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An Industry Expert Shares Insights on the Challenges and Opportunities around Bundled Payments

January 24, 2018
by Mark Hagland
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Charlene Frizzera, a former senior CMS official, has been on the front lines in helping providers succeed in bundled-payment models

Bundled-payment contracting—whether between public payers or private payers—is an enormous subject of interest in hospitals, medical groups, and health systems these days—and for good reason. Not only have a lot of developments been evolving forward with regard to bundled payment models under the Medicare program—just two weeks ago, senior officials at the Centers for Medicare and Medicaid Services (CMS) announced the launch of a new voluntary bundled payment model called Bundled Payments for Care Improvement Advanced (BPCI Advanced)—bundled-payment contracting is taking off in a big way now, too, between private health insurers and providers.

Meanwhile, policy shifts at the highest levels of the Department of Health and Human Services (HHS) have left many provider leaders feeling uncertain as to where things are headed right now at the federal level. On the one hand, CMS at the end of November finalized a rule that will cancel mandatory hip fracture and cardiac bundled payment models (HHS had issued a proposed rule for that cancellation back in August of last year). On the other hand, earlier this month—in fact, just before the announcement of the BPCI Advanced model—Alex Azar said during a Senate Finance Committee hearing on his nomination as HHS Secretary, that he was open to mandatory bundled payment models, in principle. That stance appeared to be a reversal of the position of Tom Price, who, during his relatively brief tenure as HHS Secretary, from February through September 2017, had expressed very strong reservations about mandatory bundled-payment models.

Meanwhile, “BPCI Advanced” will qualify as an advanced alternative payment model (advanced APM) under the Quality Payment Program (QPP) under the MACRA (Medicare Access and CHIP Reauthorization Act of 2015) law; under the Advanced APM track in MACRA, providers take on financial risk to earn the Advanced APM incentive payment.

So things are moving forward, even if not evenly. But industry leaders and observers in the know agree: the bundled-payment phenomenon is moving ahead. Among those leaders is Charlene Frizzera, a former acting administrator of CMS, with over 30 years of experience in federal healthcare. Frizzera is currently president of the Washington, D.C.-based consulting firm CF Health Advisors, where she advises corporate, government and not-for-profit organizations about health care policies and reform like bundled payments and joint replacement. Frizzera spoke recently with Healthcare Informatics Editor-in-Chief Mark Hagland regarding the ongoing developments in this area. Below are excerpts from that interview.

Let’s start at a 40,000-foot level. How do you see the U.S. healthcare system’s journey into bundled-payment contracting right now?

Based on 30 years at CMS, it’s important to keep in mind that bundling is not a new concept; it’s been around forever. And at CMS, how did we come up with bundled payments? We looked at claims, and when we started looking at claims for ESRD (end-stage renal disease) patients—that was probably the first bundle. We found that the services were pretty consistent across providers. And so instead of paying separately, we felt it would be more effective to pay for a bundle, rather than for separate delivery of services. That’s the same concept even now. But the more CMS gets into patient-centric payment issues, the more they’ll be looking at specific disease states, both to save money, but even more importantly, to give the controller of the bundle the ability to more effectively manage care for that patient. Where the controversy comes in is around what gets bundled. How specific, how generic, should the bundle be? And CMS has published the 48 disease states they’d like to bundle. It’s on the website of the Innovation Center [the Center for Medicare and Medicaid Innovation, or CMMI].

Charlene Frizzera

The joint replacement bundle was made mandatory, of course.

Yes, but it had actually started out as a voluntary bundle. When it started to show success, they made it mandatory. And to date, the Innovation Center has the ability to write a regulation to change a payment system, without going through legislation, as the result of a successful demonstration. And that cuts a pretty big step out of the process. What CMS tried to do that some in healthcare didn’t like is making a demonstration mandatory from the beginning. The drug pricing demonstration was what created so much furor. That was back in 2016; it was one of the last regulations that the Obama administration tried to issue.

