The accountable care revolution is being led across multiple venues in the U.S. healthcare industry, and nowhere more vigorously than in multispecialty physician groups. The logic is inexorable: physicians are the providers closest to patients, particularly the high-risk, high-cost patients whose utilization is leading the bulk of expenditures in the current healthcare system nationwide.
One of the true pioneers, in a literal sense, in this area, is the Brighton, Massachusetts-based Mount Auburn Cambridge Independent Practice Association (MACIPA), with over 500 physicians practicing in 10 communities. Founded in the mid-1980s as a contracting agent for its physicians, MACIPA became an accountable care organization (ACO) in effect years before the term was coined, says Barbara Spivak, M.D., MACIPA’s president. Not surprisingly, Spivak and her colleagues leapt at the chance to become a Pioneer ACO under the Medicare Shared Savings Program, and joined that program with the first cadre of Pioneer ACOs, in January 2012.
Barbara Spivak, M.D.
Dr. Spivak was one of a number of healthcare leaders interviewed by HCI Editor-in-Chief Mark Hagland for the magazine’s July-August cover story. Below are excerpts from her interview with Hagland this spring.
Tell me about the evolution of MACIPA as an organization, and towards accountable care development.
MCIPA was formed in the mid-1980s as a contracting agent for its physicians, when Tufts Health Plan decided it wanted to have a capitation arrangement for its providers. After about 10 years into doing this, in the mid-1990s, with a 19-physician board, the leaders agreed they had to start managing the care of patients. And over time, we have built up what is now considered to be an ACO, even before ACOs were called that.
What has been the timeline around this evolution?
If you look back historically in the 1996-2000 period, we started to build up a very robust program, first of pharmacy management, then of care management, and then of disease management with a quality improvement program that looked both at health screenings and chronic disease. As time went on, we realized that we were very limited by being on paper, and only had the claims data to work with that health plans were sending us. So in 2005-2006, the organization decided it wanted to go electronic. And back in 2006, Blue Cross Blue Shield of Massachusetts gave $50 million to the state of Massachusetts for the e-collaborative to go electronic. It was a competitive bid, and we ended up being number four, so we didn’t get that grant. So we weren’t going to get it paid for by the state; so in essence, we had convinced the physicians in the leadership that going electronic was in fact the right thing to do.
So we worked in a number of different areas, and we ended up picking a vendor, eClinicalWorks, and our first practice went live in 2007; we’re not entirely even today. And not everyone is on eClinicalWorks; our OB/gyn group is on athenahealth, our orthopedic group is on Allscripts, our dermatology-specific group is on a dermatology-specific EMR; our ophthalmologists are on ophthalmology EMRs; and our Cambridge Alliance doctors are on Epic. But the majority of our primary care docs are on eClinicalWorks; and we host eClinicalWorks.
How many physicians are at MACIPA altogether?
We have 500 physicians, and we have over 200 doctors and mid-levels on eClinicalWorks.
Are all of your physicians employed physicians?
No. Of our 500 physicians, about 100 are employed by Cambridge Health Alliance, 150 are employed by Mt. Auburn Hospital, and the rest are private. And we have about 110 primary care doctors, and about 400 specialists. So we have 49 instances of eClinicalWorks at 180 office sites. And even the employed docs are all in different offices, one-to-five-physician offices.
When were the large majority of your practices electronic?
It took us three to four years to get the majority of our practices up, but we’re still implementing some people who had decided to retire but then didn’t. So we still have five or six who aren’t on an electronic medical record, but they’re senior physicians who are going to retire soon.
Which of your organization’s contracts are risk-based contracts?
All of them: Tufts, Harvard Pilgrim Health, Medicare Advantage—all the major commercial plans in Massachusetts, plus Medicare Advantage; and, we’re a Medicare Pioneer ACO.
What made you decide to go that route?