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Value-Based Healthcare and IT: HIT Leaders Work Out New Strategies

September 27, 2017
by Mark Hagland
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Experts at leading patient care organizations discuss just how complex the IT challenges in front of them really are

When it comes to the plunge into value-based healthcare of all kinds—participating in value-based programs, both mandatory and voluntary; participating in accountable care organization (ACO) and other risk-based contracting involving population health management; participating in bundled-payment contracting; and all the rest—the leaders of patient care organizations are only beginning to fully realize how complex the strategic IT challenges involved really are.

For the leaders of the eight-hospital Orlando Health, based in Orlando, Florida, participation in accountable care/value-based healthcare has provided welcome opportunities—as well as some very practical strategic IT challenges.

As Jerry Senne, vice president of value-based care and population health, and Brandon Burket, director of value-based and accountable care, note, Orlando Health joined the Medicare Shared Savings Program (MSSP) on January 1, 2013, and, Burket reports, “We’ve been able to generate shared savings every single year. We’ve also generated some of the highest quality scores” in the program, he notes. And their organization, whose physician network encompasses 900 employed and 2,800 affiliated physicians, and a health system staff of over 18,000, continues to move forward in its accountable care/value-based care work.

Senne and Burket and all of their colleagues at Orlando Health have been making tremendous progress on all fronts, but it should surprise no one that data and IT issues have come to the forefront in this work. “At a more granular level,” Burket says, “we’ve had challenges with data, in terms of timeliness, accuracy, and the lag itself. We get the reports only monthly or quarterly with some payers, and often, that’s not often enough to be actionable, or it’s too old; so it’s more using the data as a compass than a roadmap.” Still, he adds, “The benefit from getting the data, even if it’s old—is that it creates a level of transparency and competitiveness among providers.”

Brandon Burket

Indeed, crucially, Burket notes, early on in the process as an MSSP-participating ACO organization, “We quickly developed what we called a data roadshow, and went around to physician practices, asking them which metrics would be useful for them. We developed 15 or 16 measures and developed our own homegrown data dashboard every month, and actually said, ‘Dr. Jones, you’re number 54 of 56 docs on this contract.’ We created a level of transparency that engendered a level of competitiveness that made people want to get better on these measures. And over time, the standard deviation actually got tighter; people were performing at a much higher level, and there was much less variation. That said,” he continued, “a lot of our commercial contracts are more claims-based, so it’s less onerous on the providers to report. But with regard to the MSSP, it’s quite a bear of an endeavor that many organizations struggle with every year. And it takes our care and coordination team quite a bit of time and effort to report on accurately.”

As Senne sees it, the ability to capture “population-based data—payer/claims data, pharmacy data, and to be able to distill that into reports, is important,” while at the same time moving physicians forward “to participate in medical governance and really participate in the journey, that is critical. Second,” he says, “to be able to achieve and maintain actionable data,” is crucial. “In early versions that payers came out with, they would say, your population health performance was ‘78’ on a scale of 1 to100; well, that was meaningless to physicians. On the other hand, if they gave you a list of the diabetics on your panel who were not controlled in their hemoglobin a1c, that was usable.”

Of course, all of these imperatives end up falling into the laps of CIOs and their colleagues in organizations participating in value-based care delivery and contracting. Rick Schooler, who’s been Orlando Health’s CIO for 16 years, sees all this clearly. “There are several must-do’s” for CIOs and other healthcare IT leaders in this venture, he says. “Number one, throughout your healthcare continuum, you’ve got to have integrated information, to the degree possible. And that’s a lot harder to do than to say. As your patients go through the continuum, those who are managing their care have to respond to things that do happen or don’t happen. You’ve got to have an EMR [electronic medical record] platform that’s generating and is capturing data, across that continuum. And you’ve got to have what a lot of people are calling population health platforms. And it’s not so much, ‘Hey, Rick has a lab result,’ but rather, ‘Hey, Rick didn’t get his lab work done.’ So there’s got to be a surveillance element going: are the things that should be happening, happening?”

