At a time when many accountable care organizations (ACOs) participating in the Medicare Shared Savings Program (MSSP) for ACOs are struggling to meet the cost-savings and quality-outcomes benchmarks set for them by senior officials at the Centers for Medicare & Medicaid Services (CMS), a minority of the MSSP ACOs are doing very well.
Among these is the organization that until a few weeks ago was known as Scottsdale Health Partners. A large multispecialty physician group based in Phoenix, Scottsdale Health Partners had 700 physicians at the time it joined the MSSP program in January 2014. Last month, Scottsdale Health Partners went through a merger with another local group, and has now taken the name Innovation Care Partners; the group now has over 1,200 physicians in the Phoenix area and in central Arizona.
The group’s new name does not reflect idle boasting: innovation has been a hallmark of the Scottsdale Health Partners group for years. Indeed, SHP was named by Healthcare Informatics’ editors as the second place-winning team in the publication’s Innovator Awards Program earlier this year, for its data-driven, multidisciplinary care team-led initiative to optimize care coordination and reduce avoidable readmissions. HCI Assistant Editor Heather Landi’s Innovator Awards profile of Scottsdale Health Partners can be read here.
Meanwhile, Scottsdale Health Partners was one of a small plurality of MSSP ACOs to be able to post outstanding cost savings and clinical outcomes results, when CMS officials announced results for the nationwide program, on August 25. As Managing Editor Rajiv Leventhal noted in his news report on that date, “Although more than 400 Medicare accountable care organizations (ACOs) generated more than $466 million in total program savings in 2015, nearly seven in 10 of those ACO organizations did not generate enough savings to receive bonuses, according to an Aug. 25 announcement from the Centers for Medicare & Medicaid Services (CMS).” Indeed, as Leventhal reported, “According to the just-released CMS data, 125 of the 404 total federal ACOs qualified for shared savings payments by meeting quality performance standards and their savings threshold. The results show that more ACOs are sharing savings in 2015 compared to 2014 and that ACOs with more experience in the Pioneer ACO Model and the Medicare Shared Savings Program (MSSP) tend to perform better over time. However, similar to last year, many of these ACOs did not produce enough savings to earn bonuses.”
But in a press release issued on Aug. 25, shortly after CMS’s national announcement of results, the leaders of Scottsdale Health Partners were able to state that “Scottsdale Health Partners, LLC is one of the ACOs that shared savings.” The SHP announcement quoted James Whitfill, the organization’s chief medical officer, as saying that “Scottsdale Health Partners has invested in physician engagement, innovative technology, and coordinated care models which has laid the foundation for this exciting news. As the first MSSP in Arizona to ever earn a performance payment from savings,” Dr. Whitfill said last month, “we are humbled that a second year of our positive results confirms our innovations are producing real and durable impact. We are particularly proud of our significant increase in quality scores to 94 [out of a possible 100] in this setting.”
James Whitfill, M.D.
Dr. Whitfill spoke last week with HCI Editor-in-Chief Mark Hagland regarding his organization’s accomplishments in the MSSP, and related subjects. Below are excerpts from that interview.
First of all, Dr. Whitfill, congratulations to you and your colleagues on your achievement.
So, let’s look at how you and your colleagues have achieved what you have, in the program. To begin with, when did you join the MSSP?
Scottsdale started out with a Medicare Advantage plan. We started in the MSSP in 2014—that was our first performance year. We were humbled to be the only MSSP based in Arizona that year earn shared savings that year, so for us to repeat that in 2015, and in 2015, we were one of three. In fairness, if you look at the files, there were two ACOs that span multiple states and have some presence in Arizona, that also achieved shared savings.
How much savings did you have to achieve to surpass your benchmark in 2014 and 2015?
In the end, we saved about $9.5 million on a population of 18,000 Medicare beneficiaries in 2015; in 2014, we saved around $3.8 million on a population closer to around 12,000 beneficiaries.
So you received a check each year?
Yes, the way Medicare does it—in this case, we got the results at the end of July for the 2015 performance year, and the information becomes public in August, and we anticipate the check by sometime in October, as that’s when we received it last year.
And what did you receive from CMS each year?
We got about a $1.8 million check in performance year 2014; for performance year 2015, we’ll receive a check for about $4.5 million. And not only did our financial savings go up considerably, our quality scores went up considerably as well, and we ended up with a score of 94 out of 100.
Could you mention a few areas in which you improved the most?
Some of the areas we improved most on—we’ve been very efficient in the use of post-acute care. And we’ve been able to implement a very structured form of care coordination, and have seen dramatic improves in people’s depression scores and in their functionality, and in cost savings.
What have you done to improve outcomes and increase savings?
Your publication’s profile of us that earned our place in the Innovator Awards Program covers a lot of it, which was related to leveraging IT to perform enhanced care coordination and care management; the technology we’ve leveraged has encompassed what we’ve done with our HIE [health information exchange] and our secure messaging platform, from Orion and from TigerText. And we’ve developed APIs and integration between them. We have over 47 different EMRs represented in our 200-plus physician practices. Those technologies have helped us create a bridge to improve care coordination. And the physician engagement: 90 percent of our governance positions are filled by physicians, and we’re physician-led. So it’s a true partnership between hospital-based and ambulatory-based physicians. We really have a big tent across those spaces, and a high level of engagement. When physicians get involved and own it, it really drives tremendous changes.
