There is a lot happening in the accountable care organization (ACO) market these days. It was unexpected (and exciting) to see Medicare make the announcement a couple weeks ago about their plan to shift 50% of FFS reimbursements to value-based alternative payment models by the end of December 2018 (see Medicare Bets Big On Pay-For-Value). And in the past month we’ve also seen an increase in the number of ACOs joining the Medicare program (see 89 ACOs Join Medicare Shared Savings Program In January 2015) and an announcement by the U.S.’s largest health insurers, UnitedHealthcare, about the significant addition of ACOs to their national delivery system (see UnitedHealthcare Wants To Add 250 ACOs By Year’s End).
Since ACOs are a relatively new market force – just operating over the past five years – the big question is, what have the “early in” ACOs learned that would be useful to the new players in the market? At the 2015 OPEN MINDS Performance Management Institute, early Medicare ACO adopter, Sheila Fusé, CEO of Primary Partners, LLC – one of the 27 ACOs selected to participate in the first cohort of ACOs in April 2012 – offered some great insights.
In her session, Pay-For- Performance In Emerging Care Coordination Models: How ACOs & New Models of Care are Managing Value in Health Care, Ms. Fusé provided unique advice on the processes and challenges of running a successful ACO. Her ACO, Primary Partners, is comprised of over 40 independent practices and 65 provider organizations, and serves over 14,000 Medicare fee-for-service beneficiaries in Lake, Orange, Osceola, and Polk Counties in Florida. Ms. Fusé describes the professionals participating in the ACO as “fiercely independent”, with 70% operating as solo practitioners. What makes Primary Partners, LLC unique?
Primary Partners operates under the advanced payment model, a variation of the Shared Savings Program. ACOs earn revenue through the form of shared savings when the cost of services provided under the ACO is less than their benchmark, the ACO receives a share of the savings. Under the advanced payment model, Primary Partners, LLC received a series of upfront payments to help fund the cost of starting an ACO. Those upfront payments are then paid back when they receive their share of the savings (see The ACO Snapshot).
One of the key cost containment strategies of Primary Partners was to identify the High Utilizer Group (HUG) within their ACO population. This group was defined as individuals with mental health disorders; individuals with CHF, diabetes or chronic obstructive pulmonary disease; individuals with four or more emergency room visits, or three or more inpatient admissions; and the top 50 most expensive patients at each practice. These individuals receive care coordination and wraparound services from the three social workers that the ACO employs. Additionally, these individuals are identified as HUGs in the EHR, alerting the physician that these individuals may need extra attention. One example of this additional attention – one of the practices within the ACO found it particularly effective to provide HUG patients with the provider cellphone number. This encourages the patient to call their physician when they feel they have an emergency situation, and has resulted in a decrease in emergency room services.
Of the 33 quality measures for the Medicare Shared Savings Program ACOs (for complete list, see Pay-For- Performance In Emerging Care Coordination Models: How ACOs & New Models of Care are Managing Value in Health Care), Primary Partners has excelled at some performance measures and is still looking to improve on others. The big news is that Primary Partners has seen a 22% decrease in the number of emergency department visits that result in admission to the hospital, and at only 178 admissions per 1000 visits, this number is much lower than the benchmark (205 per 1,000), as well as other MSSP ACOs (214 per 1,000). But, because Primary Partners total expenses were not under their benchmark, in year one, they did not receive any shared savings payments. The results for year two are not yet available (see Primary Partners Public Reporting).
2013 ACO Performance Summary Statistics
Primary Partners, LLC Performance Rate
Mean Performance Rate of All ACOs
|Risk Standardized, All Condition Readmissions||15.48||15.48|
|ASC Admissions: COPD or Asthma in Older Adults||1.27||1.17|
|ASC Admission: Heart Failure||1.37||1.20|
|Percent of Primary Care Providers who Qualified for EHR Incentive Payment||78.26%||66.21%|
What have the Primary Partners ACO team learned along the way?
Population health is more an art, then a science – ACOs promote freedom of choice for the beneficiary, meaning that they can switch primary care providers at any time. Physicians and their practices must build relationships with their patients, or those patients are apt to go somewhere else for services. Why is this important? If an ACO does not retain 70% of their population than they are not measuring their results against the same population that the ACOs benchmark is derived from. The amount of churn, especially in regards to “snowbirds” (individuals who winter in Florida) is higher for Primary Partners.
Depression screening is the most important quality measure – Current regulations impose 33 quality measures on the ACOs, largely to avoid another round of HMOs and the denial of services. Ms. Fusé stated that Primary Care Partners found depression screening (as performed during Medicare Wellness Visits, and which they strive for every member of the ACO to receive) is one of the most important quality measures, and the one that can make the most difference. Screening for depression early can help get patients the behavioral health care they need, before they require more intensive services. For example, individuals with anxiety tend to be the highest utilizers of expensive emergency department services.
How to measure data – Because ACOs are not health plans and not capitated, providers bill directly to Medicare. The ACO then receives a once monthly set of data that aggregates all the claims paid for their ACO enrollees on a three-month lag. How to utilize this data to identify high utilizers and patients who need more intensive care management is the difficult part. In the past three years, Primary Care Partners has used three models for data analytics from the simple to complex, and are still working on perfecting the model.
The take away, Medicare is moving more and more of its beneficiaries to a value-based payment system – and, like it or not, more provider organizations are going to operate within these models and be part of organizations that accept some form of financial risk. Ms. Fusé said that provider organization executives should start now, so they will have more time to prepare. Even though they have three years before moving to a full-risk model, there is risk involved in starting and operating an ACO (e.g. time, money for physicians and teams, capturing and utilizing data). And as she aptly stated, “It is the responsibility of the ACO to fix the system for their unique populations because if Medicare could have fixed the system for all patients, they would have.”
Why go through all this time, money, and effort? The rationale of Primary Partners is straightforward. Ms. Fuse said, “We decided we’d rather be part of the change, than be forced into it.”