Rick Schooler

What’s important, Schooler says, is to build the analytics capabilities to determine that “what should be happening is happening, and what shouldn’t be happening, isn’t happening. And you’ve got to understand physician performance: are physicians ‘in protocol’ in terms of managing their patients? You’ve also got to be able to look at claims data. And these are basically descriptive analytics. I don’t think you’ve necessarily got to have predictive analytics, though if you do have those, that’s great. But you have to make sure patients are compliant with their care plan.”

Ultimately, Schooler says, that means that “You’ve got to have integrated information across the continuum; you’ve got to have a population health or care management capability, that’s typically found in population health platforms; and then you’ve got to have analytics capabilities that allow you to look retrospectively, and potentially predictively as well. You’ve got to have the physicians and information to enable the patient-centered medical home. Do you need an enterprise data warehouse? No, but you need the ability to capture key information about patients.”

What about I.T. Strategy and Downside Risk-Based Contracting?

Things get even hairier when it comes to pursuing any contracts with downside risk, Schooler says. “The minute you get to downside risk, you’re going to need to have your clinically integrated network [CIN] fully developed,” he says. “And the more mature that clinically integrated network is, with primary care, the more successful you’ll be.” What’s more, he says, patient care organization leaders who want to become skilled enough to pursue downside risk over time, should start by mastering data analytics around their ACO work first. “ACOs are like a toe in the water. They’re basically upside reward,” he says. “But as you move into downside risk, you’ve got to have a more mature clinically integrated network, with mature IT. And these clinicians are not on the same platforms. So you have to be able to pull data in from all your points of care, and bring them into your database.” In other words, referring to the health information exchange phenomenon, he says, “You need an HIE platform. When you start taking on downside risk, everybody in that platform needs to know what’s going on. And when you expand that CIN, there’s no way you’re going to have all the providers on the same platform, so you need an HIE platform to bring all the data into the same place, absolutely including images.”

Christopher Longhurst, M.D., CIO of UC San Diego Health, agrees with Schooler with regard to the analytics tools needed to pursue value-based contracting. “With regard to value-based purchasing,” Dr. Longhurst says, “I think the critical unmet need from an infrastructure standpoint is self-service analytics tools. The more we can empower our physicians and administrators to query the EHR [electronic health record] analytics, the faster we will develop a data-driven culture.”

Physician Group Leaders Plunge into Intensifying Efforts

The healthcare IT leaders at hospitals and health systems would do well to heed the advice of the CEOs of physician groups that have already spent several years participating in accountable care organizations and value-based purchasing. Those medical group CEOs, as they plunge more intensively into continuous clinical performance improvement work, say that the slope only gets steeper over time.

Asked what the hardest thing is about using data in his organization’s ACO work, Jeffrey LeBenger, M.D., says, “I could go through a list.” LeBenger, M.D., chairman and CEO of the nearly-800-physician Berkeley Heights-based Summit Medical Group, a multispecialty physician group practice that covers a broad swath of northeastern New Jersey, and which is involved in several ACOs, says, “You need data aggregation, master-patient indexes, provider data management, and provider performance management reporting. You have to be able to do ad-hoc reports, you have to have a mechanism to monitor your quality metrics, you need to look at all your claims analytics, you have to put it into a clinical workflow model, you have to look at your attribution lists coming from payers, and your HCC coding lists, and on and on.”

Jeffrey LeBenger, M.D.

Is that a lot? Absolutely, Dr. LeBenger says. “There are all of these issues. And everything has its own IT solution. And how do you bring those IT solutions together? That’s where the cost really comes in. It’s a million dollars for every solution; and you could be talking about 12 different solutions. And sometimes you can’t aggregate the data 100 percent, sometimes you can only achieve 80 percent, and that has to be good enough. But I bring it back to the business model. If you have a good clinical practice system and you bring it back to managing things in the ambulatory environment, and looking at your high-acuity patients in a certain way, and looking at your skilled nursing patients, and how you manage your patients in a quality metric. It’s the clinical model that’s of the utmost importance, but then you need all these data points, to make sure you’re doing it right. So it’s really a conundrum here, because it’s so expensive.”

