Things are moving forward quickly along several fronts at Atlantic Health System, the five-hospital based integrated health system based in Morristown, New Jersey. There, a broad-based strategic initiative that encompasses two separate accountable care organizations (ACOs) developed by the health system, is pushing the envelope on quality and efficiency along multiple dimensions.
Atlantic Health System has two active ACO organizations, the Atlantic Accountable Care Organization (AACO), and Optimus Healthcare Partners. Among other efforts, the leaders of AACO and Optimus have identified a set of quality measures for skilled nursing facilities to target, around such concerns as length of stay, reduced hospital readmissions, and cost reductions, and have been able to work with 61 SNFs to achieve advances in all three areas.
Meanwhile, Atlantic Health continues to evolve forward its two ACOs. And in that context, one of the senior executives in the organization who is helping to lead its accountable care strategic push is Poonam Alaigh, M.D. Dr. Alaigh is working with Atlantic Health System, with the title of corporate consultant (though she is an employee). She has a long and distinguished career in healthcare; most recently, she was the Commissioner of Health and Senior Services for the state of New Jersey, where she had responsibility for the operational oversight and management of the state’s Department of Health and Senior Services. Prior to that, she had been executive medical director at Horizon Blue Cross Blue Shield of New Jersey, and before that, she had been national medical director for GlaxoSmithKline. An internist, she continues to practice part-time at the New Jersey Veterans Administration at Lyons, and is an assistant professor in the Department of Family Practice at UMDNJ/Robert Wood Johnson University Medical Center. She spoke recently with HCI Editor-in-Chief Mark Hagland about the accountable care efforts at Atlantic Health System. Below are excerpts from that interview.
You’ve got a lot of activities going on. You’re also still practicing medicine?
Yes, I’m an internist. I’ve always kept my clinical practice, through all the different roles I’ve worked in. I’ve been seeing patients at the VA here in New Jersey, for the past ten years. I was one of the first hospitalists in the country in the 1990s. I’ve worked with different health plans, with pharmaceuticals. Then in 2010, Governor Christie asked me to join his team. And at the state level and now working in the private sector, I’ve been involved in different elements of healthcare reform. And in April 2012, we started an MSSP [Medicare Shared Savings Program] ACO, Atlantic ACO. Now it’s commercialized, too.
Poonam Alaigh, M.D.
It’s really been an interesting journey. We started with 45,000 Medicare members; now we have 100,000 Medicare members, and 350,000 altogether, including Optimus. Atlantic Health System had two ACOs. We brought the two ACOs together in the last two years, so we went from 45,000, only Medicare beneficiaries in April 2012, to 350,000 members, 100,000 of whom are Medicare, and 250,000 of whom are commercial.
Are they still operating under two different corporate brand names?
Yes, and actually, we’re still two ACOs, even as we’ve now brought them together under the same MSO [management services organization].
Has Atlantic ACO achieved shared savings under the MSSP? Any savings?
We have not achieved shared savings yet in Atlantic ACO. You can form ACOs for two reasons. One is for immediate gratification. We went as a system with 2,000 physicians, nearly 70,000 Medicare beneficiaries. We went into this to be a change agent. And any physician who wanted to participate could participate. We never set any criteria for participation. We just always said, if you want to be part of change and learn with us and have the intention of evolving with us as a system, then come join us. So we went into this to change healthcare. Meanwhile, the Optimus model was a provider-driven model. It’s achieved shared savings every year. But this was a highly selected group of physicians who had experience in pay for performance healthcare, and who had had experience in patient-centered medical homes—about 500 right now.
Have you wrapped your ACO work into the core organizing strategy for the Atlantic Health System organization?
Yes. This was a way for us to become more intimate with the physicians, aligning them, bringing them on board. And they could retain their independent practices. We wanted to offer them different kinds of alignment with physicians, and we approached this as a core strategy. This was their bridge for understanding what was happening around the shift from fee-for-service to value-based care. So we went into Atlantic ACO with a very different mindset and goal than with Optimus. We haven’t yet achieved shared savings, but we may this year.
What have you achieved so far?
The first piece of this is to generate data and do analytics to risk-stratify your population and develop mass customization for interventions and solutions for individual patients, at a mass level. The second tenet of this is to create team-based care coordination, with social workers, nurses, pharmacists, discharge planners, community resource managers, to take care of our most vulnerable and sickest population, to develop an infrastructure and team to meet the needs of our patients, many of whom have social issues. So care coordination. The third piece is our health information technology strategy—to have all elements of care on one platform, and it incorporate evidence-based care. So in my mind, our focus has been around those three, as we’ve been transforming office-based practices, and as we’ve transformed hospital care, and developed a post-discharge strategy.