What’s interesting about the joint replacement bundle is that it was one of the most successful bundles they had ever put together. And when you think about what they bundle, they bundle things that have the least amount of risk to the beneficiary. Joint replacement—when you look at all those DRGs, it’s the one where there was the least amount of risk to the beneficiary, and the greatest potential reward, with the belief that a long hospital stay was not necessary. And the most successful orthopedic surgeons started doing pre-habilitation and post-habilitation with the patients. The pre-hab got the patients ready for the surgery, and because of the pre-habilitation, the post-habilitation was usually shorter, too. And that bundle was incredibly successful, when the surgeons found a way to rethink, how to make the beneficiary healthy when they come in, and get healthier more quickly afterwards. That was hugely successful.

What is your perspective on the politics of this going forward? As we all know, Secretary Price made numerous very strong statements disparaging mandatory bundles; he also changed the joint replacement bundle from mandatory to voluntary.

A couple of things. Secretary Price was very politically committed. I think he made a lot of promises to physicians when he became secretary, when he described “bad bundles”—though he didn’t use that phrase. But then they [at HHS and CMS] started looking into the bundles… And the bundles that saved money—if you stopped the bundle, you’d have to find some way to replace that savings—it’s called “pay-fors.” That was the first piece of this, per the budget. Further, they found out that there actually were a lot of people who did like the bundles. And taking away the bundle—that’s a big process, right? And so to de-bundle a set of payments is hard. What Price did do is that he stopped the mandatory bundle on joint replacement.

And again, the headlines were… but he just said, it’s not going to be mandatory. So in the end, he didn’t do much to change bundles, except make the joint replacement not mandatory. Interestingly enough, they’ve come out with a new bundle incorporating hospital and outpatient care together [the BPCI Advanced model] that they just announced, and put out the award for the new bundle and are looking for recipients. And they’re looking for people to apply by October 1.

Do you have broad overall thoughts about mandatory versus voluntary bundles?

The folks who didn’t like the mandatory bundle are just the folks who liked being paid a lot of fee-for-service money. You probably won’t make as much money under a bundled payment. But you can actually make just about as much money under the joint replacement bundle if you do the pre- and post-habilitation. CMS’s idea is that, mandatory or not, folks will stop going to those organizations that don’t do as well under the program. So what happens is word of mouth. And it’s not going to happen overnight. But there is going to be movement in the beneficiary space for practices that do the bundles that keep patients healthier. So I think it should be mandatory. It’s going to force surgeons to manage and coordinate care. And again, that’s just for joint replacements. They don’t have bundles for back surgery. And it’s so common these days.

Ultimately, how many potential areas might there be in which to develop bundles?

There could be hundreds of bundles, depending on where CMS wants to go. For this latest, they’ve identified 29 inpatient and 3 outpatient codes, to bundle together. And the idea is that they want the hospitals and outpatient clinics to work together—it’s for cardiac defibrillation; the second is back and neck except spinal fusion; and the third is percutaneous coronary intervention (PCI). So, that’s two heart procedures, and a back-and-spine procedure.

How quickly will providers get good at managing bundled payments?

Obviously, it depends on the physicians. I think that, for the surgeons and other physicians who are part of a bigger provider group or healthcare systems, this will be easier to do; for the others, for the smaller practices, it will be harder; it’s hard to just call someone up and say, “Hey, you wanna do a payment with me?”

Data, analytics and information-sharing will prove to be very important to success in this area, correct?

Absolutely. If you don’t know who you’re serving, what you’re paying, and what services you’re providing, you can’t manage a bundle. And sharing is important, but you have to have the data first. And part of the original joint replacement bundle concept was gathering the data together. And as you know, claims data is not great. That’s all CMS has, so that’s what they’ll use. But the clinical record with that is what makes it work.

And, as provider leaders are telling us, marrying the clinical and claims data remains a huge challenge, correct?

Yes, absolutely.