The leaders of the Mt. Auburn, Mass.-based Mount Auburn Cambridge Independent Practice Association, or MACIPA, have been intensifying their ACO development over the last few years, reports CEO Barbara Spivak, M.D. Dr. Spivak, who has been CEO of MACIPA since September 1997, helped lead the organization into the federal Pioneer ACO Program, which MACIPA participated in for three years; MACIPA is now in Track 3 of the Medicare Shared Savings Program (MSSP) for ACOs. The challenge in Massachusetts, Spivak says, is that payment levels simply do not fully reward the amount of work required of physician groups to succeed in ACOs. Nonetheless, she and her colleagues are persevering; and they’re finding that the more deeply they plunge into clinical performance improvement work, the more significant the data and IT needs become.

In fact, Spivak and her colleagues made a significant decision a couple of years ago, even as they were barreling forward with their ACO work. After years of MACIPA’s physicians practicing on a very wide range of electronic health records (EHRs), they moved to integrate onto a single EHR platform, as they found their clinical performance improvement work being hampered by the heterogeneity issue. “A majority of our docs were on eClinicalWorks,” she reports, “but because we had implemented in 2007, the government was saying that even though we had taken on shared risk, we weren’t legally clinically integrated—you had to be officially labeled clinically integrated. We had 89 different instances of eClinicalWorks, and we had some on athenahealth and Centricity, and Allscripts, and the hospital [Mt. Auburn Hospital] was on Meditech.” As a result, Spivak and her colleagues decided to unify onto a single EHR, from the Verona, Wis.-based Epic Systems Corporation; as of July, all the practices had migrated to Epic.

Meanwhile, asked about the dashboards and analytics tools she and her colleagues use, she says, “We use a wide variety of dashboards and analytics. Beginning back in Medicare Advantage,” she says, “we began to engage heavily in analytics-facilitated work.” One of the key things that she and her colleagues are doing right now is using analytics to monitor which nursing homes MACIPA patients are discharged to, following inpatient hospital stays. This is combined with MACIPA’s narrow-network program, which explicitly favors the five skilled nursing facilities in the area whose cost-effectiveness and clinical outcomes the MACIPA physicians have found to be the best. “So we have preferred providers in our area,” she says. “Obviously, we give them choice. But we also let them know that we have very intensive systems in these five SNFs, with nurse practitioners, and trusted physicians. There are hundreds of nursing homes in the area, and we picked five we trust the most. And we monitor admissions, lengths of stay, discharges to home, and what happens after 30 to 90 days after patients are discharged from the facility.” All of those processes are very important when it comes to succeeding as an ACO, she notes—and IT and data are essential to success in those processes.

Broader Development Needed for the Journey Ahead

Industry leaders are looking to broad strategic IT development, especially around infrastructure and interoperability, in order to solve some of the fundamental problems facing the leaders of patient care organizations, as they take their organizations further into value-based healthcare contracting.

Don Crane, president and CEO of the Los Angeles-based CAPG, which describes itself on its website as “the leading association in the country representing physician organizations practicing capitated, coordinated care,” with “close to 300 multispecialty medical groups and independent practice associations (IPAs)” as members, says this: “Your IT folks will need to keep developing better data warehouses, and find ways to make IT more interoperable, and provide better informatics for stratifying populations of patients, and physicians, and managing care, and getting the right providers in place. All of this, to me, is a dream come true for IT people, because you’re talking about a massive shift taking place, and one that needs to be tech- and specifically, IT-enabled. There’s lots of opportunity involved, and that’s very exciting,” he says.

Asked what some of the early stumbles have been in the IT sphere, Crane says, “One stumble has been around interoperability, and the lack thereof. All of these systems that have been designed and developed and sold, don’t work well with other systems. So this plethora of ways to interface and integrate data and systems—that’s been one of the barriers, for sure.”

Ultimately, Crane emphasizes, it will be a highly sophisticated blend of efforts—IT- and data-facilitated performance improvement work—that will successfully lead patient care organizations forward into the emerging world of value-based healthcare. “You need a clinical intelligence running this, but also one connected to a P&L and a balance sheet. So it is this dyad, this blend, of the clinical and the administrative,” that will determine the future, he says. “And the intelligence of the system is this blend of the clinical and administrative; that dyad produces the best results or the potential for the best results,” going forward.


