Editor’s Note: Part 1 of this two-part series on Medicare ACOs in the trenches, which highlights Atrius Health’s Pioneer ACO story, can be read here.
Advocate Health Care, the Downers Grove-based health system that is the largest in the state of Illinois, with more than 400 sites of care, has been entrenched in value-based care initiatives for years. As such, 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, it was not a big surprise to see Advocate Physician Partners Accountable Care, Inc. as one of the Medicare Shared Savings Program (MSSP) ACOs to generate shared savings for Medicare and the patient care health system.
After all, says Lee Sacks, M.D., chief medical officer and executive vice president of Advocate Health Care, “This has been an evolution,” ever since Advocate made the decision back in 2010 that the health system would focus on value as leadership’s priorities turned to reducing the total cost of care. One way to do this was by making the move to join the Medicare Shared Savings Program ACO model, which serves as one of many of the federal government’s initiatives to move the healthcare system toward one that provides patients with high-quality, cost-effective care.
However, CMS data from the government’s two federal ACO programs have shown a mixed bag of success so far, particularly in terms of participating organizations being able to generate savings. To this end, a Healthcare Informatics visual analysis of how organizations performed in the two models—the 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. For just the MSSP model itself, in 2015, 119 of the 392 organizations (30 percent) earned shared savings, while 83 of 392 ACOs in this model, or 21 percent, earned some savings, but not enough to garner bonuses. Nearly half (48 percent) generated no savings at all last year. As one of the 30-percent shared savers, generating $72 million in financial savings in 2015, Advocate Health Care has been able to experience a level of success that the majority of participants in the program have not.
Lee Sacks, M.D.
One of the biggest reasons why this is, says Sacks, is that Advocate Health Care has increased its value- based contracts in the Medicare Advantage space and the commercial space. “We have a mass of patients and contracts in value-based agreements, and that’s critical,” Sacks says. “That’s a reason why a lot of the MSSP programs have not been successful. For many of them, [value] is just a small piece of their business. It’s hard to treat one group of patients different from another. If the majority of incentives are tied to volume, you won’t succeed in the value arena,” he says.
What’s more, Advocate Health Care has a more than ten-year history in a clinical integration program that was initially tied to commercial PPOs, but has since helped the organization focus on quality and utilization metrics, especially with chronic disease, says Sacks, adding that this is one of the contributors to the strong results in the third MSSP reporting period.
As part of this program, Advocate Health Care has a set of metrics in a number of areas, including clinical outcomes, patient safety, efficiency, and patient satisfaction, as well as the mandatory education programs which physicians get points for. The metrics are specific to their specialties so they get benchmarked against others in that specialty, Sacks explains. “We look for year-over-year improvement, and we tie pay-for-performance dollars to that, and it has encompassed our commercial patients, and now we are using it for MSSP, Medicare Advantage, and for our Medicaid value arrangements too,” he says. “It has created the infrastructure to let our physician practices to do population health management with robust registry systems and links to databases—the clinical data we generate, claims data, data on prescriptions, lab results, and more. It all becomes readily available and it’s used to assess performance,” he says.
Sacks additionally points to the development of a successful series of partnerships for a post-acute network with skilled nursing facilities (SNFs) that provide rehabilitative care for patients following a hospital stay. Here, Advocate Health Care provides advanced practice clinicians supervised by geriatric physicians in 38 facilities, which has led to a significant 25 percent reduction in length of stay, improvements in quality, and no regression with readmissions, Sacks notes. “In our market place, the use of post-acute facilities is way above national benchmarks. There is a big opportunity there, and we are starting to see real changes in those practice patterns,” he says.
Speaking further to the post-acute network significance, Sacks notes that Advocate Health Care has been investing in care management with team-based care to better coordinate care and manage transitions, something that’s “clearly having an impact,” he says. Also in the last two years, the healthcare organization is using telehealth to provide access for behavioral health in the ER and for urgent consultations. “We are having behavioral health clinicians round on medical surgical patients on routine basis so we can address those issues. This leads to a big reduction in complications and length of stay,” Sacks says. “All of those things together impact our performance, and we have seen a reduction in physician spend, in hospital spend, and a big reduction in post-acute spend, which is mostly driven by the skilled nursing facilities,” he says.
Sacks takes pride in the fact that Advocate Health Care, with a network of 5,000 physicians, roughly 3,500 of whom are independent in mostly very small practices, can match quality with some of the tightly integrated multispecialty groups. “We tend to be in top decile on a great majority of metrics that are benchmarked by the NCQA [National Committee for Quality Assurance], and while our overall quality improved in the MSSP—we are slightly above 94 percent of total points—we are not in the [overall] top decile, so that means there a lot of organizations doing well [in this program],” he says.
Regarding challenges for the ACO, Sacks talks about both the timeliness and the ability to get actionable data and getting it down to the physician practice level. “In all of these programs, it’s the lag. We got [performance] results from 2015 in late August 2016. For some of our physicians, this was about things they did in January 2015, so that means 18 months prior. It’s hard to go back and say ‘If you just did this differently’ when it was so long ago.” Sacks notes that Advocate Health Care’s senior leadership team just had a meeting about the ACO’s performance, with the goal to see if it can build on this success with four months to go in 2016. “But it’s hard to know if we’re doing well this year, since we just got data from last year. We don’t have a good sense,” he says.
In the end, Sacks says that the government’s push into pay-for-quality will ultimately force patient care organizations into a model like the MSSP ACO. He notes that with upcoming changes set to take place under MACRA (the Medicare Access and CHIP Reauthorization Act), there will be even more major change on the physician payment side. “It will be very hard for doctors in most specialties to be successful without being in a program that helps support them in population health management that’s integrated,” he says. When asked about his ACO’s outlook, Sacks attests that “We’re feeling good.” He adds, “We still need to do a lot of drilldown on the data.”