Do you have any advice for the CIOs and CMIOs of patient care organizations around this?

I say this at every conference I speak at: the only way to change the healthcare system is through data. You don’t really know what to change until you have data to show what’s happening. And part of what limits our data today is providers and payers collecting data based on what they’re paid on. If you get a capitated payment, you collect data for a capitated payment; if you get paid a bundle, you collect data on a bundle. And the successful providers of tomorrow will figure out today what kinds of data they’ll be paid on years down the road. What are the three or four possible types of payments I’ll be receiving? And the services provided.

Tell me a bit more about the “pre-habilitation” concept?

Certainly. I’ve been advising a start-up company called PeerWell, which has developed a patient-facing app. The thing is that, while physicians automatically factor post-acute care into how successful their patients might be post-surgery, many don’t realize how pre-habilitation activities can help patients’ processes. By participating in a pre-hab program, such as that offered by PeerWell, hip and knee replacement candidates can optimize their health before surgery, offering a way for hospitals to contain the cost of care per patient by focusing on improving patient health pre-procedure, therefore reducing the amount of time needed in a costly skilled nursing facility for post-op rehab. By doing so, more patients are in a better condition to be discharged directly home after surgery, cutting after-care costs dramatically—which has shown to be a large cost to providers.

Do you have any metrics to share around that?

Yes. A one-percent improvement in terms of the percentage of patients discharged to their homes, will result in $100,000 in cost savings. Meanwhile, if clinicians can reduce the cost of an episode by $1,215 through one to two hours of pre-hab care, that would represent a cost savings of $1.2 million in cost, for a hospital that performs 1,000 joint replacement cases a year.

What are the critical success factors involved in this pre-hab care management?

There are several. First, they connect very directly to patients. Patients connect pretty easily with the presentation. It’s simple. Patients can review with them what the plan is. It really does create the continuity between the beneficiary and the surgeon, and they guide them through the pre-hab process. So having a care manager do the pre-hab process. It needs that little bit of a personal touch. So that they pay attention to the pre-hab procedures, and patients stick with the program and prepare for the surgery; it’s really pretty impressive.

The reality is that bundles aren’t going away. So people who think bundles aren’t going to be a form of payment in the future, are kidding themselves.



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CMS’ MSSP Proposed Changes Slammed by Leading ACO Organization

August 10, 2018
by Rajiv Leventhal
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Industry stakeholders fear that ACOs will drop out, while CMS doesn’t seem to mind if upside-only ACOs that are costing the government money leave the program if they aren’t willing to take on more risk

The National Association of ACOs (NAACOS) called CMS’ (the Center for Medicare & Medicaid Services) proposals to redo the Medicare Shared Savings Program (MSSP) “misguided,” noting that the changes, if finalized, “will upend the ACO movement by creating havoc with a significant overhaul introducing many untested and troubling policies.”

Late yesterday evening, CMS proposed a rule that included major changes to the existing MSSP ACO (accountable care organization) program. As Healthcare Informatics reported last night, referred to as “Pathways to Success,” CMS’ proposal, which has been expected for a few months, looks to redesign the program’s participation options by removing the traditional three tracks in the MSSP model and replacing them with two tracks that eligible ACOs would enter into for an agreement period of no less than five years: the BASIC track and the ENHANCED track.

Much of the discussion following the rule’s release will likely center around the BASIC track, which essentially limits ACOs to stay in “upside-only” risk models for just two years, compared to the existing allowance of six years. What’s more, those ACOs in an MSSP Track 1 upside-only model would only be able to get 25 percent of any savings they take in, compared to 50 percent, which is the current max.

When ACOs are in a one-sided risk model, they do not share losses with the government when they overspend past their benchmarks, but they do share in the gains. As such, in these one-sided risk models, CMS is on the hook for any losses all on its own.