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When It Comes to The Big Debate on ACOs, What Is “Big Enough” Savings?

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The back-and-forth interaction between CMS Administrator Seema Verma and the ACO community is unfolding at a key inflection point in the evolution of the MSSP program

Intense debates on every subject are constantly swirling in the healthcare policy sphere; that has always been the case. But one debate that is both impactful and being closely watched is the intensifying argument between the Centers for Medicare and Medicaid Services, particularly CMS Administrator Seema Verma, and some leader organizations in the accountable care organization (ACO) area.

At its base, the proposal on the part of CMS, as outlined in a proposed rule published in August, to push more ACOs into two-sided risk, is being pushed back against by many ACO leaders, particularly by their nationwide association, NAACOS (the Washington, D.C.-based National Association of ACOs). As Managing Editor Rajiv Leventhal noted in his report Dec. 5, CMS’s “core aim” is “to push these organizations into two-sided risk models—so that Medicare isn’t on the hook when ACOs overspend past their financial benchmarks—suggested 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.”

As Leventhal noted, “One option, per CMS’ proposal, would be the BASIC track, which would allow eligible ACOs to begin under a one-sided model and incrementally phase-in higher levels of risk. The second option would be 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. But where CMS, in its proposals, truly clamped down was through two core recommendations that stakeholders took issue with: shortening the glide path for new ACOs to assume financial risk, reducing time in a one-sided risk model from the current six years to two years; and cutting potential shared savings in half, from 50 percent to 25 percent for one-sided risk ACOs. These proposals, if finalized, will certainly deter new entrants to the MSSP ACO program. So far, the proposed rule has been met with varying degrees of scrutiny.”

Clifton Gaus, Sc.D., NAACOS’s president and CEO, recently gave Leventhal an interview, and in that interview, he confirmed his association’s stance that the reduction of shared savings and the shortened time allowed in one-sided models are two of the biggest problems the group has with the proposal. Indeed, Gaus said in that interview that the reduction in potential shared savings “would be very devastating to the growth of new ACOs.”

In fact, Gaus said, in polling their members, NAACOS’s leaders asked them whether they would in theory join a federal ACO program knowing that, at least at first, they would be limited to 25 percent of shared savings at most; and, in fact, “the near universal response was no, they wouldn’t have joined the program,” Gaus said, adding that “The potential of 25 percent savings just isn’t enough to offset our investment costs of starting and operating the ACOs,” noting that ACOs have to obviously put up money to get going, and sometimes it’s very hard for medical group practice-dominant ACOs to buy IT systems, not to mention the whole clinical transformational aspect of ACOs where they are typically hiring nurse coordinators, and in some cases opening 24/7 call centers. “There is a real start-up and operational cost that’s involved, and [getting] 25 percent of the shared savings doesn’t return enough income to offset those,” he said.

Meanwhile, this morning, NAACOS issued a new press release focused on the value that the MSSP program has created for CMS. “In the latest data proving the financial benefits of accountable care organizations (ACOs), Medicare’s largest value-based care initiative – the Medicare Shared Savings Program – saved $859 million in 2016, an independent analysis published today shows,” the press release began. “Since 2013, the first full year of the program, ACOs have saved Medicare $2.66 billion, well above the $1.6 billion calculated by the Centers for Medicare and Medicaid Services (CMS).” What’s more, the press release reported, “After accounting for bonuses paid to ACOs for hitting spending and quality targets, the program, which accounts for 561 ACOs and 10.5 million patients nationwide, netted more than $660 million to the Medicare Trust Fund between 2013 and 2016, contrasting the net loss of $384 million CMS estimates.”

And the press release quoted NAACOS’s Gaus as stating that “These results are the latest data point in a growing body of evidence unequivocally proving ACOs’ value. ACOs are saving American taxpayers hundreds of millions of dollars at a time when it’s most needed.” Indeed,  he added, “Given the natural lag time in collecting and analyzing data and the well-established trend that ACOs need a few years to start demonstrating results, we are only seeing the beginning of the nation’s return on investment in accountable care. This data doesn’t even mention the quality benefits ACOs have generated, which have also been substantial.”

