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The Leaders of a Unique Michigan ACO Organization Share their Perspectives on ACO Development

May 30, 2017
by Mark Hagland
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The leaders of Prime Accountable Care share their perspectives on the critical success factors involved in ACO development

As the accountable care organization (ACO) phenomenon evolves forward, new, innovative organizations and arrangements are emerging every day now. One organization that defies easy categorization is the Southfield, Michigan-based Prime Accountable Care organization. As the organization’s website describes it, “Prime Accountable Care, LLC is a physician-owned company with the sole purpose of operating as an accountable care organization (ACO). Our corporate office is located in Southfield, Michigan and we serve communities all across metro Detroit including Downriver, Dearborn, and Southfield. We also cover a large portion of Mid-Michigan, including: Flint, Saginaw, the Bay Region, and stretches into parts the Thumb and Northern Michigan. Prime Accountable Care, LLC was established on the same principle as an ACO, to improve health care delivery through higher quality of care and lower cost.” The organization’s website goes on to note that “Prime Accountable Care, LLC is unique in the sense that we are a single Tax Identification ACO with a focus on primary care providers. There is great synergy between the Medicare Shared Savings Program and our objective, which is placing the primary care provider at the hub of delivering care to the patient.”

Recently, three Prime Accountable Care senior executives—Mazhar Jaffry, its COO; Abbas Kermani, its CFO; and Diane Blackburn, executive director of its ACO—spoke with Healthcare Informatics Editor-in-Chief Mark Hagland regarding their organization’s unusual journey forward in ACO development, and what they and their colleagues have been learning so far. Below are excerpts from that interview.

Tell me a bit about the origins of your organization, and your core organizational strategy?

Mazhar Jaffry: There are three types of ACOs in the United States. The first program was the Pioneer ACO Program—32 started in 2011-2012; only eight were in existence in 2016, when the Pioneer program ended. The others went out of business or converted to the MSSP [Medicare Shared Savings Program] program. That’s evolved and has three tracks. Track 1-Plus starts in January 2018, so there will be four. And starting January 1, 2016, they started the Next-Generation ACO Program.


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Mazhar Jaffry

Currently, 560 Medicare ACOs are functional; nearly 480 are MSSP ACOs. More than 60 percent are owned by hospitals; the remaining 30-plus percent are owned by private bodies—one group is existing IPAs or physician organizations already in existence. 80-85 percent of the 40 percent. And the remaining groups were formed and structured just to create an ACO. And Prime ACO falls into that category. It emerged by itself. The organization began to form in March or April 2015, and the approval process took 7-8 months. By January 1, 2016, CMS announced that we were part of it. website. There’s a tab for public reporting, which the announcement.

To form the group, the task for any ACO is to show they have 5,000 lives. So we gathered together more than 100 primary care doctors, and seven or eight specialists. The first day, we had 8,5000 lives, and 11,500 assignable beneficiaries in 2016. We’re now at 11,000-plus. And we have more independent primary care physicians. And those are mostly internal medicine and geriatrics, with a few family physicians. No pediatrics or OB/gyn, because Medicare doesn’t cover those. And 70 percent are in internal medicine. So we’ve got 150 providers managing 11,000 patients, in the ACO. And we have around 19,500 assignable beneficiaries, who will be added into the ACO here in Michigan. We’re also differently organized from many ACOs—we cover the metro Detroit area; then the second area is the Flint area; and the third area, comprised of two different parts, Saginaw, and the thumb of Michigan, with smaller towns, where there are three or four doctors here and there. And we’re doing a pilot project with Caro Community Hospital, in the town of Caro.

This is entirely physician-led, then?

Jaffry: Yes. There are 15 fully functional ACOs in Michigan, and nine are owned by the hospitals. The others are owned by physician organizations or physicians. In our case, we structured the ACO first. That’s why our focus is purely on the ACO. And in the future, we will go for participation in Medicaid and in Medicare Advantage plans.

Tell me a bit about the processes you’ve pursued around analytics-driven population health risk management, and around leveraging analytics to assess financial risk issues?

