Value-Based Care’s Landscape Tilt | Healthcare Informatics Magazine | Health IT | Information Technology Skip to content Skip to navigation

Value-Based Care’s Landscape Tilt

May 31, 2018
by Mark Hagland
| Reprints
As the policy and payment landscape shifts, U.S. healthcare leaders look at the opportunities and challenges inherent in plunging into risk-based contracting

When it comes to aligning physician incentives and processes in order to master value-based contracting in healthcare, senior leaders at the 30-plus-hospital, Arlington-based Texas Health Resources (THR) have been working assiduously to put everything together, confirms R. Todd Richwine, D.O., chief medical informatics officer at the Texas Health Physicians Group, the umbrella physician group attached to the THR integrated health system.

Referring to the Next Generation accountable care organization (ACO) program sponsored by the federal Centers for Medicare and Medicaid Services (CMS), Dr. Richwine notes that, “As part of the Next Gen ACO, we have 85,000” Medicare beneficiaries being managed under that program. “And we’re in multiple other ACOs,” he adds, referring to the 29,000 Medicare beneficiaries covered under the North Texas Specialty Physicians Medicare Advantage contract the system services, the 21,000 Medicaid beneficiaries covered under the AmeriGroup ACO, and, in the commercial realm, the 112,000 United HealthCare, 69,000 Aetna, 48,000 Cigna, and 19,000 Humana health plan members that THR clinicians are caring for, for a total of more than 354,000 patients altogether.

As for Texas Health Resources’ journey into value-based care delivery and payment, “I would say it’s been slow and steady,” Dr. Richwine says. “We started into ACO work years ago with a group called Medical Edge, which became Texas Health Physicians Group. So we have a long history of working towards quality and being physician-led. We have a large number of very active physicians—anything around reimbursement or quality measures, is, led by physicians,” he adds.

Asked about the biggest challenges, Richwine offers, “I think the biggest challenge has been developing the support staff necessary to do well on the measures. The physicians are very motivated to do the right things for their patients. Unfortunately, some of what’s required falls outside of what physicians can accomplish themselves. It really requires an entire multidisciplinary team to achieve results, on behalf of sometimes-difficult populations. We make sure that we’re providing the care—everything from physicians to PAs and nurse practitioners, to social workers and case managers.”

Richwine and his colleagues at Texas Health Resources are far from alone in facing down the complexities of value-based healthcare. As early on in the collective journey as the U.S. healthcare system is, the leaders of organizations like THR are learning valuable lessons in how to prepare broadly to take on financial risk in contracts with the public and private purchasers and payers of healthcare, and how to engage and align physicians.

Early On in the Journey of a Thousand Miles

Certainly, the grand adventure in value-based healthcare is in its early stages. Asked to characterize how far along on the proverbial journey of a thousand miles U.S. providers are in that journey, Joe Damore, vice president at the Charlotte-based Premier Inc., says, “I think we are still in the childhood years, about to enter the teenage years, maybe, on this. We’ve got about 20 percent of both commercial and Medicare arrangements, that are two-sided—it’s actually 17 percent in Medicare that are on two-sided risk now, up from 13 percent,” he adds. “We’re moving more and more towards two-sided risk, but it’s a slow process. The delivery systems want to make sure they’re ready, and that they have the tools, knowledge, and information to manage two-sided risk. But one-sided risk has continued to grow, with over 500 Medicare ACOs across the country, and about the same number of commercial ACOs.”

What’s more, Damore says, “Our forecast that two-sided risk will pick up even more soon, as providers need some downside risk to really focus on this. And we’ll also see a growth in Medicare Advantage and Medicaid managed care, involving some downside risk to providers. Many health plans want to do this and shift risk to providers, too, but many don’t have the infrastructure in place to move towards a capitated arrangement for primary care plus shared savings for specialty care; very few have built the tools to do that. There’s a desire to do that. Blue Cross of Hawaii has implemented that model, where they’re capitating over 500 physicians in Hawaii for primary care, and providing shared savings for total cost of care.”