Further, the press release noted, “A sizable amount of recent data show ACOs are saving money: 472 Shared Savings ACOs generated gross savings of $1.1 billion and netted $314 million in savings to the Medicare Trust Fund last year; CMS’s August 17 proposed rule estimates the overall impact of ACOs, including ‘spillover effects’ on Medicare spending outside of the ACO program, lowered spending by $1.8–$4.2 billion in 2016 alone.”

So now we reach the rubber-meets-the-road place. Here’s the fundamental question: Do Seema Verma and her fellow CMS and HHS (Health and Human Services) senior officials truly understand the complexities involved in what they’re asking of provider leaders? Verma and her fellow federal healthcare officials are facing a kind of Scylla and Charybdis situation right now. On the one hand, as everyone knows, the Medicare actuaries have predicted that total U.S. healthcare spending will explode from $3.1 trillion annually (in 2014) to $5.4 trillion annually (by 2024), in the next several years, amounting to a 70-percent increase in less than a decade, and bringing the percentage of GDP spent on healthcare in this country from 17.4 percent in 2013 to 19.6 percent in 2024.

On the other hand, as Clifton Gaus and the NAACOS folks have pointed out, based on surveying their membership, patient care leaders are going to recoil at the over-intensification of change mandates coming out of CMS. That feeling is quite widespread. As one ACO CEO told me just two weeks ago, Seema Verma is deluded if she thinks that ramping up the downside-risk requirements in the Medicare Shared Savings Program is going to inspire more patient care leaders to join the MSSP program or renew their participation in it. And, as this morning’s press release notes, ACO community leaders are documenting real progress in capturing savings.

The million-dollar (or maybe, $1.1 trillion-dollar?) question is, is the broad level of savings that ACOs are netting for CMS, progress enough? Indeed, what is “enough”? And what is “fast enough”? Because Administrator Verma and her fellow senior federal healthcare officials seriously risk cratering the MSSP program, the core federal ACO program, if they push too hard on the downside-risk issue. On the other hand, if they don’t push hard enough, the progress made so far could simply be dwarfed, in the broader scheme of things, by the current acceleration of overall U.S. healthcare spending inflation.

So right now really does feel like an inflection point—but one without an obvious resolution. Only time—and the interactions of federal healthcare officials and providers—will tell.

 

 

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At UPMC, Turbo-Charging Quality Improvement Efforts through Data Analytics

December 11, 2018
by Mark Hagland, Editor-in-Chief
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At UPMC, Dr. Oscar Marroquin is leading a team of data analysts whose work is facilitating intensive efforts around readmissions

At a time when the leaders of patient care organizations are facing intensifying pressure to shift away from a dependence on volume-based payment and to plunge into value-based care delivery, some U.S. hospitals, medical groups, and health systems are helping to lead the way into a future of continuous clinical improvement and of clinical transformation. That topic—of organized continuous quality improvement—was the subject of the fourth-quarter 2018 Healthcare Informatics cover story. Numerous leaders of pioneering organizations were interviewed for their insights into the health system change focused-quality improvement movement that has been emerging across the U.S. healthcare system.

Among the leaders interviewed for that cover story was Oscar Marroquin, M.D., a practicing cardiologist and epidemiologist, who is helping to lead a team of clinical data experts at the vast, 40-hospital UPMC health system in Pittsburgh. Dr. Marroquin and his colleagues have been busy harnessing the power of creating and nurturing purpose-specific teams focused intensively on the management of data to power performance improvement, particularly in the clinical area. Marroquin’s team, of about 25 data specialists, was first created five years ago. Of those, half are IT- and infrastructure-focused, and, says Dr. Marroquin, “The rest are a team of folks dedicated to data consumption issues. So we have clinical analysts, data visualization specialists, and a team of data scientists who are applying the right tools and methods, spanning from traditional analytical techniques to advanced computational deep learning and everything in between. Our task is to use the clinical data, and derive insights”—and all 12 clinically focused data specialists report to him.

