Late last month, Centers for Medicare & Medicaid Services (CMS) data on two federal accountable care organization (ACO) programs—the Medicare Shared Savings Program and the Pioneer program—revealed that while many ACO organizations achieved savings for Medicare in 2014, far fewer generated enough savings to receive bonuses.
However, in their third performance year, Pioneer ACOs showed improvements in 28 of 33 quality measures and generated total model savings of $120 million, an increase of 24 percent from performance year 2 ($96 million), which was itself an increase from performance year 1 ($88 million). One of the 19 remaining Pioneer ACOs (the program started with 32 in 2012) is the Newton, Mass.-based Atrius Health, a nonprofit alliance of community-based medical groups (Dedham Medical Associates, Granite Medical Group, Harvard Vanguard Medical Associates), and a home health agency and hospice spanning across the eastern region of the state.
After the CMS announcement in late August, Atrius Health made an announcement itself, publicizing that it has ranked highest on CMS overall quality scores among Pioneer ACOs in New England, and has ranked third highest nationally based on 33 ACO quality measures tracked by the CMS. CMS chose 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 as compared with over 300 ACOs nationally, according to officials at the health system.
Based on the CMS analysis, Atrius Health was also ranked fourth for meaningful use of its electronic health record (EHR) across all Pioneer ACOs. In addition, Atrius Health rated above the 90th percentile on four preventative measures including screening for fall risk, effectively identifying patients at highest risk of depression, tobacco use assessment and cessation intervention, and blood sugar control in patients with diabetes, according to officials at the organization. Further, for its third year in a row as a Pioneer ACO, Atrius Health has seen improved financial performance. For the 31,000 Medicare beneficiaries served by the Atrius Health medical groups participating in the Pioneer ACO model in 2014, Atrius Health saved Medicare $4.5 million compared to its target, returning $2.8 million in savings to the organization.
How has Atrius Health been able to remain so strong in a federal ACO program that has seen more than one-third of its members drop out since its 2012 inception? According to Emily Brower, vice president of population health at the organization, it’s about two critical factors: making quality care the center of its core philosophy and working with its health plan partners on moving as much of its business into value-based payment models as possible. “We have been doing that for decades; we have always had a strong quality measurement and performance improvement team. We came into this program [in 2012] with this culture around quality, so we had a leg up as compared to delivery systems that didn’t have as much of their financial performance depending on quality. We have built a strong foundation here,” Brower says.
Brower says that Atrius Health takes a systematic approach whenever there is a new model that has different or new measures that is rich and engaging for the clinical team. For example, she explains, there was a new measure for depression screening and readmissions, not something that Atrius Health had built into its other health plan arrangement. So the organization took time to do research, literature review, and talk to experts to figure out the right way is to identify risk for depression in the elderly, and then figure out the best way to set up clear pathways for interventions depending on what risks were covered. “So I think part of our success, and I feel strongly about this, is that quality is at the center of the way we do work. It’s not something that’s on the side,” says Brower. “If you think about a typical pay-for-performance contract, which isn’t in same bucket as the ACO models to me, you have your financial results and then there’s a small additional component of savings you might earn based on a set of measures that sort of live on their own on the side. We put quality in the center here, we take it head on, and we say that the way we will achieve savings is by improving quality outcomes,” she says.
Brower says that Atrius Health is able to do that because most of its contracts are in value-based models, meaning most of its health plans work with the health system in a value-based way. Other places don’t have that history of partnering with health plans based around quality performance, she says. “It’s a natural learning system throughout the organization. We have 42 sites where we are delivering care, so we can test things and spread what we learn. That learning environment helps us a lot,” she says.
Indeed, Atrius Health is made up of those 42 care delivery sites, split about 50/50 between primary care and specialty practices, serving some 675,000 adult and pediatric patients throughout Eastern Massachusetts. The organization’s Level 3 patient-centered medical home (PCMH) is the backbone of its system, Brower says. “That’s how we deliver care. It’s different than a hospital-based system,” she says. “All of those groups and primary care teams are at the center—that is our system for delivery. We partner with many hospitals in our market, including skilled-nursing facilities and a home health agency, and it’s through affiliation and partnership that we do work outside our walls.”
As such, because Atrius Health has been in value-based payment models going back to the early days of the groups that formed the health system, value-based delivery has always been a part of its DNA, Brower says. That was a big reason why the organization jumped into the Pioneer program, she notes. “We wanted to be right in the middle there and help shape how Medicare would be paying for care. We will always raise our hands as an organization to move into an accountable care model. That’s our bread and butter. We believe that it’s the right way to deliver care,” she says.
More Risk, More Reward
As mentioned above, in the Pioneer ACO model in 2014, Atrius Health saved Medicare $4.5 million compared to its target, returning $2.8 million in savings to itself. Part of whether or not an organization earns savings is what its threshold is for savings that it has to meet. In the Medicare Shared Savings ACO model, that threshold can be fairly high, while in the Pioneer program, it can be lower if the delivery system chooses that option—an option unavailable in the MSSP model, Brower explains, adding that Atrius Health’s target is the lowest among Massachusetts Pioneer ACOs because of the system’s historical cost. It’s more of a challenge for systems that have been working at it for a while, she says.
As such, if you look at the detailed results of CMS’ data, ACOs have generated some significant dollars in savings, but many haven’t hit their thresholds. As a result, you might see systems choosing lower thresholds, says Brower. “We have reduced our threshold each year,” she says. “We have seen the work that it takes to get 1 or 1.5 percent savings, so we are willing to take more risk on the downside for more reward on the upside. However lots of delivery systems wanted to or needed to get in the game of limited upside and complete protection on downside. It’s not a bad place to start, as they are still generating savings for Medicare. They just are not getting those savings back because they are risk adverse. That’s a business decision,” Brower says.
There are some choices when it comes to an organization’s threshold across different models, Brower continues, adding that downside protection is an understandable place to start, particularly depending on what kind of market you’re in. “If its you’re first foray into a value-based payment model, I can totally see why you would want to maximize your downside protection and take a more conservative approach. So [the CMS data] on ACOs not generating savings for themselves is not really bad news if you’re generating savings for Medicare,” she says.
With this in mind, Brower says she is glad to see ACOs generating more savings in general, along with an uptick in program participation. However, she adds that it can be quite challenging for a healthcare system to have only one of these value-based payment models. “It’s hard to do change the way you practice medicine and coordinate care across the continuum for just one set of patients. If as a delivery system, in addition to Medicare, you get some commercial payers on board, and then perhaps you get your own population, such as your employees, into a value-based model, then you can make investments that will make a difference. But it’s hard to do that for one segment of patients,” she says.
That said, you have to start somewhere, Brower adds. “Medicare beneficiaries do have the greatest utilization of the healthcare system, so if you can make it work for them, you will be well-positioned. It’s hard to make change if you’re too conservative, and in some ways the riskier you can be, the faster you will move. Pressing down on that pedal will get results.”