At a time when leaders of patient care organizations across the U.S. are looking for pathways forward into accountable care and population health management, a cadre of innovative integrated health systems is showing the way forward on a number of fronts. Among those is the Memorial Hermann Accountable Care Organization (MHACO), created and operated by leaders of the Memorial Hermann Health System, a 16-hospital integrated health system based in Houston, Texas.
According to a spokesperson for the Memorial Hermann Accountable Care Organization, the MHACO has been the country’s number-one Centers for Medicare & Medicaid Services Shared Savings Program (MSSP) ACO in the country for three years running, generating nearly $200 million in savings across three years of participation in the program. The MHACO, which cares for 50,000 lives (up from 22,000 when it started operations three years ago), encompasses a clinically integrated network of 2,500 physicians, which includes the University of Texas academic faculty, employed physicians, and independent physicians. That 2,500 total includes 700 academic faculty practice physicians, of them 200 employed, and 1,800 independent physicians.
Recently, Memorial Hermann senior executives—Chris Lloyd, CEO of the Memorial Hermann ACO and of the Memorial Hermann Physician Organization; Nishant "Shaun" Anand, M.D., physician-in-chief of those two organizations; and Shawn Griffin, M.D., CMIO of both organizations—spoke with Healthcare Informatics Editor-in-Chief Mark Hagland, to discuss the advances that their ACO has been making in its three years of operations. Below are excerpts from that interview.
Tell me a bit about the physicians involved with the ACO. How many of them are primary care physicians?
Chris Lloyd: We have about 500 primary care physicians. What we really bring to the table is a clinically integrated network of 2,600 physicians, which includes the University of Texas academic faculty practice, employed physicians, and independent physicians. That distinction is important, because we’ve brought together the physicians in the community, in an employment-agnostic model, and gathered them around the ACO and the care delivery network, around some of these principles associated with total cost of care. Some ACOs have primarily employed or physician organizations; we’re an employment-agnostic physician organization that’s partnered with our health system, and we think that that’s particularly strong.
Can you share about your ACO’s cost savings and clinical outcomes?
Lloyd: Our most recent savings were approximately $90 million across those lives. And our aggregate quality score was at the 96th percentile, in terms of member outcomes. Shaun?
Nishant (Shaun) Anand, M.D.: I can give you a three-year trend: in terms of cost savings, we’ve documented $58 million, $53 million, and $89 million, in our three years of operation. In terms of clinical outcomes within the Medicare Shard Savings Program, we’ve been at 83 percent, 88 percent, and 96 percent, respectively.
To what do you attribute your success so far?
Anand: The first success factor is that we have a philosophically aligned group of providers who are very talented at providing holistically aligned care for their patients. They’ve been willing to go the extra mile in addressing quality gaps upfront; and have agreed to improve access to care in their clinics, so we can provide that holistic care. The second success factor is that we’ve built a care management structure to take care of patients with multiple chronic conditions—heart failure, those on dialysis, those with COPD [chronic obstructive pulmonary disease], etc. And when they’re admitted to the hospital, they’re able to make sure they’re care-managed in the hospital. The third success factor involves the fact that we’ve built a data reporting analytics capability that allows us to track and trend our data and identify hot spots. So we can look at claims information and the EHR [electronic health record] and lab data, and we combine those to determine the hot spots [in terms of care gaps]. And finally, around our IT infrastructure, we’ve deployed registries and have worked on interoperability, with data flowing through it, with support tools.
Nishant (Shaun) Anand, M.D.
Can you speak to the human infrastructure and to the processes for care management, that are facilitating your success, and the physician culture changes that have occurred?
Anand: Chris and my team, before I arrived, were already building a culture focusing on partnering and clinical integration. That culture is really there. There’s also a willingness to partner as care teams; that’s a culture change, that healthcare now is a team sport. It’s something where physicians are often the quarterbacks, but you have to rely on your care management teams, and on your hospital teams as well.