And that work—“allowing people to ask questions to generate opportunities”—has paid off handsomely. Among the advances has been the creation of a data model that predicts the chances of patients who are being discharged, being readmitted. The model, based on the retrospective analysis of one million discharges, is also helping case managers to more effectively prepare patients for discharge, specifically by ensuring that patients being discharged are promptly scheduled for follow-up visits with their primary care physicians. “If those patients are seen within 30 days of discharge,” he notes, “there’s a 50-percent reduction in their 30-day rate of readmission.” The program is now active in six UPMC hospitals.


Oscar Marroquin, M.D.

Below are excerpts from the interview for that cover story that Healthcare Informatics Editor-in-Chief Mark Hagland conducted with Dr. Marroquin this summer.

From your perspective, what does it really mean to be data-driven, in the pursuit of continuous quality improvement and clinical transformation?

From my perspective, I’m very passionate in that I feel that you really can’t do any of the things that doing in terms of moving towards value, without having a robust data infrastructure, a robust strategy on how to use data and analyze it, and without then deriving evidence for how you’re going to transform your organization. There are a lot of buzzwords involved in all of this, but the only way to get from a buzzword to a true action of transformation, is if it’s data-driven.

I’m a cardiologist by training and an epidemiologist; I still practice. Over the past five or so years, I’ve been asked to oversee how we’ll derive insights from clinical data in our system; in other words, this work is around anything related to big-data analytics, with those analytics being used to help our clinicians. In order to do that, we’ve had to do many different things, including more intelligently aggregating our data, and focusing on specific analytical purposes. They’ve been structured as databases for transactional systems, but not with the intent of improvement.

So we’ve spent a lot of time creating a purpose-built environment for analytics. That’s involved a lot of technical work, to create tables, what we call our consumable layers, for analytical purposes. And we’ve created a team whose only job is to do analytics. We’ve had folks in the past managing back-end databases, who have generated reports, but that doesn’t lead to a sustainable way of using data. And so we have a team that is dedicated to maintaining the warehouse and consuming the data.

With regard to the team of 25 data analysts, do all of them report to you?

The 12 who do data consumption report directly to me; the others have a dotted-line report to me. They sit on our infrastructure team within our IT Information Services Division. Both teams are part of the Clinical Analytics Team. Data analytics—Health Services Division. Integrated team. Two sides of the same coin.

When did these teams come together?

There have been different phases. The analytics program development started in 2012, and we learned a lot of lessons. A lot of the work early on had to be dedicated to technical issues—identifying data sources, etc. That was a pretty labor-intensive process. We really got enough aggregated data to use it consistently in 2015, so from 2015 on, we’ve had this structure of teams dedicated to doing this as I’ve described.

Can you share a few examples of key advances that your team has made so far?

When asked what our team does, I tell folks we do work at the higher level in three different buckets. The first bucket is the entry point for the majority of projects. Not everybody in the system necessarily knows which questions to ask.

We allow people to ask questions to generate opportunities. Off of that, two things will happen. One, hypotheses can be generated, and so we can do hypothesis testing, we can do comparative effectiveness studies, we can formal testing of hypotheses. Also, when insights get generated, one can say, oh boy, there’s a lot of heterogeneity in this population, why is one group more at risk? So we can identify who is at high risk of a condition, and who within the high-risk category is at high risk of developing specific conditions? And the third level or bucket, we apply machine learning and AI tools to develop models that allow us to do a variety of things, from more precise phenotyping of our populations; we can build predictive models to identify patients at various levels of risk. And we also use these models to do unsupervised learning, where we can start to generate hypotheses. So most people in this space love to talk about the latter part, the predictive modeling, and we have done a fair amount of work there, with things like identifying patients at highest risk of rehospitalization after 7 or 30 days of discharge, and we’re using that in our hospitals to guide clinicians. There are resources everywhere.

So we developed a model derived out of retrospective analysis of one million discharges, and we’ve prospectively verified that the model allows us to identify patients at the highest risk of readmission, so our case managers can help us identify plans to help those patients transition from hospitalization to post-acute care in a more effective way. And we see that if they’re seen within 30 days of discharge, there’s a 50-percent reduction in their 30-day hospitalization if they get in to see a clinician. So we make sure that the patient has an appointment made and is ready to see their doctor once they’re discharged, to address any issues.

