Shortly after the federal Centers for Medicare & Medicaid Services (CMS) announced the latest results coming out of the two main accountable care organization (ACO) programs operating under the aegis of the Medicare program, the Medicare Shared Savings Program for accountable care (MSSP) and the Pioneer ACO Program, leaders at the Charlotte-based Premier, inc. were able to trumpet positive results coming out of Premier’s population health initiative.
As the statement attributed to Joe Damore, vice president, population health management, at Premier, noted, “Members of the Premier healthcare alliance commend all 353 participating care providers on the successes of the Medicare Shared Savings Program (MSSP) and the Pioneer Accountable Care Organization (ACO) Program for their notable quality improvements and $411 million in total savings. We believe ACOs hold great promise and are particularly pleased that more than 45 percent of the MSSP and Pioneer ACOs participating in Premier’s population health management collaborative, one of the largest ACO collaboratives in the country, qualified for shared savings payments,” Damore’s statement said. “Critical to their success, collaborative members focus on 10 key strategies to operate a highly-successful population health management entity, including benchmarking performance with peers, population health data management, leveraging a gap assessment tool and sharing best practices.
Futhermore, the statement stated that “All participants deserve credit for taking accountability for the quality and cost of care for a defined population. This is difficult work that requires new capabilities and investments. Moreover, the Centers for Medicare & Medicaid Services (CMS) model is evolving and we believe additional steps need to be taken, which we outlined in our recommendations to CMS.”
In fact, Damore reported to HCI Editor-in-Chief Mark Hagland, the details of Premier’s ACO collaborative’s progress are particularly positive. Here’s how the numbers stack up: in 2014, 181 of the 333 MSSP ACOs generated some level of savings, while 152 ACOs in that program generated no savings; and 15 of the 20 ACOs in the Pioneer ACO Program generated some level of savings, while five generated none. Expressed in terms of percentages, 55 percent of MSSP ACOs generated some level of savings, while 45 percent generated none; meanwhile, 75 percent of Pioneer ACOs generated some level of savings, while 25 percent generated none.
Meanwhile, among ACOs involved in Premier, Inc.’s ACO collaborative, the 2014 results were as follows, Damore noted: 50 percent of the Pioneer ACOs in Premier’s collaborative achieved some level of savings, while that same percentage, 50 percent, also received shared savings payments from CMS. Meanwhile, 63 percent of MSSP ACOs in Premier’s collaborative achieved some level of savings, and 47 percent received shared savings payments from CMS.
In other words, among the MSSP ACOs participating in Premier’s collaborative, 63 percent achieved some level of savings, compared with 55 of MSSP ACOs overall.
On August 27, Damore spoke with Hagland about the results, and shared his perspectives on what is working in moving accountable care/population health initiatives forward. Below are excerpts from their interview.
What have been your and your colleagues’ key learnings so far in the ACO venture?
The key question is, where do you invest your time in improving quality and lowering costs? That’s what we’re good at. We’ve worked with 65 ACOs that are MSSPs and Pioneers so far. And we’re really excited about it, because we think we’re doing some things that are really helping organizations. And if you talked to them, they’d tell you that. We provide a benchmarking tool for them, and a service we provide is that we’ll come in and do a gap assessment for them so they can focus on their efforts. We’ve done about a dozen of those, and the reaction, among a mix of Pioneer and MSSP ACOs, has been very positive. We identify the gaps.
What are the biggest gaps you’re finding?
In general, what we’re finding is that the organizations not making money have not made care management changes. We’re talking about managing high-risk patients, setting up a care management program for the 2-3 percent who make up 40 percent of the total expenses. And we use a hybrid model that includes clinical people and non-clinical people, so nurses, and also laypeople, who would be addressing issues like transportation, support systems for people, and there’s a high return on investment in using the care management, it’s very cost-effective.
