing the qual­ity mea­sures to 33 from 65. Fed­eral of­fi­cials also agreed to of­fer one of

two pay­ment op­tions with­out the risk of a po­ten­tial penalty.

Blum says no data was yet avail­able in July on per­for­mance of Medi­care’s first ACOs. Pub­lic re­port­ing of the ACOs’ per­for­mance won’t be­gin un­til next year, he says.

“I think, hon­estly, it’s too early,” he says. “The or­ga­ni­za­tions just came into the pro­gram. So it’s too early to give an in­di­ca­tion of qual­ity im­prove­ment, cost sav­ings. Ob­vi­ously, this is go­ing to be a key fac­tor that we’re go­ing to track very care­fully. We have a very strong in­ter­est to en­sure that ben­e­fi­cia­ries get bet­ter ser­vices than they do to­day,” Blum says.

Medi­care’s ac­count­able care ini­tia­tives served as a model for or­ga­ni­za­tions as they planned their own ef­forts, ex­ec­u­tives says.

That was the case for Mercy Health in Cincin­nati. Paul Hiltz, pres­i­dent of the Cincin­nati health sys­tem’s ACO, Mercy Health Se­lect, says of­fi­cials re­lied on Medi­care’s ini­tia­tive to for­mu­late plans even as le­gal chal­lenges to the Af­ford­able Care Act re­mained un­set­tled.

A U.S. Supreme Court case this year threat­ened to strike down the en­tire law. In June, the court largely up­held the Af­ford­able Care Act.

Mercy of­fi­cials be­lieved that prepa­ra­tion for Medi­care ac­count­able care would not go to waste de­spite the un­cer­tainty ahead of the de­ci­sion, he says. If the court threw out the ACA— and with it, Medi­care ac­count­able care—fledg­ling com­mer­cial ef­forts would nonethe­less continue and Mercy would be ready, he says.

‘A great start­ing point’

Charles Vig­nos, chief oper­at­ing of­fi­cer for Summa Health Sys­tem’s ACO, the NewHealth Col­lab­o­ra­tive, says early plan­ning ef­forts were de­vel­oped with Medi­care’s ini­tia­tive in mind. Al­ter­na­tives such as bun­dled pay­ments do not as com­pre­hen­sively tackle the goals of im­proved care and re­duced costs, he says.

He de­scribed Medi­care’s ACO as “a great start­ing point” that he says he ex­pects to evolve. “We need to start some­where.”

Summa’s ex­pe­ri­ence with Medi­care man­aged care, which be­gan in Jan­uary 2011, and its ac­count­able care ef­fort with em­ploy­ees, which be­gan six months ago, pre­pared the sys­tem for Medi­care’s ACO, he says.

As more pa­tients come un­der ac­count­able care con­tracts, it will be eas­ier to per­suade physi­cians to be more proac­tive about man- ag­ing pa­tients’ health rather than wait­ing to care for some­one who grows acutely ill. Summa’s en­roll­ment in­cludes about 25,000 se­niors in a Medi­care ACO launched July 1 and 17,500 mem­bers in Medi­care Ad­van­tage and pri­vate self-funded plans.

Hospi­tal and med­i­cal groups have be­gun hir­ing as they seek to more closely man­age pa­tients’ care un­der ACOs.

Akron, Ohio-based Summa part­nered with about 225 in­de­pen­dent doc­tors, who pro­vided some seed money for cap­i­tal in­vest­ments, in­clud­ing in­for­ma­tion tech­nol­ogy and the hir­ing of data an­a­lysts and care co­or­di­na­tors, Vig­nos says.

In Cincin­nati, Mercy Health Se­lect will continue to ex­pand its staff of care co­or­di­na­tors, who will team up with be­hav­ioral health and so­cial work pro­fes­sion­als to man­age pa­tient care within pri­mary-care prac­tices, says Luisa Hur­tado, di­rec­tor of op­er­a­tions for the ACO.

It’s a model that has helped re­duce read­mis­sions within six physi­cian prac­tices that have served as pi­lot sites within the past nine months, Hiltz says.

Mercy is expected to em­ploy one care co­or­di­na­tor for ev­ery 350 pa­tients, she says. The

Medi­care ACO is expected to in­clude 22,000 se­niors.

Of­fi­cials do not ex­pect an im­me­di­ate pay­off from in­vested cap­i­tal. “In terms of a re­turn on in­vest­ment, in the short run, we’re look­ing at this as more re­search and de­vel­op­ment,” Hiltz says.

Sharp will spend $800,000 to­ward ex­pand­ing its case-man­age­ment staff through 2012 and an­other $85,000 for its nurse triage line.

Part­ners Health­Care will dou­ble its num­ber of care co­or­di­na­tors from the 25 it hired for a demon­stra­tion that pre­dated the Medi­care ACO, Ferris says. Each will work with 200 to 250 high­risk pa­tients and will be em­bed­ded within a pri­mary-care prac­tice. Ferris says the or­ga­ni­za­tion is work­ing hard to get in­fra­struc­ture in place, “know­ing that the clock is tick­ing.”