“To add to what Joe has said, in the past many years, I’ve been focusing on the bundled payment side, and one of the interesting things with bundled payment is that if you go back to the BPCI (Bundled Payments for Care Improvement) program under Medicare, announced in 2011, the thousand-plus participants have been dealing with two-sided risk across the life of that program,” says Mark Hiller, vice president of bundled payment services at Premier. What’s more, Hiller notes, “There’s two-sided risk in the total joint replacement program. We’re working with providers on CHF, pneumonia, COPD, and so forth, in addition to total joint, and with two-sided risk. So that’s growing, if more slowly, than the broad population health-related programs. But in the bundle area, it’s growing fast. I wouldn’t be surprised if the new program took off quickly, he says, referencing what’s called BPCI-Advanced—the Bundled Payments for Care Improvement Advanced program, sponsored by CMS.

A fundamental challenge, says their colleague, Shawn Griffin, M.D., Premier Inc.’s vice president, clinical performance improvement and applied analytics, is that, collectively, “We’re still standing on opposite sides of the gym, trying to figure out if anyone wants to dance, and nobody’s a good dancer yet.” “Living in both worlds—the world of fee-for-service incentives and of value-based payment—is very difficult,” Damore agrees. “We have an expression” at Premier, Damore says: “fee-for-service is the enemy of value-based payment. That is the number-one challenge, that the model of payment to providers has to be aligned on a value-based model.” With reference to discussions about capitated payment in primary care, he says, “If my incentive is to get patients into the office, that’s what I’m going to do; but if my incentive is to manage my patients on a capitated model, I’m going to grow my panel and have advanced practitioners see my patients more.”

“I think the provider market is moving forward at a measured pace,” says Laurie Sprung, Ph.D., vice president, consulting, at The Advisory Board Company, the consultative firm based in Washington, D.C. “But,” Sprung says, referencing the recent announcements around potentially disruptive market changes on the horizon—from the proposed CVS takeover of Aetna, to the announcement earlier this year that Amazon, Berkshire Hathaway, and JP Morgan Chase are planning to create an employer-based disruption in the healthcare delivery market—“we all recognize that the opportunity for disruption is there. And part of what I see in all those areas is a wide-open space that many of our progressive members are in, where they’re on a value path, but they’re also on a consumer-focused path. What good is a clinically integrated network, if I can’t access it easily?” she asks, referring to the acceleration taking place in the development of clinically integrated networks in many local and regional healthcare markets across the U.S. Simply building new organizations of organizations won’t move providers forward fast enough, she adds. “You have to be willing to disrupt how you do things. It’s incredibly disruptive for a physician practice to do some visits live and some by telehealth; it’s hard operationally. But we’ve got to think through what the package is, ours or somebody else’s, that gets the consumers what they want when they want it, and how they want it. There are already a lot of low-cost alternatives to seeing a physician,” she notes.

The View from the Health Plan Side

All those interviewed for this article agree that it’s very important for the leaders of hospitals, medical groups, and integrated health systems to understand where the leaders of commercial health plans are moving, within leaders of more innovative health plans are moving ahead as quickly as possible.

One health plan whose senior executives would like the market to move forward faster than it is, is the San Francisco-based Blue Shield of California, which serves more than 4 million members in California. There, notes Chris Jaeger, M.D., Blue Shield’s vice president of accountable care innovation and clinical transformation, the organization’s entire provider-facing strategy is based on the presumption of value-based healthcare as a core building block. “We start with a base commercial contract with the providers, and then we lay on top of that a multi-party accountable care/HMO agreement,” in every instance possible, Jaeger says. “That involves Blue Shield, a provider group, and two facilities. And we set a global budget for the population attributed to that contract, and if they perform well and there are savings, we all share the savings, and if we come in over the budget, we share in the costs as well. The global budget helps us keep the premium rise at a better level than the non-HMO market,” he adds.