When was that program put into place?

We spent a lot of last year validating the data. And then this year, we started rolling this out to our hospitals in a phased approach, so throughout 2018, we’ve been deploying this to our hospitals, and we’ve trained and educated different hospitals to use the model, and we’re actively following patients to measure the impact of the tool. And as an epidemiologist, I’m always cautious about declaring victory too soon. We’re seeing good trends, our smaller hospitals are seeing decreases in patients coming back early.

So you don’t have any metrics to share yet?

We have three hospitals, smaller ones we started the program with first, that different units, have shown that this program has had an impact. The numbers are still small enough that I have reservations about absolute certainty. But already, we’re using the program in 20 of our hospitals.

What would your advice be for CIOs, CMIOs, and other healthcare IT leaders, as they consider these kinds of initiatives?

If we all are serious about transforming the way we care for patients, we need to do it in a data-driven way. There has to be a philosophical belief and commitment to do that. Number two, as a result of the institutional commitment and philosophy, then there has to be a team that’s dedicated to this work. I don’t think this is achievable in an ad hoc way, when people just have time. And three, it’s not for the faint of heart; it takes time and effort, but if you have the philosophical belief and institutional commitment, it’s doable. If I say to myself, I don’t ever want to leave my house and get drenched because I wasn’t prepared for a storm, then I need to check the weather app before I leave my house. In medicine, we haven’t yet taken that approach, but the data and analytics are there to guide us in helping us to make decisions, and making it a part of the everyday decision-making process. And in the same way I use examples of rehospitalization prediction, we also do condition-specific predictive analytics, around patients with asthma, kidney disease, etc., so there’s a lot of work going on there. And the message I give clinicians is, there will be companies that say they don’t’ sell you the predictive models they’ve developed; but in our experience, the models have to be a part of an organic process that leads to the building of the models. Clinicians won’t feel alienated, disenfranchised, or threatened, if you bring them in and engage them from the beginning.

 


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EXCLUSIVE: NAACOS President Foresees “Shrinkage in Accountable Care Movement” Pending MSSP Final Rule

December 5, 2018
by Rajiv Leventhal, Managing Editor
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If CMS doesn’t scale back some of its proposed changes to the MSSP, the government’s largest value-based payment program will be significantly affected, says one ACO leader

When the Centers for Medicare & Medicaid Services (CMS) released its proposals to overhaul the federal Medicare Shared Savings Program (MSSP), it was expected that industry associations, along with the ACOs (accountable care organizations) themselves, would push back strongly.

After all, in the August proposed rule, CMS, which has the core aim to push these organizations into two-sided risk models—so that Medicare isn’t on the hook when ACOs overspend past their financial benchmarks—suggested 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.

One option, per CMS’ proposal, would be the BASIC track, which would allow eligible ACOs to begin under a one-sided model and incrementally phase-in higher levels of risk. The second option would be 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.

But where CMS, in its proposals, truly clamped down was through two core recommendations that stakeholders took issue with: shortening the glide path for new ACOs to assume financial risk, reducing time in a one-sided risk model from the current six years to two years; and cutting potential shared savings in half, from 50 percent to 25 percent for one-sided risk ACOs. These proposals, if finalized, will certainly deter new entrants to the MSSP ACO program. So far, the proposed rule has been met with varying degrees of scrutiny.

One of the trade groups that has done much of the heavy lifting when it comes to pushing back on the government’s proposals, and offering evidence as to why ACOs need more time in one-sided risk models while being able to reap more of the shared savings, is NAACOS (the National Association of ACOs,) an association comprised of more than 360 ACOs across the U.S.

In a recent interview with Healthcare Informatics, Clif Gaus, president and CEO of NAACOS, confirmed that the reduction of shared savings and the shortened time allowed in one-sided models are two of the biggest problems the group has with the proposal. Specifically, Gaus says that the reduction in potential shared savings “would be very devastating to the growth of new ACOs.”

