On October 7 at the Medical Group Management Association (MGMA) conference in a packed room at the San Diego Convention Center that included a standing-room-only audience, practice executives representing three medical groups currently participating in a Medicare accountable care organization (ACO) program—established by the Centers for Medicare & Medicaid Services (CMS)—shared experiences, insights, and challenges that come with participating as a Medicare ACO.
The panel of executives included: Gary Gaspard, CEO, Clinics of North Texas (Wichita Falls, Texas); Donald Stumpp, manager of payer contracting, American Health Network in Indianapolis; and Stephen Nuckolls, CEO, Coastal Carolina Health Care in New Bern, N.C.
Anders Gilberg, vice president of MGMA government affairs, Washington, D.C., moderated the panel, engaging the executives with an array of questions. Below are excerpts from the panel discussion.
Can you talk about your experiences when you first became a Medicare ACO?
Gary Gaspard: We were big on training and educating, because you can’t just hire someone that knows about this stuff—they don’t exist.
Stephen Nuckolls: We started in April 2012. When it comes to funding, you have to look at where you want to spend your money. For us, one big aspect was bringing in care managers. We carried 11, and each would care for between 70 and 100 Medicare patients. We set up a 24/7 call line to help patients at night, and expanded urgent care hours and capabilities. And early on, one of the big mistakes we made was in regards to that line. The care managers didn’t have access to our electronic health record (EHR) after hours, and they would quickly refer patients to emergency room (ER) services. But once we brought the data in-house, we were able to cut down on that.
Donald Stumpp: When all this started, the vendors with solutions weren’t out there. It does look like they’re finally catching up and understanding the needs of ACOs.
What are some of the strategies you have deployed?
Nuckolls: For our ACO, with 11,000 members, we must show savings of greater than 2.9 percent before we are to achieve savings. Some of the strategies include how do we reduce ER visits and unnecessary hospitalizations? Having one hospital, we have it a little easier than others. We have someone who looks at emergency department (ED) summaries and admission summaries every day to look for opportunities. And we have found many opportunities, where patients can go to the doctor rather than the ER. Once we see those things, we can create the right culture. The more access you have for patients, the better—they don’t want to go to the ER and wait for six hours.
Stumpp: We do have multiple communities and different hospitals, so it’s a different challenge. The little things matter too, such as, what your answering machine says. For instance, if it says, “If this is an emergency, call 9-1-1,” that is urging them to run. We try to revamp those things, particularly for high-risk patients. We want to make sure care coordinators are engaged with them, and let them know that it’s okay to call your doctor and not run to the ER. We are deploying the strategies of a patient-centered medical home (PCMH), even though we’re not really one.
Nuckolls: Remember, under our program, you have to improve the quality of care, or you don’t get a dime. Also, when you save CMS money, you save the patients money. It’s an 80/20 model. It works for them, and it’s a great program, which I really enjoy. Our group has a point of care dashboard, so this enables us to see any gaps in care. The goal for the nurses and physicians is to take the red (gaps) and turn it to green.
Stumpp: You need to meet quality measures, or you don’t get paid for anything, Of course, CMS hasn’t told us what we have to hit yet, but we do know what the 33 measures are. We’re going to have a natural bell curve in terms of physician performance.
Physician buy-in is such a key aspect to this. How were you able to achieve it?
Stumpp: To be honest, there may not be 100 percent buy-in, but there is a majority. We’re an independent group, so we have attracted like minds. We wanted to stay independent and deliver quality care. Our results weren’t always what we wanted, so we got together and said we have to have the right coordination and the team must come together. The motivation is in the numbers; physicians want the money, yes, but they also want to be associated with a high-level Medicare group.
Gaspard: The closer you are to the physician’s practice, the more likely for buy-in. My physicians will take their laptops home and work until midnight. But to get them to come to an ownership meeting, you better be voting on something. We have to manage to those personalities. It’s key for physicians to lead physicians.
Nuckolls: It’s important to show the physicians the bottom line. At the end of the day, there is a reward for changing the behavior.
Have you seen your first-year results yet?
Nuckolls: We have not gotten numbers for our first year yet. We were supposed to get them last week, but government shutdown affected that. We have seen hospitalizations and ER visits down, though. Being in a rural, underserved area creates a challenge, too Pioneers have different benchmarks than we do. But have we saved money? Absolutely.
Stumpp: We had some preliminary data, and we were right at the minimum threshold. Our benchmark was also low, compared to the national average. Our doctors were griping that they have done a good job, that they have wrung the towel dry, and it’s hard to get anything more from it. My advice is that if you’re going to become a Medicare ACO in 2015, spend like hell in 2014.
Gaspard: CMS warns you that you cant calculate to see if you will have savings. That seems odd, since you’re a business. But you’re not privy to part of the CMS formula. Few startups make money in year one.
What would your advice be to the people in the room who are considering the program?
Gaspard: I think you have to consider it as an option. Healthcare is changing, and we know the direction it’s going in. This is a good place to start. You can’t turn a blind eye to what is going on in the industry. We were lucky enough to receive upfront funding, but that’s not always necessary. Physicians do want to practice this way, anyway. I really think the ups and downs are well worth your future.
Stumpp: It’s where we’re going. You have to look at your market, and if it can give you a competitive edge. If so, you might as well jump on board. We tell our doctors that this isn’t something that’s being forced or that we’re picking on them. Everyone is headed in this direction.