What have the biggest challenges been so far in all this?
I think the biggest challenge has been the impatience we have as a healthcare community to see effects. It’s been shown that healthcare changes slowly, and it’s so complicated. The issue is, how do we demystify our healthcare system, to bring about measureable change, and then to be able to engage the right people in the system to bring about this change? So the willingness to change, the ability to change, as a measure of change, all those are critical success factors.
What about the cultural changes involved, particularly around physician participation and buy-in?
Yes, the more you’re engaging physicians in leadership activities, helping them to lead the change, the better. Showing them the data, having them help to shape the strategy, and the tools, is so important. It’s got to be a win-win situation. And when patients and consumers understand healthcare-and one of the big things I see is the whole movement around transparency, so when you have information that’s understandable to the layperson and consumer, and it helps to demystify healthcare and helps them to make informed decisions, we have the ability to be catalysts for change.
We can help physicians, but they have to be leading change, and helping change, and responding to their patients. So, transparency, consumerism, technology, and advancement of new models of healthcare, are all changing things now. There’s a company I’m familiar with, Teledoc, and to be able to able to see a patient through a Facetime-like interaction, is so much more effective sometimes than spending a whole day in a waiting room and such; so technology is going to be one of the keys to change.
Have there been any struggles around IT and data?
Are we where we need to be on that? No. But we’re better than we were. The data has to be actionable. We first built data, then we analyzed it, then we acted on it. And making data actionable is so important. With IT, the biggest challenge is with interoperability. There are lots of good solutions, but they all have to be able to talk with each other and be interfaceable. And I’m hoping with the new APIs that that will help.
Can you discuss the challenges around marrying claims and clinical data?
Yes, it’s the first time ever we’ve got data now on patients’ claims histories wherever they got care from. So for us, it’s very exciting, to have so much robust data, and know the background. It’s very exciting o be able to have that information; but it can also be overwhelming to have it. So how do we come up with sources of information that will really help us? So how do we come up with a standardized, simplified way of doing this, including allowing physicians to mine their own data? That’s the challenge.
Have you implemented dashboards for the physicians, to help them analyze their care management of their patient panels?
Yes, they have access to McKesson’s’ patient registry system, and they can analyze what’s going on with their patients. But this is still a journey. We’re building those now, but we’re not where we should be yet.
Do they have access to dashboards for their outcomes yet?
Yes, they can see if their diabetic patients have a hemoglobin a1c under 9, for example, yes.
What have the biggest lessons learned so far?
I think the biggest lesson learned is that you have to go into ACO work with the right goal. Our goal with Atlantic ACO was to align incentives across our system, including with our physicians, and to move forward and be in the vanguard. So you have to have clear goals and success metrics. And you have to know how to lead change. And everything has to align with everything else. So it takes about three to five years of building an infrastructure of systems to be able to succeed in a value-based model. The other lesson is, don’t let the perfect be the enemy of the good. Start with what you can. The time is now. You can’t be waiting on the sidelines Do what you can with what you have, and evolve your model forward.
And when we started off, I had no idea that we would have an interest in the commercial world. And having worked for the government and in the private sector, I know that with government regulation, there are things you have to do, but the true value potential of an ACO only comes through private partnership. We were doing fine with Medicare, but we also moved very quickly to bring our commercial payers on board. And we quickly added them in, even though we weren’t perfect yet or anywhere near that. It was almost like, you know, it’s a government program, but we’re going to maximize our private market potential as well.
What will happen in the next two years in the forward evolution of this work?
We’re going to evolve into a more integrated model. Our ACO will be the nexus of change for the hospital system. We’re going to join the bundled payment program for joint replacement. For that, we are going to e the nexus for the entire system to participate in the mandatory joint replacement program that CMS is coming out with. So anything new we’re involved in, we as the ACO will be the nexus, the catalyst and the foundation for how the rest of the system is going to evolve.
Do you have any words for CIOs and CMIOs in healthcare, with regard to what they should know in this context?
No matter how difficult things look like, whether it’s around technology, or physician engagement, or changes in the regulatory environment, or with payers you have to have a core group of strong leadership working together in cohesion, to bring along the rest of the organization. You have to be very clear about why you’re doing what you’re doing. And you have to have core metrics to start with. Because no one’s going to be behind the change unless you can measure along the way. And celebrate the small successes, don’t wait ‘til the end. And there’s no better time to be in healthcare than now.