Indeed, CMS has a clear goal to move ACOs more quickly into two-sided-risk models as the agency has noted that upside-only ACOs are not reducing costs and are costing Medicare money. “We project these changes will result in $2.24 billion in savings to Medicare program over next 10 years,” CMS Administrator Seema Verma stated yesterday.

Stakeholders Show Concern

As expected, NAACOS—a coalition whose members include more than 300 ACOs—had plenty of gripes with CMS’ proposals. Previously, following a survey of its members, NAACOS urged CMS to refrain from mandating ACOs to assume more risk. The organization, earlier this year, specifically reached out to Track 1 ACOs that were about to enter the final agreement period in 2019 before moving into two-sided risk models. The results of their survey showed that 71 percent of ACO respondents indicated they would likely leave the MSSP as a result of having to assume risk.

In a statement released last night, NAACOS President and CEO Clif Gaus noted, “The administration’s proposed changes to the ACO program will halt transformation to a higher quality, more affordable, patient-centered healthcare industry, stunting efforts to improve and coordinate care for millions of Medicare beneficiaries.”

According to Gaus, “The downside financial risk for patient care would be on top of the significant financial investments ACOs already make, jeopardizing years of effort and investment to improve care coordination and slow cost growth.” He continued, “CMS discusses creating stability for ACOs by moving to five-year agreements, but they are pulling the rug out from ACOs by redoing the program in a short timeframe with untested and troubling polices.”

In the proposal, CMS itself is predicting that more than 100 of the 561 MSSP ACOs will drop out of the program in the next 10 years as a result of this rule. But Gaus said that the number of ACOs who will leave will be far greater than that, referencing NAACOS’ survey from earlier this year. “Given the proposals put forth today, 70 percent could be an underestimate, with even more ACOs leaving the program,” he said.

“It’s naïve to think that ACOs that aren’t ready can be forced to take on risk, given that the program is voluntary. The more likely outcome will be that many ACOs quit the program, divest their care coordination resources and return to payment models that emphasize volume over value,” Gaus said. “This would be a significant setback for Medicare payment reform efforts and would undermine implementation of the overwhelmingly bipartisan Medicare Access and CHIP Reauthorization Act (MACRA), which is designed to move providers into alternative payment models such as ACOs,” he added.

CMS, however, doesn’t seem to have a problem if upside-only ACOs that are costing the government money leave the program if they aren’t willing to take on more risk. Verma said yesterday on a press call that “[Upside-only] ACOs have no incentive, at all, to reduce healthcare costs while improving outcomes, as they were intended.”

On the contrary, NAACOS believes that “The best scientific evidence shows that the Medicare Track 1 ACOs overall are returning millions of dollars of savings to Medicare and improving the quality of care for millions of beneficiaries. To shrink and disable this leading alternative payment model in its early stages defies logic.”

Premier Inc., which has some hospital-led ACOs in its population health management collaborative, released a statement agreeing with NAACOS when it comes to forcing ACOs into more risk. Blair Childs, senior vice president of public affairs, Premier, said, “First, the level or investment and change required to move to two-sided risk is far greater than CMS clearly appreciates by providing only a two-year onramp of no risk for organizations newly entering into an ACO.  Forcing providers to accept risk too quickly will deter participation.”

Further, the American Hospital Association (AHA) also believes that CMS’ proposals are too aggressive. Tom Nickels, AHA’s executive vice president, noted that “drastically shortening the length of time in which ACOs can participate in an upside-only model ignores the reality that providers are starting at vastly different points and will have vastly different learning curves when moving toward value-based care.” He added, “The proposed rule fails to account for the fact that building a successful ACO, let alone one that is able to take on financial risk, is no small task; it requires significant investments of time, effort and finances… A more gradual pathway is critical for hospitals and health systems that are interested in participating in risk-bearing models – particularly those that are exploring such models for the first time.”