He explains that after polling NAACOS’ members, asking them if they would hypothetically apply to be an ACO knowing that at first, they would be limited to 25 percent of shared savings at most, “the near universal response was no, they wouldn’t have joined the program.” Gaus adds, “The potential of 25 percent savings just isn’t enough to offset our investment costs of starting and operating the ACOs,” noting that ACOs have to obviously put up money to get going, and sometimes it’s very hard for medical group practice-dominant ACOs to buy IT systems, not to mention the whole clinical transformational aspect of ACOs where they are typically hiring nurse coordinators, and in some cases opening 24/7 call centers.

“There is a real start-up and operational cost that’s involved, and [getting] 25 percent of the shared savings doesn’t return enough income to offset those,” he says.

Regarding the proposal to shorten the time in a one-sided risk model from the current six years to two years, Gaus points to CMS’ own data which shows that more experience in a federal ACO model drives more savings, but typically the first few years are not profitable for the ACO.

“We have many examples where an ACO has been in the program and was able to turn the corner by the fifth or sixth year,” he says. “Medicare has to have a long-term view of this. We are investing in a totally new redesign of the healthcare system, so give us time to learn how to transform that care into more efficient and higher-quality care. We are troubled by two years,” Gaus frankly admits. He believes that capping the time in a one-sided risk model at three to four years “is reasonable,” and is what many other associations have proposed.

Indeed, while NAACOS and other industry groups have made their arguments to CMS clear, the federal agency has so far taken a firm stance that upside risk-only ACOs have not been effective. A such, CMS seems to be fine with these ACOs leaving the MSSP— by far the largest federal ACO model, with 561 participants—if they are unwilling to take on more risk.

But Gaus believes that even though CMS did come out of the box with an “aggressive negative message” about one-sided ACOs, the agency has now moderated its views. To this end, a recent study from NAACOS and Dobson Davanzo & Associates, based on a different way of measuring financial success—by comparing actual costs over time in the ACO’s market as opposed to CMS’ method of calculating an initial risk-adjusted spending benchmark for each ACO based on its historical spending, without considering underlying market factors—revealed that MSSP ACOs generated gross savings of $1.84 billion for Medicare from 2013 to 2015, nearly double the $954 million estimated by CMS.

“The whole dialogue has changed,” says Gaus. “We have met with Seema and a number of her staff over the last two months, and the driving factor to this change in dialogue is that the 2017 data, from CMS’ benchmarks, turned the corner and showed that net-net the ACO program was saving Medicare money. You don’t see CMS coming out anymore arguing that the program is losing money,” he says.

What a Final Rule Might Look Like

Gaus acknowledges that a core challenge for CMS is being in the precarious position of pushing down too lightly in its regulations, which could result in the pace of change being too slow, or pushing down too hard, which could result in provider organizations fleeing value-based care initiatives.

“We know the government is wrestling with this issue, and so are we,” Gaus says. “In the crafting of our comments to CMS, as well as the comments from the AHA [American Hospital Association], AMA [American Medical Association], and others, we felt that the balance is the issue here, and there needs to be some movement toward the direction that CMS is pushing. We do respect their concerns, to a degree, but we just thought they were too aggressive in their speed to risk, or speed to remove an ACO from the program,” he says.

Gaus is hopeful that the final rule on the future of the MSSP—which he believes could come by the end of the year, but no later than the end of January—will reflect the industry’s concerns. “History says that this administration, like many others, does listen to input from stakeholders that the rule affects. I believe that they really do understand our positions,” he adds.

At the same time, NAACOS’ position is that the reduction in potential shared savings, as currently proposed, is a “total deal breaker,” and that there is no wiggle room for a number between 25 and 50 percent, Gaus asserts. He adds, “If they don’t go back to 50 percent, we will see a long-term significant shrinkage in the ACO movement and a significant emanation of accountable care.”

Importantly, Gaus also notes that ACO programs are voluntary in nature, a key consideration that he believes CMS often forgets. “Nobody has to be an ACO. [Providers] are making a bet of their capital, that they can invest that capital in cost containment, in care transformation, and [in return], they will get back in the shared savings more than they invested. It’s almost like buying stock—you made the investment and you hope the return is worth it,” he says.

Gaus says that he has told Verma in their many conversations that in many ways “we are at a crossroads, and we have to get the balance right, or we are going to see a denigration of what still remains the largest government value-based payment program.”


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