Is Phoenix a pretty advanced managed care market? Because you’ve obviously been involved in advanced healthcare market-related activities.
Yes, it is. If you look at a map of the U.S. and you look at Medicare spending per capita, and then you overlay where there are a lot of ACOs, in general, you find Medicare ACOs concentrated where the per-capita spends are high, which makes sense. But Phoenix is a big exception to that. We think that, though our per-capita spending is lower for Medicare patients than in other places in the country, we think that California’s innovations have impacted us, as well as the innovations of organizations like Banner. That makes all of us have to step up our game and really work harder on this. So Phoenix is an interesting place because of that level of innovation.
What have been your organization’s biggest challenges in all this so far? And what have been some your team’s biggest learnings so far on the journey?
The challenges are many. Moving an organization from a fee-for-service mindset to a mix of fee-for-value and fee-for-service, that in itself is very hard, particularly when people are still largely reimbursed on a fee-for-service basis. I’m an informatics fellowship-trained guy, and I will say that the informatics is really hard—harder than you’d think. I spent a decade as an internal medicine practitioner. And the informatics involved in all this is very hard, surprisingly so; but you can’t wait for the informatics to get good to begin. So we started an initiative around HIE and secure messaging. But we haven’t waited for that infrastructure to be done, to move our physicians forward on shifting into value and care management, and efficiency. So the challenges are myriad; the data and culture issues are big, but the successes we’ve had have been based on starting these processes early. We think it’s because we’ve had physicians helping us and telling us upfront what they can and want to do; and that’s made a big difference.
Are you still in clinical practice at all?
I’m halftime as CMO for Scottsdale Health Partners, now Innovation Partners. I’m essentially the default CMIO as well. And I still have my own analytics and consulting firm, too, with a number of radiology clients in that space—people needing help with analytics and business intelligence. And I’m trained as an internist, and did my fellowship in informatics. So I round on Wednesdays with our transitional care coordinators, our nurses, and meet the patients. And that’s been great.
There are so many things to do in all this ACO work. How should CIOs and CMIOs think about the IT governance, project management, and other aspects of this? How do they prioritize?
Probably one of the biggest challenges is that, certainly on the vendor side, there are a million people trying to sell their tool that claims to be population health-enabled; that’s the buzz term. And so many folks are just digging their way out of their Epic or Cerner implementations. What’s more, they’re still largely operating in a fee-for-service world. And the reality is that value-based care is largely on the outpatient side, and it’s a whole different ball of wax. So you need to tap into people who have been anchored in the ambulatory space, and let them tell you how to make this journey. This is simply not an inpatient play.
I’m assuming you have dashboards for the physicians, to help them analyze and improve their clinical performance, correct?
Yes, we do. On a quarterly basis, I and Tiffany Nelson, M.D., whom you’ve met, we’re the two physicians from Scottsdale—and we’ll expand the that now after the merger—we meet with each primary care physician quarterly, using a dashboard that encompasses financial elements, utilization, and some clinical measures as well, in terms of risk scoring, quality metric scoring, things of that sort. It’s not elegant, but it’s been a powerful tool to give physicians feedback.
What have been the biggest challenges for the individual physicians, in all this?
It’s this: that they’re absolutely bombarded—they’ve got so many things coming at them every day. And it’s very difficult to make this transition. And for the individual physicians, number one is just even understanding what this is all about. And to be frank about it—I’m a pretty smart person, and it took me six months of working in one of these things, to be able to understand how all these pieces work together. And most physicians get 25 minutes a quarter to have this explained to them, and trying to understand the breadth of all this is hard. It’s a lot of information, it involves a complete model, and learning this takes time.
But seeing comparative data, motivates them towards clinical performance improvement, correct?
Yes, and whenever there are any financial stakes involved, people pay a lot of attention. And physicians—we really do want to do a good job. We’re faced with so many competing elements, and oftentimes, just the Hawthorne effect of giving people feedback, can be very motivating.
Of course, the reality is that there is a bigger context around all of this. We’ve been reporting and commenting on the most recent estimates of overall U.S. healthcare spending coming from the Medicare actuaries, and really, the healthcare system is heading over a cost cliff. Do you think that physicians in practice are starting to see that bigger healthcare system picture more now?
That’s a great question. And I’m giving a talk on Monday at the Arizona chapter of HFMA [the Westchester, Ill.-based Healthcare Financial Management Association], and I’ve had to change my talk because of Slavitt’s announcement. The paradox is that on a macro level, we have unsustainable amounts of GDP, and of the federal budget, going to healthcare. And yet at the micro level, physicians feel resource-constrained. They’re working harder and longer than ever. And the unit reimbursement on the average radiology procedure has fallen 40 percent recently. So people are having to work harder just to stay even. And physicians have a hard time grasping this, because reimbursement to them has been cut so much. But as physicians begin to see how these new models work, I think they have a little bit of hope—they allow for collaboration and interaction, and maybe even improvement of patient health status based on the new models. So I think there’s a glimmer of hope there, while at the same time, the same storm clouds of gloom remain.