Jaffry: Keep in mind that the future is all about the payment models changing. It all starts with the Triple Aim, and a focus on health management and outcomes, improving the patient experience, and managing the cost. So for ACOs, the focus for Medicare is to really change how the physicians have been practicing for the past 30 years. For example, if you’re a patient calling after hours, historically, you would get a greeting saying, just go straight to the hospital ER; but the greatest challenge there is the cost. And so this fee-for-service model has to change to FFS plus pay for performance. So how to change that? The first thing introduced in 2012 was meaningful use, to promote EMR adoption. A lot of grant money was given to physicians. And in 2015, they introduced more of a pay-for-performance model. Meanwhile, Medicare insists that every physician in the country be measured using the same yardstick, so there are 41 quality measures. And the most basic things have to be done in a primary care setting, such as health screenings/disease screenings, and penalizing physician payment over time. And MACRA and MIPS… In 2017, 60 percent of the rating is coming from GPRO reporting, which is the group version of PQRS, and is the predecessor to MIPS.

And what have you learned around the process of prospectively assessing financial risk for ACO contracting?

Abbas Kermani: There are two key points about that topic. One is that everything that’s happening right now is moving in the direction of patient care organizations bearing some level of risk. Medicare has put out many different versions of ACOs; and most MSSP ACOs so far are still only on one-sided risk. But the advent of Track 1 Plus is meant to be a stepping stone to downside risk. All the features in all these programs, whether the CPC-Plus Program, with a few areas where you can take risk, the federal healthcare officials are trying to push organizations forward. And I asked them to their faces—I said that I believed they wanted organizations to enter a risk-based model and take it upon themselves, and the answer was yes.

Abbas Kermani

So how do organizations like ours navigate these waters? There needs to be more data available to such organizations; and there needs to be better analytics driven from that data. Medicare itself set the tone by for the first time releasing claims-related data. And if you’re willing to take a full, two-sided risk contract, they’ll often be willing to provide cost data, in addition to the utilization data they’ve already providing. And that’s significant, because it’s difficult for providers to take on this level of risk. And physicians are a little bit more advanced in partnering with vendors than, say, some strictly commercial insurance-focused IPAs. Some vendors are entering that space, to close that gap. The amount of data available is gargantuan and unprecedented. Unfortunately, most of the vendors in the space are not yet up to the task.

In fact, we went through about 50 companies ourselves, and in addition to the company we chose, the number of companies worth working with was literally countable on the fingers of one hand.

And at NAACOs [National Association of ACOs] meetings, I’ve seen a turnover of about 70 percent, if not more, among ACO-focused vendors. The one we chose, a software called Collaborate Network, they are pulling in data—they’re working with a lot of ACOs, CINs [clinically integrated networks], etc.—and they’re pulling in claims data itself, EMR data that they’re interfacing among physicians. Our vendor is dealing with 50 EMRs. So we’ve created a population management hub for incoming data, so you have insights from that, at the point of the physician-patient visit. We’re also trying to find out which specialists they’re seeing, which hospitals they’re admitted to. And this is where the state-level HIEs come into play. So three components—claims-level data from the payer, EMR data from within the practice, and data from the HIE [health information exchange]—those three are the key. And the endgame is getting towards a full capitation model.

How did you know when you were on firm ground with risk analysis?

Kermani: The nature of the financial risk in the different ACO programs is quite different. What’s really interesting in Track 1 Plus, and this aligns with our beliefs—for the first time, Medicare is somewhat bifurcating the customer base into organizations like ours that are completely physician-led, versus those that are owned and run by a giant health plan or health system network. Either will make you liable for the total exposure for a patient, or for the fee-for-service revenue being generated by the physicians in your ACO. And there’s an underlying theme there, which is how much you do and don’t have control in your organization. And you basically want to take on risk for things you have control over, but not for things you don’t have control over. And the Track 1 speaks to that. We’ve been focused on working closely with partners. We’re expanding into four other ACOs. We’ll eventually expand to additional ACOs, and then take the higher performers from each, and roll them over into a higher-risk ACO model.

Diane, what do you see as the critical success factors for physicians and physician groups developing ACOs?

Diane Blackburn: Physicians have to really know and understand the numbers. We’ve put into place a very robust and dynamic population health solution. When they actually take the time to look at it and understand the numbers, and sometimes they’re somewhat shocked by what they find, that’s the key. Because otherwise, they can’t manage the risk; that’s the absolute key.

Kermani: We’re essentially trying to empower the physicians themselves.

Blackburn: We want them to feel that they truly own and operate their ACO. So all the information is available and transparent. We’re available to support them. But they have to use the data and information to change practice.

Diane Blackburn

Diane, what have the physicians learned about thinking about populations?

Blackburn: Where they’ve started to turn the corner is in really creating specific protocols based on the information we’re providing to them through the software—as you’re saying, looking horizontally and vertically. And we’re helping them design the protocols they’re using to implement care management.