There are six main chronic diseases that are the cause of the bulk of healthcare costs in this country: asthma, diabetes, congestive heart failure, COPD [chronic obstructive pulmonary disease], hypertension, and chronic depression. Those are the chronic diseases to focus on. If you look at a pyramid of healthcare utilization, the sickest two to three percent are the folks we have to focus on. Among the Americans in that top 2-3 percent, there are five main subgroups. The first subgroup includes people with multiple chronic diseases; typically, they’re obese with diabetes, high blood pressure, etc. Another subgroup is anybody over 85 years of age. The third subgroup would be people with renal disease, a very expensive group. The fourth group have both a chronic disease plus a behavioral health issue. And the fifth subgroup are facing end-stage, life-threatening diseases. Those are the most common groups of people in those subgroups of the 2-3 percent. Historically, no one really paid attention to those groups of people.
So the first large group that any ACO needs to look to take care of are those individuals I’ve just described, including those five subgroups. Below that top 2-3 percent of high utilizers in your patient population, the next group to look at is the 10-15 percent of people with at least one chronic disease. There are all kinds of studies showing that caring for them is very cost-effective.
So you start by looking at those populations. That is the first area to get involved in. The next area is integrating a patient-centered medical home model into a team-based primary care model.
The third area is re-visioning post-acute care. Under the old healthcare model, no one was paid to pay attention to the quality and cost of post-acute care. There were no studies on the most effective sites, providers, etc. So people were referred to skilled nursing facilities without any analysis. So there are a lot of people in skilled nursing facilities for two or three weeks until their co-pay kicks in, and under Medicare, it kicks in at 21 days, so we see a lot of SNF stays of 20 days, and we’re finding that the model is really primarily economically driven, not clinical.
And how is that model being impacted by ACO participation?
Well, we’re seeing a shift over to home-based care. One of the ACOs we’re working with has seen a 30-percent reduction in their average daily census at skilled nursing facilities. That is the result of a shorter average length of stay, and a decrease in skilled nursing facility admissions, and an increase in the use of home care. And they’ve built a much more advanced home care-based model, one that includes telemetry in the home; they also provide a small camera connected to their flat screen TVs, so the nurse can do virtual visits through their TV. And the nurse will ask them their blood pressure, heart rate, blood sugar, etc. and then we figure out how to advise the patient across that telemedicine connection. This is an early adopter of that technology; we’re going to see that spread across the U.S.
And we’re seeing an actual improvement in patient satisfaction and in quality scores, not a decline. So we’re really doing what’s right and focusing more on the patient, so that works.
A fourth area of activity is around end-of-life care, and how we’re really supporting people. Can we do a better job by providing palliative care and hospice care? We’re seeing a growth in much more support to families and patients.
So those are some of these areas working across all these sites. And we have an agreement with CMS under which we’re getting the claims data for these sites, and then we prepare comparative reports for them, to see how they’re stacking up with other ACOs in areas like ER visits per 1,000 patients. And we know there’s overuse of ERs, and if we can increase access to primary care, we can reduce ER utilization and improve care outcomes. We also look at post-acute care costs per member per month.
That’s a full menu of efforts and activities.
Yes, it is. And the measures I’ve mentioned are just a few of the total number that we’re looking at with the members of our ACO collaborative. But it really works. It’s just so impressive to see what some of these organizations are doing across the country. Among the pioneers in this are Banner Health and Mosaic Life in St. Joseph, Missouri, a smaller town, doing really well. Another one is Summa Health in Akron, Ohio—just a few organizations that really have embraced this transformation of care, and they’re focusing on value-based care. We’re really blessed to work with these organizations. And we’re trying to learn from them and help others, and that’s the whole point of our benchmarking program.
And this may be the first time these organizations have ever had full access to claims data; because you can’t possibly manage a population without having access to all that data. So when we help our member organizations to prepare for contract negotiations with private payers, we tell them, you’ve got to have all that.
So it’s exciting; I think the country’s moving in the right direction. And we’re seeing savings. And we’re just at the beginning of transformation, and this is hard stuff. A lot of this requires change management, which is difficult. And we’re all trying to help organizations integrate care across the entire organization. I go to a provider that is a patient-centered medical home, and my family does. And I think this is what needs to be done across the U.S. healthcare system.