What’s more, Jaeger notes, Blue Shield of California’s accountable care contracts also include “quality parameters around which providers can see extra compensation as well. Where I see us going is in extending that kind of agreement to other stakeholders, including skilled nursing facilities and other stakeholders important to the continuum of care,” he says. “Beyond that, we’re working on alternate payment models separate from ACO arrangements. Those include bundled payments, where we create the bundles for certain conditions, procedures, or diseases, with clear guiderails or boundaries. For example, if we’re looking at a bundled payment for an elective hip replacement, those guiderails help us innovate with providers, around things they’re working on, so it makes sense for them and for us. So for instance, on that hip replacement, would there be an opportunity to collaborate with the physical therapists, rehab facilities, and even startups in the space, to use more technology in the home, versus building more bricks and mortar facilities.”

Jaeger emphasizes that the opportunity to collaborate to improve patient outcomes is one that he believes provider leaders should find appealing, in that collaboration to improve outcomes is a banner under which everyone can march together. Still, he acknowledges, the leaders of many patient care organizations are finding the path forward challenging. Asked whether the provider organizations partnering with Blue Shield of California have been achieving improved clinical and financial outcomes, Jaeger says, “Of course, it varies by provider. What matters first and foremost is their willingness and their skill; those are critical success factors. Another relates to how many patients are involved, both at the group level and the individual-physician level. The more at-risk members, the greater the likelihood to improve outcomes. And another factor relates to how long they’ve been working with us. Those groups that have been doing this for a longer time also have the benefit of Blue Shield investing in efforts around complex care management, certain types of clinics, etc.”

From the Physician Side: Slow, Steady Acceptance and Progress Seen

Meanwhile, leaders of multidisciplinary physician groups are working hard to make progress, even as they face obstacles and challenges. Still, confusion remains among leaders and clinicians at many patient care organizations about how various alternative payment models work, even bundled payments. Premier's Hiller says, “There’s still a misunderstanding out there about how these models work. When I meet to talk with providers about bundles, especially when I talk to providers new to the concept, there’s a vast different between how the program actually works, and their understanding of it. There’s this notion that you’ll get a single payment and figure out how to distribute that, and many providers aren’t comfortable with that, because they think they’ll now have to act as a payer. But the vast majority of bundles today still involve a fee-for-service payment upfront, and it can actually be successful for them financially. To be successful with these bundles really requires managing quality of care: you don’t want multiple readmissions under a bundle. When you can reduce readmissions, and look across the continuum of care, which most providers aren’t used to doing, you can be quite successful, both financially and from a quality perspective,” he emphasizes.

In the end, a classic differentiator remains operational here, says Sohail, the CIO of the Dallas-based Premier Management Company, a firm that organizes and manages ACOs (and is unrelated to the Charlotte-based Premier Inc.). And that differentiator, says Sohail (he uses one name only), is the element of personal leadership. “Looking nationwide,” Sohail says, “it is clear to me that, among those organizations that have had tremendous success in value-based healthcare, personal leadership is, in my humble opinion, the primary trait. When leadership understands why it’s important to move into value-based care, that’s when things move faster. And there is a learning curve involved. It’s better to fail earlier. So in my opinion, personal leadership is core. Secondly,” he says, “with the bureaucracy of large organizations, any set of changes has to go through so many iterations—and that can only be addressed through strong leadership.”

 

 


2018 Seattle Health IT Summit

Renowned leaders in U.S. and North American healthcare gather throughout the year to present important information and share insights at the Healthcare Informatics Health IT Summits.

October 22 - 23, 2018 | Seattle


/article/value-based-care/landscape-tilt
/article/value-based-care/cms-mssp-proposed-changes-slammed-leading-aco-organization

CMS’ MSSP Proposed Changes Slammed by Leading ACO Organization

August 10, 2018
by Rajiv Leventhal
| Reprints
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.


More From Healthcare Informatics

/article/value-based-care/breaking-cms-proposes-sweeping-changes-mssp-aco-program

BREAKING: CMS Proposes Sweeping Changes to MSSP ACO Program

August 9, 2018
by Rajiv Leventhal and Heather Landi
| Reprints
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

/article/value-based-care/pioneering-md-leader-shares-insights-successfully-navigating-massachusetts

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

August 9, 2018
by Rajiv Leventhal
| Reprints
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.”


See more on Value-Based Care