So you’re sending out care management experts to work with physicians and their teams in their practices?

Blackburn: Yes, absolutely. And we’re educating and supporting them on the plan. They are the quarterbacks of patient care, and we’re helping them Some are obviously getting it much quicker than others; but with constant support, they’re learning how to bring this in, build this into their daily routine, design care plans for chronic care management.

So the key is to assess financial and health risk, provide solutions, and the development of care management within the workflow, etc.?

Blackburn: Yes, getting the physicians, the nurses, the MAs, everyone, involved—and design the process and trust the process, so you can truly implement the Triple Aim.

Where are organizations stumbling on this journey, in your view?

Blackburn: From my perspective, what I’m seeing is that physicians aren’t really appreciating what CMS wanted the ACO to be about. If you’re in this to make short-term financial gains, that’s not really the point. This is about long-term success. We’re focusing on what CMS wants organizations to accomplish, but doing it in the right way so that this is a sustainable model. So some organizations might do relatively well in one area, but they’re short-sighted, and later crumble.

Kermani: And then those physicians won’t be well-prepared to be rated as high-level providers over time. It’s not about generating savings for just one year. The program should really be a foundation for physicians providing excellent care under MACRA. And we want to make sure our physicians are as well-prepared as possible, in terms of everything—referral patterns, in-office protocols, becoming high-performance in every way—not just the ACO being a loss opportunity. Thinking short-term is not good; this is really a long game. And even though we take certain approach towards managing our financial risk, by separating certain regions, or diversifying our portfolio contracts, or whatnot, the fundamental approach for us is a synergistic one. And that can be brought to them, via tools.

Mazhar, if you look at the future, how do you see your team’s vision playing out?

Jaffry: the vision and future will be changing from the existing fee-for-service system, into pay for performance. There are a lot of hoops and hurdles to change. And that will require effort and support. For hospital structures, they may be able to mandate their physicians working in their hospitals to follow guidelines; but anybody who wants to stay independent, has to go through a very steep learning curve—with different demands from Medicare, Medicaid, state-level reforms—there’s so much going on. There’s no way a private-practice physician can keep abreast of all of this without participating in some kind of ACO-type structure. Otherwise, it’s a hardship for physicians to go through all the hoops. ACOs are structured to learn via these models. And their biggest goal is to help any physician who joins, to learn how to succeed. So it’s a win-win situation, and there’s the opportunity to generate shared savings. So any physician not working under the umbrella of a hospital, will need to work under some kind of structure.

And what should CIOs and CMIOs in patient care organizations know about all of this?

Kermani: In the value-based care space, whether an ACO contract or similar is involved, this is the first time you’re holding the interests of patients, physicians, and payers, in the same direction. And that’s why you see payers being very receptive to ACOs. That being said, this all goes back to a very critical component of success, which is the depth and breadth of the data you have to play with. The CEO of Collaborate Network, Pranam Ben, used to say to us, it’s about getting data into your system, and intelligent decision-making coming out. You want informed insights to allow you to do better and more efficient delivery of patient care. You’ll hear the buzzword of “big data” being thrown around; and you’ll see vendors coming in from all sorts of different industries and spaces. But the common theme among all organizations in this is that we need better information than we’ve had or are even getting right now. This market is still evolving and growing. You need to drive efficiency, and then drive further efficiency, given how the benchmarks in these programs will continually be reset. And a lot of information is just becoming available now, and some are making good use of it. But the IT vendors need to further refine what they’re offering.



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NCQA Moves Into the Population Health Sphere With Two New Programs

December 10, 2018
by Mark Hagland, Editor-in-Chief
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The NCQA announced on Monday that it was expanding its reach to encompass the measurement of population health management programs

The NCQA (National Committee for Quality Assurance), the Washington, D.C.-based not-for-profit organization best known for its managed health plan quality measurement work, announced on Dec. 10 that it was expanding its reach to encompass the population health movement, through two new programs. In a press release released on Monday afternoon, the NCQA announced that, “As part of its mission to improve the quality of health care, the National Committee for Quality Assurance (NCQA) is launching two new programs. Population Health Program Accreditation assesses how an organization applies population health concepts to programs for a defined population. Population Health Management Prevalidation reviews health IT solutions to determine their ability to support population health management functions.”

