In late October, the Centers for Medicare & Medicaid Services (CMS) announced that Downers Grove, Ill.-based Advocate Health Care, the largest health system in the state, and its affiliated Medicare accountable care organization (ACO), Advocate Physician Partners Accountable Care, Inc., realized $60.6 million worth of cost savings in 2016.
Ranking second in savings of 432 ACOs participating in the Medicare Shared Savings Program (MSSP), Advocate was among the highest in quality results while providing care to the largest group of Medicare beneficiaries, the organization’s officials attested at the time of the announcement.
Since Advocate’s ACO participation in the MSSP commenced in 2012, the health system has reduced the total cost of care for its 139,000 assigned beneficiaries. Indeed, as Advocate’s officials have attested, “The total cost of care for our Medicare population was less in 2016 than it was in 2013. We’re not just bending the cost curve; we’ve turned it downward.”
As Healthcare Informatics reported in September 2016 following the release of CMS’ 2015 MSSP ACO results, Advocate Health Care’s deep history in value-based arrangements has led to its success in this model. Just recently, we caught up with Lee B. Sacks, M.D., chief medical officer of Advocate Health Care, to talk about the ACO’s impressive 2016 results, reasons for its successful performance, challenges faced, and next steps for the organization. Below are excerpts from that interview.
First off, congratulations on another year of strong ACO results. What do you think are one or two core reasons for Advocate’s success in the MSSP model?
We are past the tipping point in terms of having a cohort of risk patients and managing risk, not just in MSSP but in Medicare Advantage and on the commercial side, too. So it’s becoming our standard of care—to be efficient and challenge ourselves on unnecessary utilization—and I think it’s an evolution from fee-for-service to population health and value. The more of your business that’s in “value mode,” the easier it becomes. The year before, we made some big strides in the post-acute space and continued to build on that, recognizing that there was a lot of overutilization in our marketplace and in the skilled nursing facilities, so we created a network in which we have our clinicians rounding. We have reduced length-of-stay by about 25 percent, we reduced transfers to the ER as well as readmissions, and we continued to get more of our patients into that network and cared for by the team. So that’s another fairly sizable area, but there are lots of little things that go on at each practice level tied to improving quality and reducing overall cost.
Lee B. Sacks, M.D.
What are some ways the ACO has been able to leverage data, IT and analytics?
All of our primary care physicians are on an IT system that has achieved meaningful use, but that hasn’t been a requirement for a good portion of our specialty doctors. We use a registry across the whole network that focuses on the prevention of and evidence-based chronic disease management, and that helps get gaps in care in front of everyone in real time. And that’s helped us improve our quality scores year-over-year; we’re at 97 percent with 5,000 doctors. That’s pretty amazing.
We do have a group working on predictive analytics. We score readmission risk in real time on the hospital EHR (electronic health record), and it gets updated every two hours or whenever there’s a change in medications or in condition to identify who’s at high risk for readmission. We also have a tool that helps identify what the best place for hospital post-discharge is that will reduce the risk of readmission. And besides over-utilizing skilled nursing facilities, one insight [we discovered] was that we were under-utilizing home care. Being more proactive and having one or two home visits can make a big difference in the hospital-to-home transition, and that could end up being far less expensive than ending back up in the ER or being sent to a skilled nursing facility.
Last year, you also mentioned that your use of post-acute facilities was way above the national benchmark. How are you continuing to evolve here?
It has come down; the CMS data on Medicare spend per beneficiary, when it first came out two or three years ago, showed that all of our hospitals were an outlier in post-acute [usage]. Now about half of the network is at the median and everyone is improving. So we are changing practice patterns.
One big challenge that you mentioned last year was not being able to get your performance data back in real time. Is that still an issue?
The data is still an issue; CMS actually missed their deadlines this year. In other years, they would give you the previous year’s reconciliation in the last week of July. This year (2017), we got our quality scores in July, but didn’t get the financial reconciliation until mid-September. So that was about another six weeks or so [later]. We were almost into the fourth quarter of the current year before knowing how we performed in the previous year. That’s frustrating. Not getting the quarterly reports risk adjusted, which is what you get in that financial reconciliation, really makes it hard to understand or interpret your performance.
Do you have future plans to move into another federal ACO program?
We have applied for MSSP Track 1 +, which has downside risk and qualifies us as an Advanced APM (under MACRA), and that of course gains additional reimbursement for the doctors. So we are waiting to hear back from CMS on that. They need to finalize and select it before telling people.
What advice can you offer to those are still grappling with the decision on whether or not to join a value-based model such as this one?
You want to get started. No matter how good your organization is, there will be a learning curve if you have been purely in the fee-for-service world. Track 1 is a good way to start because there is no downside [risk]. Contracts are typically for three years and that’s a realistic timeframe to make an investment; by the third year you should see a return in savings. But at the same time, you need a plan to get to a critical mass of value-based business so it becomes the way your clinicians and organization approach it as opposed to it being a one-off on the side. If it’s the latter, you won’t be successful.
Medicare Advantage enrollment also just recently closed, and we’re hoping that we see a nice uptick in enrollment there. The benefit design makes it even easier to provide high-quality, efficient care as there is much less out-of-network care. That is the downside of regular Medicare ACOs—about one-half of care is provided by our competitors, meaning you are accountable for it but really have no ability to influence it.