Some Show Positivity

It should be noted that not all of the reaction that has come in thus far has been negative. Leaders from Orange Care Group, a South Florida-based organization that owns and operates four independent, physician-led Medicare ACOs—including one of the first risk-based Track 3 ACOs—are pleased that CMS is “formally recognizing downside risk ACOs as the future of the model and evolving ACOs to better service Medicare and its patients,” according to Frank Exposito, Orange Care Group’s executive vice president of finance and strategy.

Exposito, in response to e-mailed questions from Healthcare Informatics, also agreed with Verma’s comments yesterday when she said upside-only ACOs have not lived up to the accountability part of their name. “ACOs, by definition, need to be accountable and ACOs who have continually failed to generate savings and improve quality are not contributing to the model and the industry at-large. With the entire market shifting to risk, the ACO model will gain strength in the communities they serve because all ACOs will be incentivized for moving the needle forward,” he said. Exposito further noted, “This will foster more innovation in the space as ACOs seek to mitigate their risk through novel partnerships with high-quality and high-performing acute and post-acute providers, while placing primary-care physicians at the center of their patients’ care. This will ultimately help extend the efforts of Medicare reform across the healthcare continuum.”

Overall, America’s Physician Groups (APG) also considers the proposed rule a very balanced approach to various stakeholders’ concerns as well as a positive step forward in the movement from volume to value, the organization said in a statement, also noting that physician-led ACOs that take on two-sided risk provide superior quality at a lower cost than other ACOs, while saving Medicare money.

Valinda Rutledge, vice president, federal affairs, APG, added that the CMS proposals build in a transitional pathway for those ACOs who are looking to take on more risk. “We know that many of today’s ACOs have experience in upside risk only. The proposed rule acknowledges this and provides for a transition period instead of forcing groups into downside risk right away. We believe that no group should be forced into risk; however, when groups decide to accept the opportunity for shared savings, we also believe that they then should take on the responsibility of saving money for our healthcare system and the people and communities they serve,” she said.

The Health Care Transformation Task Force, meanwhile, said it welcomes the release of CMS’ proposal. “This is an important step to promote value-based transformation and to push industry momentum forward. At first pass, the proposed rule presents novel ideas and careful thinking on how ACOs may better lower cost and improve patient outcomes,” said Jeff Micklos, the group’s executive director.

Official public comments on the rule are due Oct. 16.

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BREAKING: CMS Proposes Sweeping Changes to MSSP ACO Program

August 9, 2018
by Rajiv Leventhal and Heather Landi
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CMS is proposing to push ACOs into two-sided risk models by shortening the duration of one-sided risk model contracts

The Centers for Medicare & Medicaid Services (CMS) is proposing a new direction for ACOs (accountable care organizations) in the Medicare Shared Savings Program (MSSP), with the goal to push these organizations into two-sided risk models.

Referred to as “Pathways to Success,” CMS’ proposal, which has been expected for a few months, looks to redesign the program’s participation options by removing the traditional three tracks in the MSSP model and replacing them with two tracks that eligible ACOs would enter into for an agreement period of no less than five years: the BASIC track, which would allow eligible ACOs to begin under a one-sided model and incrementally phase-in higher levels of risk; and the ENHANCED track, which is based on the program’s existing Track 3, providing additional tools and flexibility for ACOs that take on the highest level of risk and potential rewards. At the highest level, BASIC ACOs would qualify as an Advanced Alternative Payment Model (APM) under the Quality Payment Program.

Currently, the MSSP model includes three tracks and is structured to allow ACOs to gain experience with the program before transitioning to performance-based risk. The vast majority of Shared Savings Program ACOs have chosen to enter and maximize the allowed time under Track 1, which is an “upside-only” risk model. MSSP Tracks 2 and 3 involve downside risk, but participation in these tracks has been limited thus far.

When ACOs are in a one-sided risk model, they do not share losses with the government when they overspend past their benchmarks, but they do share in the gains. As such, in these one-sided risk models, CMS is on the hook for any losses all on its own.