“The Population Health Management Programs suite moves us into greater alignment with the focus on person-centered population health management,” said Margaret E. O’Kane, NCQA’s president, in a statement in the press release. “Not only does it add value to existing quality improvement efforts, it also demonstrates an organization’s highest level of commitment to improving the quality of care that meets people’s needs.”

As the press release noted, “The Population Health Program Accreditation standards provide a framework for organizations to align with evidence-based care, become more efficient and better at managing complex needs. This helps keep individuals healthier by controlling risks and preventing unnecessary costs. The program evaluates organizations in: data integration; population assessment; population segmentation; targeted interventions; practitioner support; measurement and quality improvement.”

Further, the press release notes that organizations that apply for accreditation can “improve person-centered care… improve operational efficiency… support contracting needs… [and] provide added value.”

Meanwhile, “Population Health Management Prevalidation evaluates health IT systems and identifies functionality that supports or meets NCQA standards for population health management. Prevalidation increases a program’s value to NCQA-Accredited organizations and assures current and potential customers that health IT solutions support their goals. The program evaluates solutions on up to four areas: data integration; population assessment; segmentation; case management systems.”



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At the D.C. Department of Health Care Finance, Digging into Data Issues to Collaborate Across Healthcare

November 22, 2018
by Mark Hagland, Editor-in-Chief
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The D.C. Department of Health Care of Finance’s Kerda DeHaan shares her perspectives on data management for healthcare collaboration

Collaboration is taking place more and more across different types of healthcare entities these days—not only between hospitals and health insurers, for example, but also very much between local government entities on the one hand, and both providers (hospitals and physicians) and managed Medicaid plans, as well.

Among those government agencies moving forward to engage more fully with providers and provider organizations is the District of Columbia Department of Health Care Finance (DHCF), which is working across numerous lines in order to improve both the care management and cost profiles of care delivery for Medicaid recipients in Washington, D.C.

The work that Kerda DeHaan, a management analyst with the D.C. Department of Health Care, is helping to lead with colleagues in her area is ongoing, and involves multiple elements, including data management, project management, and health information exchange. DeHaan spoke recently with Healthcare Informatics Editor-in-Chief Mark Hagland regarding this ongoing work. Below are excerpts from that interview.

You’re involved in a number of data management-related types of work right now, correct?

Yes. Among other things, we’re in the midst of building our Medicaid data warehouse; we’ve been going through the independent validation and verification (IVV) process with CMS [the federal Centers for Medicare and Medicaid Services]. We’ve been working with HealthEC, incorporating all of our Medicaid claims data into their platform. So we are creating endless reports.


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We track utilization, cost, we track on the managed health plan side the capitation payments we pay them versus MLR [medical loss ratio data]; our fraud and abuse team has been making great use of it. They’ve identified $8 million in costs from beneficiaries no longer in the District of Columbia, but who’ve remained on our rolls. And for the reconciliation of our payments, we can use the data warehouse for our payments. Previously, we’d have to get a report from the MMIS [Medicaid management information system] vendor, in order to [match and verify data]. With HealthEC, we’ve got a 3D analytics platform that we’re using, and we’ve saved money in identifying the beneficiaries who should not be on the rolls, and improved the time it takes for us to process payments, and we can now more closely track MCO [managed care organization] payments—the capitation payments.

That involves a very high volume of healthcare payments, correct?

Yes. For every beneficiary, we pay the managed care organizations a certain amount of money every month to handle the care for that beneficiary. We’ve got 190,000 people covered. And the MCOs report to us what the provider payments were, on a monthly basis. Now we can track better what the MCOs are spending to pay the providers. The dashboard makes it much easier to track those payments. It’s improved our overall functioning.

We have over 250,000 between managed care and FFS. Managed care 190,000, FFS, around 60,000. We also manage the Alliance population—that’s another program that the district has for individuals who are legal non-citizen residents.

What are the underlying functional challenges in this area of data management?

Before we’d implemented the data warehouse, we had to rely on our data analysis and research division to run all the reports for us. We’d have to put in a data request and hope for results within a week. This allows anyone in the agency to run their own reports and get access to data. And they’re really backed up: they do both internal and external data reports. And so you could be waiting for a while, especially during the time of the year when we have budget questions; and anything the director might want would be their top priority.

So now, the concern is, having everyone understand what they’re seeing, and looking at the data in the same way, and standardizing what they’re meaning; before, we couldn’t even get access.

Has budget been an issue?

So far, budget has not been an issue; I know the warehouse cost more than originally anticipated; but we haven’t had any constraints so far.