Lloyd: We’ve been at this for about 10 years in terms of building a clinically integrated network. When the ACOs came along to stress care management and improved quality outcomes, those elements were already a part of the culture of this organization anyway, so ACOs became an extension of that. And without a culture that invites measurement and focuses on doing the right thing for the patient and absorbing new ways of doing things for the patient—that’s all a part of success.
Can you speak to how you’ve been able to change the physician culture in order to engage physicians around this?
Lloyd: We actually don’t spend a whole lot of time talking about saving money; that’s a nice side benefit, total cost of care reduction. But we really went into this around the management of quality and leveraging new tools and processes, around population. In fact, in our original MSSP application, we shared a diagram for what we would do if we got money back, and didn’t really look back at that until we received a distribution.
Have you received a distribution all three years?
Yes, with regard to the savings that Shaun had referenced earlier [$58 million, $53 million, $89 million], we’ve received roughly 50 percent of those savings amount back from the Medicare program each year.
Anand: There are three things that have been really impactful for changing physician behavior. One is giving our physicians data. Different groups are very competitive, so being able to share the data is really eye-opening in many cases. Two, we’ve been making it easier to do the right thing—eliminating workarounds and putting in enabling technologies. And with our clinical program committee, we’ve been able to invoke the best clinical practices and sharing those through clinical decision support in the EHR. We’re on this journey like many. We have roughly 57 committees across all specialties looking at best practices. But one key aspect is hardwiring good practices through ordering and via alerts. And for radiology and pharmacy, we’re looking at CDS for the future.
Lloyd: The clinical programs councils, we bring the physicians together and talk about clinical guidelines we want to hardwire, and that existed before we joined the MSSP; you have to create a level of understanding and engagement with the physicians.
What are some of the key elements that must be in place, for that to occur?
Shawn Griffin, M.D.: I think that, as a CMIO, the EMR in the offices and we’ve had a rollout of a subsidized EHR platform to many of our physicians, so we have a decent base across three main platforms, and that covers about 80 percent of our physicians. And we’ve worked with optimization and standardization across those platforms. And our physicians are incredibly engaged in the technology.
Shawn Griffin, M.D.
What should CIOs and CMIOs know and do, with regard to all this?
Anand: Based on my experience here and previously—I would say, build the foundational elements first and well. Building data visualization tools is key and then layer on an analytics layer. If you don’t have the analytics to guide you, healthcare becomes more expensive, so that’s key. Then the next level ifs EHR connectivity, registry tools, CRM [customer relationship management] tools, etc.
Lloyd: And as we get further down this path, the marriage of information sets is pretty key. So creating a longitudinal view of inpatient and outpatient systems, and marry that between the EMR and the claims data, that is changing. It’s challenging bringing together disparate groups who’ve grown up using disparate systems, as well.
Griffin: And you always need to communicate why you’re doing what you’re doing. Recognizing physician burnout means that, if you’re going to give physicians something more to do, you need to also be taking something off their plates at the same time.
What will happen next two years at Memorial Hermann ACO, and also U.S. healthcare system-wide?
Anand: Regardless of the election outcomes, the journey towards value-based healthcare is well underway. We’re just getting into the details now, but we’ll be accelerating this, building care management programs, integrating across the organization from inpatient to outpatient, and launching both a longitudinal health record and case management record; so we’ll continue to build that out.
Griffin: My comment is that we’re going to be working with our physician partners and our technology partners to mature the tools and workflows to make sure care is delivered more efficiently and effectively across populations.
And how would you frame your experiences as physician leaders, with regard to your leadership in helping to transform the healthcare system?
Griffin: This is a revolutionary time in medicine, both in terms of the tools available to us and how we practice, and supporting physicians in this is incredibly important in building towards the future.
Anand: We’re in the third phase of healthcare--the science of healthcare—where people have to come together to work as teams and to leverage tools across the continuum. Physicians are engaged by this and excited by the prospect, but they’re not in there alone in having to manage complex patients.