Broadly, CMS is now essentially proposing that the contract agreements of upside-only ACOs be two years, rather than allowing six years (two, three-year agreements) like the government has previously permitted. Overall, there are 561 MSSP ACOs out of 649 total Medicare ACOs, with 82 percent of those 561 MSSP ACOs taking on upside risk only.

While ACO contracts normally renew at the start of the year in January, CMS is giving ACOs whose contracts expire this December a one-time-only six-month extension, until July 2019, so they can apply for a new agreement beginning on July 1, 2019, if they so choose. Moving forward, CMS would resume the usual annual application cycle for the performance year starting on January 1, 2020 and subsequent years.

As the federal agency continues to steer ACOs away from upside-only models, CMS noted that some Track 1 ACOs are generating losses (and therefore increasing Medicare spending) while having access to waivers of certain federal requirements in connection with their participation in the program. These ACOs may be encouraging consolidation in the market place, reducing competition and choice for Medicare FFS beneficiaries, according to agency officials.

CMS Administrator Seema Verma previously has criticized upside-only ACOs, remarking that they have not generated enough results to date. And today, she hammered this point home on a press call. “[Upside-only] ACOs have no incentive, at all, to reduce healthcare costs while improving outcomes, as they were intended. Thus, the program has not lived up to the accountability part of their name,” Verma asserted.

Meanwhile, the ACOs in twosided risk models “have shown significant savings to the Medicare program and are improving quality,” CMS said in today’s announcement. As such, Verma said today that requiring ACOs to take on downside risk more quickly, matched with increased risk and flexibility, would reframe the Medicare Shared Savings Program to deliver value to the 10 million patients currently in ACOs, and taxpayers. “We project these changes will result in $2.24 billion in savings to Medicare program over next 10 years,” she stated.

How will Upside-Only ACOs Respond?

Indeed, as it stands today, MSSP Track 1 remains by far the most popular option for ACOs. Recently, the National Association of ACOs (NAACOS) surveyed Track 1 ACOs that were entering their third agreement period and found that 71 percent of ACO respondents indicated they are likely to leave the MSSP as a result of having to assume risk.

In CMS’ proposed rule, the agency internally estimates that more than 100 ACOs will drop out of the program over the next 10 years. CMS said in the rule that “The overall drop in expected participation is mainly due to the expectation that the program will be less likely to attract new ACO formation in future years as the number of risk-free years available to new ACOs would be reduced from six years (two, three-year agreement periods in current Track 1) to two years in the BASIC track, which also has reduced attractiveness with a lower 25 percent maximum sharing rate during the two risk-free years.”

Verma was asked on the press call about the expected drop in ACOs, to which she noted that since the two-sided risk ACOs are the ones who are generating savings, having organizations who are losing the government money eventually leave the program is not a bad thing. “We know that they are losing money when they are only taking on upside-only risk. So, we’re only allowing them to do that for the first two years of the program.”

Verma continued, “The other change we’re making is that for six years we’ve been allowing [ACOs] to only take upside risk while also take in 50 percent of the savings. Now, we’re saying you can only do this for two years and only get 25 percent of the savings. So, that’s why we’re mitigating the losses that we’re having in the program.”

It remains to be seen how stakeholders will respond to CMS’ proposal today, but with the survey NAACOS administered in May, the organization stated that it encourages ACOs to prepare to move to risk and strongly supports ACOs that are ready to do so, but that it does not support forcing ACOs to assume risk if they are not ready.

Verma, when asked on the press call about the new proposals, said that it’s simply time for the program to evolve. “When we developed this program, we wanted to move the entire program towards providers taking more risk because we know that works. We want to work with ACOs that are serious about participating in the program and investing in the type of changes that are going to deliver value to patients,” she stated.

The CMS chief acknowledged on the press call that, “For some, change is always difficult, and we understand that there are those who say they haven’t had enough time to live up to their commitment to achieve value."