What are the lessons learned so far in going through a process like this?

One big lesson was that, in the beginning, we didn’t really understand the scope of what really needed to happen. So it was underfunded initially just because there wasn’t a clear understanding of how to accomplish this project. So the first lesson would be, to do more analysis upfront, to really understand the requirements. But in a lot of cases, we feel the pressure to move ahead.

Second, you really need strong project management from the outset. There was a time when we didn’t have the appropriate resources applied to this. And, just as when you’re building a house, one thing needs to happen before another, we were trying to do too many things simultaneously at the time.

Ultimately, where is this going for your organization in the next few years?

What we’re hoping is that this would be incorporated into our health information exchange. We have a separate project for that, utilizing the claims data in our warehouse to share it with providers. We’d like to improve on that, so there’s sharing between what’s in the electronic health record, and claims. So there’s an effort to access the EHR [electronic health record] data, especially from the FQHCs [federally qualified health centers] that we work closely with, and expanding out from there. The data warehouse is quite capable of ingesting that information. Some paperwork has to be worked through, to facilitate that. And then, ultimately, helping providers see their own performance. So as we move towards more value-based arrangements—and we already have P4P with some of the MCOs, FQHCs, and nursing homes—they’ll be able to track their own performance, and see what we’re seeing, all in real time. So that’s the long-term goal.

With regard to pulling EHR information from the FQHCs, have there been some process issues involved?

Yes, absolutely. There have been quite a few process issues in general, and sometimes, it comes down to other organizations requiring us to help them procure whatever systems they might need to connect to us, which we’re not against doing, but those things take time. And then there’s the ownership piece: can we trust the data? But for the most part, especially with the FHQCs and some of our sister agencies, we’re getting to the point where everyone sees it as a win-wing, and there’s enough of a consensus in order to move forward.

What might CIOs and CMIOs think about, around all this, especially around the potential for collaboration with government agencies like yours?

Ideally, we’d like for hospitals to partner with us and our managed care organizations in solving some of these issues in healthcare, including the cost of emergency department care, and so on. That would be the biggest thing. Right now, and this is not a secret, a couple of our hospital systems in the District are hoping to hold out for better contracts with our managed care organizations, and 80 percent of our beneficiaries are served by those MCOs. So we’d like to understand that we’re trying to help folks who need care, and not focus so much on the revenues involved. We’re over 96-percent insured now in the District. So there’s probably enough to go around, so we’d love for them to move forward with us collaboratively. And we have to ponder whether we should encourage the development and participation in ACOs, including among our FQHCs. Things have to be seen as helping our beneficiaries.

What does the future of data management for population health and care management, look like to you, in the next several years?

For us in the District, the future is going to be not only a robust warehouse that includes claims information, vital records information, and EHR data, but also, more connectivity with our community partners, and forming more of a robust referral network, so that if one agency sees someone who has a problem, say, with housing, they can immediately send the referral, seamlessly through the system, to get care. We’re looking at it as very inter-connected. You can develop a pretty good snapshot, based on a variety of sources.

The social determinants of health are clearly a big element in all this; and you’re already focused on those, obviously.

Yes, we are very focused on those; we’re just very limited in terms of our access to that data. We’re working with our human services and public health agencies, to improve access. And I should mention a big initiative within the Department of Health Care Finance: we have two health home programs, one for people with serious mental illness issues, the other with chronic conditions. The Department of Behavioral Health manages the first, and the Department of Health Care Finance, my agency, DC Medicaid, manages the second. You have to have three or more chronic conditions in order to qualify.

We have partnerships with 12 providers, in those, mostly FQHCs, a few community providers, and a couple of hospital systems. We’ve been using another module from HealthEC for those programs. We need to get permission to have external users to come in; but at that point, they’d be able to capture a lot of the social determinants as well. We feel we’re a bit closer to the providers, in that sense, since they work closely with the beneficiaries. And we’ve got a technical assistance grant to help them understand how to incorporate this kind of care management into their practice, to move into a value-based planning mode. That’s a big effort. We’re just now developing our performance measures on that, to see how we’ve been doing. It’s been live for about a year. It’s called MyHealth GPS, Guiding Patients to Services. And we’re using the HealthEC Care Manager Module, which we call the Care Coordination Navigation Program; it’s a case management system. Also, we do plan to expand that to incorporate medication therapy management. We have a pharmacist on board who will be using part of that care management module to manage his side of things.



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