Ex­ec­u­tives at the ear­li­est or­ga­ni­za­tions to adopt ac­count­able care say they are learn­ing and adapt­ing as they go.

At the Univer­sity of Michi­gan, the fac­ulty prac­tice group was one of 10 med­i­cal groups in a five-year Medi­care pi­lot that be­came the model for ac­count­able care. That pi­lot ended in 2010, but the univer­sity’s doc­tors en­tered a tran­si­tion con­tract be­fore be­ing named in Jan­uary one of the first Medi­care ACOs cre­ated un­der the Af­ford­able Care Act.

Thanks to that his­tory, the Univer­sity of Michi­gan al­ready op­er­ates the data an­a­lyt­ics and care co­or­di­na­tion that oth­ers are seek­ing to build, says Dr. Caro­line Blaum, med­i­cal di­rec­tor for the ACO and as­sis­tant dean of

clin­i­cal af­fairs and as­so­ciate med­i­cal di­rec­tor of fac­ulty group prac­tice at the univer­sity.

The ACO has be­gun to fo­cus on how to best man­age com­plex pa­tients, such as the frail el­derly or those with con­ges­tive heart fail­ure. Ac­count­able care is de­signed around pri­mary care, but the costli­est pa­tients of­ten rely on spe­cial­ists to man­age com­plex dis­eases, she says. In­deed, 1 out of 4 pa­tients within the Michi­gan ACO lacks a pri­mary-care doc­tor.

New strate­gies may in­volve joint ef­forts to man­age pa­tient care be­tween pri­ma­rycare and spe­cialty physi­cians. “This is now the new fron­tier,” she says.

The group prac­tice also learned from ear­lier ef­forts. The ACO dis­con­tin­ued a pro­gram for pa­tients to speak with a phar­ma­cist as they left the hospi­tal as it proved too costly and reached too few pa­tients, she says. Pa­tient calls will now be di­rected to care co­or­di­na­tors within physi­cian of­fices in­stead of a cen­tral call cen­ter.

And its Medi­care ACO for the first time in­cludes in­de­pen­dent doc­tors, Blaum says, in an ef­fort to ex­pand its net­work ca­pac­ity and the num­ber of Medi­care en­rollees in­cluded in the ACO. In­te­gra­tion of an in­de­pen­dent prac­tice into the ACO faces some chal­lenges, in­clud­ing di­verse IT sys­tems. The part­ners meet ev­ery two weeks to dis­cuss data, she says.

Set­ting new goals

Ad­vo­cate Health Care, based in Oak Brook, Ill., en­tered the sec­ond year of its ac­count­able care con­tract in Jan­uary with Blue Cross and Blue Shield of Illi­nois.

Ad­vo­cate suc­cess­fully met its first-year goal to keep its pa­tient days per 1,000 pa­tient months at 5% be­low the mar­ket, a key mea­sure of uti­liza­tion, says Dr. Lee Sacks, ex­ec­u­tive vice pres­i­dent and chief med­i­cal of­fi­cer. The hospi­tal is the most ex­pen­sive place to care for pa­tients, and ef­forts to re­duce hospi­tal vis­its will re­duce health­care spend­ing.

But of­fi­cials in­tro­duced new mea­sures for the sec­ond year that Sacks says give doc­tors more con­crete goals. The first-year goal was a tar­get, but it left doc­tors to fig­ure out what ac­tions to take to ac­com­plish the goal.

Now Ad­vo­cate’s ACO tracks per­for­mance us­ing five new mea­sures: emer­gency depart­ment vis­its, ad­mis­sions, read- mis­sions, length of stay and net­work care co­or­di­na­tion. If the sys­tem can re­duce uti­liza­tion—vis­its to the emer­gency room and time spent in the hospi­tal—and im­prove care co­or­di­na­tion, fi­nan­cial re­sults should im­prove as well, Sacks says.

The Illi­nois Blues ACO in­cludes 370,000 pa­tients and Ad­vo­cate launched an em­ployee ACO for roughly 8,000 work­ers and their de­pen­dents in Jan­uary. The Medi­care ACO adds an­other 130,000 to the sys­tem’s ac­count­able care ef­forts and Ad­vo­cate may ex­tend its pro­gram into Medi­care man­aged care next year, he says

“It’s an ex­cit­ing time,” Sacks says. “The feed­back from pa­tients and physi­cians and care co­or­di­na­tors is that ev­ery­body sees the op­por­tu­ni­ties and the value that this has al­lowed us to pro­vide and it gives me a con­fi­dence that a good num­ber of the 154 (Medi­care ACOs) will be suc­cess­ful and pro­vide bet­ter care at a lower price.”

Sharp’s ACO, which in­cludes Dr. John Hip­pen of the Sharp Rees-Stealy Med­i­cal Group, has found that a num­ber of its Medi­care pa­tients don’t have a pri­mary-care doc­tor.

Dr. Stephen Wil­son prac­tices at Mercy Health-For­est Park In­ter­nal Medicine and Pe­di­atrics in Cincin­nati, which op­er­ates as a pa­tient-cen­tered med­i­cal home and was part of a pi­lot Mercy Health ran in ad­vance of its ACO.

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