Proposal Specifics

In its proposal, CMS said that the BASIC track’s glide path would offer an incremental approach to transitioning eligible ACOs to higher levels of risk and potential reward. The glide path includes 5 levels: 

  • A one-sided model available only for the first two years to eligible ACOs (ACOs identified as having previously participated in the program under Track 1 would be restricted to a single year under a one-sided model);
  • And three levels of progressively higher risk and potential reward in years three through five of the agreement period. Under the one-sided model years of the glide path, an ACO’s maximum shared savings rate would be 25 percent based on quality performance, applicable to first dollar shared savings after the ACO meets the minimum savings rate. The glide path concludes with a maximum 50 percent sharing rate, based on quality performance, and a maximum level of risk which qualifies as an Advanced APM for purposes of the Quality Payment Program.  

ACOs in the BASIC track glide path would be automatically advanced at the start of each performance year along the progression of risk/reward levels, or could elect to move more quickly to a higher level of risk/reward, over the course of their agreement period.

In the end, ACOs entering the BASIC track’s glide path for an agreement period beginning on July 1, 2019, would have at most 2 ½ years under a one-sided model (with ACOs identified as having previously participated in the program under Track 1 restricted to 1 ½ years) and their first automatic advancement would occur at the start of performance year 2021, CMS explained.

What’s more, ACOs identified as “low revenue”—typically composed of physician practices and rural ACOs—could participate in the BASIC track for up to two agreement periods.  For instance, a low revenue ACO that participates in the BASIC track’s glide path could renew under the BASIC track, at the highest level of risk and reward, for a second agreement period. ACOs identified as “high revenue”—typically ACOs that include hospitals—would be required to transition to the ENHANCED track more quickly, after no more than a single agreement period under the BASIC track.

CMS has observed that low-revenue ACOs have outperformed high-revenue ACOs, but that some low-revenue ACOs lack a pathway to transition from a one-sided model to more modest levels of performance-based risk. Agency officials noted its Medicare Track 1+ ACO Model, a time-limited Center for Medicare and Medicaid Innovation (Innovation Center) model which began this past January, demonstrates that a lower-risk, two-sided model is an effective way to rapidly progress to performance-based risk. 

Related Insights For: Value-Based Care


A Pioneering M.D. Leader Shares Insights on Successfully Navigating the Massachusetts Healthcare Market

August 9, 2018
by Rajiv Leventhal
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Dr. Barbara Spivak details her organization’s long, but rewarding journey to value

On the ongoing journey to value-based care, provider organizations are all over the map when it comes to how advanced they are. Some are just starting out on that road while others are much further along.

In Massachusetts, the Mt. Auburn Cambridge Independent Practice Association (MACIPA), based in Brighton, includes 500 affiliated physicians and operates an ACO (accountable care organization) that is in Track 3 of the federal Medicare Shared Savings Program (MSSP) model—the track in which ACO participants take on the most risk for their patients. Indeed, the organization, headed by Barbara Spivak, M.D., CEO, has been engaged in risk-based contracting since the 1980s. Needless to say, MACIPA is on the advanced side of the road.

At the Boston Health IT Summit on August 8, Dr. Spivak joined Healthcare Informatics Editor-in-Chief Mark Hagland on stage to discuss MACIPA’s value-based care journey, the core health IT and policy-related issues physicians are facing these days, and much more as it relates to healthcare in the state.

Massachusetts healthcare, said Spivak, a local practicing physician for the last 30 years, is unlike most U.S states in that nearly every doctor belongs to some type of health system. But the biggest issue doctors face today, she contended, is that when they belong to a network, they are supposed to keep business inside it. At the same time, the healthcare market is moving more into “open access,” she said. “Patients choose health plans [in which] they can go anywhere [for care]. And now, more patients are expecting that no matter where they go, their primary care physician and specialist should know what happened to them, even if they go to other physicians [in other systems],” she said. 

