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Medicare ACOs in the Trenches: How to Survive in Healthcare’s Changing World (Part 1)

September 7, 2016
by Rajiv Leventhal
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In Massachusetts, Atrius Health’s strong foundation in value-based care has helped the organization soar to the top of the ACO landscape

When the Centers for Medicare & Medicaid Services (CMS) released 2015 financial and quality performance results for accountable care organizations (ACOs) in two federal programs late last month, the data mostly revealed varying degrees of success.

Indeed, a Healthcare Informatics visual analysis of how organizations performed in the two models—the Medicare Shared Savings Program (MSSP) and the Pioneer ACO program—found that financially, many ACOs (69 percent) are struggling to generate shared savings for Medicare and their organization, while a significant amount (48 percent) are finding it difficult to produce any savings at all. On the contrary, however, there were positives to take out of the data. For one, ACOs with more experience tend to perform better over time. Further, ACOs in both programs continued to showed improvements in their quality scores.

There are now more than 400 federal ACOs across the two models, and the number of Medicare beneficiaries served by ACOs continues to grow, according to CMS officials. They get judged on their performance, as well as their improvement, on an array of metrics that assess the care they deliver. Those metrics include how highly patients rated their doctor, how well clinicians communicated, whether patients are screened for high blood pressure, and their use of electronic health records (EHRs).

In sum, while many ACOs are finding it tough to deliver results, others have been able to succeed. In the Pioneer model, which is now down to 12 participating organizations after starting with 32 in 2012, Newton, Mass.-based Atrius Health is one patient care system that been able to hold its own in a program that has seen two-thirds of its members leave.  

Atrius Health, whose participating Pioneer ACO clinicians serve more than 25,000 Medicare beneficiaries in the central and eastern parts of the state, 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 last year. It was only one of six Pioneer ACOs to generate shared savings in 2015. And, this was the fourth year in a row that Atrius Health has seen improved financial performance while in the Pioneer model.

Regarding quality, CMS chooses 33 quality measures to represent patient/caregiver experience, care coordination, and patient safety, preventive health, and risk for patients with diabetes, hypertension, ischemic vascular disease, and heart failure and/or coronary artery disease. On 30 of the 33 measures, Atrius Health scored above the mean, while performing over the 90th percentile benchmark on several measures across all care domains examined. For both financial and quality results, Atrius Health officials note that 2015 was the best year for the ACO, which was one of the original 32 Pioneer program members.

Going “All-In”

According to Emily Brower, vice president of population health at Atrius Health, the organization’s ACO story has been one of focus, quality and partnership. One of the keys, Brower notes, was bringing traditional Medicare fee-for-service patients who were not part of any value-based payment model into the existing risk-based programs that Atrius Health was already partaking in. After all, the health system has been involved for years in working with its health plan partners on moving as much of its business into value-based payment models as possible. “Considering the place we were coming from, a lot of the reason our performance has been sustained is that part of what we do is not new work for us,” says Brower.

Emily Brower

Indeed, for many organizations, their participation in a Medicare ACO is an early or initial step into value. For them, it will take years to build year-over-year savings, says Brower. “We have seen this in the Medicare ACO results that have been published so far over the four years,” she says. “Earlier beginners have gotten better results. There are no shortcuts; this is hard work that will take years of investment. Healthcare is going through a huge shift as an industry, so the idea that you would expect to get nationwide achievement at some very high level would be really unusual,” she says, responding to ACO naysayers. Even in the first two years that Atrius Health was in the Pioneer model, its results were up-and-down, and wasn’t able to exceed its minimum savings rate, despite coming in with a “really strong foundation in value-based care delivery,” Brower notes.

What’s more, Brower says that getting most of its contracts in value-based models, compared to only some, makes it easier to embrace a care delivery process centered around quality. “It’s not something we are doing a little of; we’re all in,” she says. “It is so hard to do business in two very different streams for how you’re delivering the service and how the service is paid for. And that goes for any business. A lot of it is about embracing that model across payers, as you get more bang for your buck.”