As such, preventing patient “leakage” out of the system has become an enormous pressure on physicians, Spivak attested. “We have talent in every system so it’s not like you will get good care in system A but bad care in system B. They are all great systems that will provide great care. So you can’t deny people based on quality because the quality is great everywhere,” she asserted.

Regarding health IT, Spivak noted that years ago, MACIPA was doing population health management even before the organization ever got an EHR (electronic health record). She said that when EHRs started to gain traction, MACIPA applied for a state grant to get the funding to implement one. And although MACIPA just missed out on that funding request, Spivak said by that time she had already convinced her colleagues to get the EHR anyway, so they did. “And over the years we have done more and more population health, using real clinical data, not just claims data. We were also one of the first Pioneer ACOs, and now we’re in MSSP Track 3 with significant upside/downside risk,” Spivak said, speaking to how far along MACIPA has come.

As such, Spivak said that when MACIPA was considering which ACO model to join, an endeavor that would involve taking on risk for Medicare fee-for-service patients, Mt. Auburn physicians were already accustomed to managing care for their patients via their Medicare Advantage contracts. “Those patients got a lot of support. They were provided social workers, health coaches, and had care managers,” Spivak recalled, noting the biggest complaint from physicians at that time was why MACIPA couldn’t do these things for their Medicare fee-for-service patients as well. “But we didn’t have the data on them and there was no risk involved,” she said.

Spotting Flaws in Quality Metrics

Spivak went on to note that for all of issues facing the healthcare industry, as physicians continue to manage populations of patients, they have to “staff up” and getting the data and documenting is quite challenging. “One of key factors in physician burnout, particularly in primary care, is the documentation required for all of the quality metrics,” she said.

Even though MACIPA is a small organization, its physicians are still held accountable for hundreds of quality metrics that differ across various health plans. But Spivak said her physicians are taught just one set of metrics. For example, if there are 50 diabetic quality metrics spanning across all MACIPA’s health plan contracts, Spivak and her team narrow those 50 down to eight and then teach the physicians just those eight.

Nonetheless, Spivak believes that there are some major flaws in how certain quality metrics are measured, offering CMS’ (the Centers for Medicare & Medicaid Services) measure for screening for future fall risk as an example. Originally, she explained, physicians had to simply ask at-risk patients if they had two or more falls in the past six months and if they were injured. But a new CMS proposal may make things more complicated than that, Spivak noted. If the proposal passes, starting in 2019, physicians will have to ask these patients many more questions, including finding out details about stairs in the patients’ home as well as their vision.

But there are timing issues, Spivak continued. The final rule on this proposal will come out in October and the mandated start date for complying would be in January 2019, meaning EHR systems will have to remove those two original questions and replace them with another seven or eight. “Once that happens, I have to go out and teach all of my doctors, nursing homes, advanced practitioners, and others that the old [method] is out while the new questions are in. And that takes three to four months. Think about health systems that have 1,500 doctors. It’s an impossible situation,” she attested.

What’s more, Spivak offered, there are plenty of quality metrics that don’t measure quality. She noted one measure that looks at whether or not the physician prescribed antibiotics for bronchitis. This, Spivak, asserted, is a “coding measure” and has nothing to do with the amount of antibiotics the physician gave, since it all depends on if that physician coded for viral bronchitis or bacterial, as it’s OK to give antibiotics out for the latter, but not for the former. “Am I a trained or untrained rat?” Spivak jokingly asked. “That’s what this measure is about.”

Indeed, Spivak advised providers to not to blindly listen to the EHR companies who say that quality metrics are imbedded inside their systems, and that physicians can document easily. “Everyone’s quality metrics are a little bit different across the U.S. and its important to work with clinicians on them,” Spivak offered. “One advantage for me is that I still see patients about one-third of the time and it’s not the healthy 20-year-olds who I am seeing. I see chronically ill patients who are tough to document for. So you have to run things by your clinicians, and ask them if the [EHRs] work for them as is or if they’re making documentation [harder].  Don’t just rely on what your vendor tells you.”

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