Can Medicare ACOs Learn from Commercial ACOs? | Mark Hagland | Healthcare Blogs Skip to content Skip to navigation

Can Medicare ACOs Learn from Commercial ACOs?

October 13, 2016
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A Commonwealth Fund-sponsored analysis of ACO development is offering fascinating insights

It was fascinating to thoroughly read a new analysis from the Commonwealth Fund, which, as this publication reported last week, examined the results of a Commonwealth Fund-supported study published in the October issue of Health Affairs and authored by researchers from Harvard University, the University of California-Berkeley, Dartmouth College, and elsewhere, which looked at data from national surveys of 399 accountable care organizations (ACOs), examining differences between the 228 commercial ACOs studied, and the 171 non-commercial (Medicare or Medicaid) ACOs studied.

The Commonwealth Fund analysis, by David Peiris, Madeleine Phipps-Taylor, Stephen M. Shortell, Valerie Lewis, Merdeith B. Rosenthal, Carrie H. Colla, Courtney A. Stachowski, and Lee-Sien Kao, and written by Brian Schilling, began with a synopsis that reads, “Online survey data show that accountable care organizations (ACOs) with commercial contracts outperform ACOs with public-payer contracts on selected measures of quality and process efficiency. These differences in performance are linked to variation in organizational structure, provider compensation, quality improvement activities, and management systems. The public sector can and should play a lead role in supporting and guiding the future growth of ACOs to ensure that desired quality and efficiency gains are realized.”

As the Commonwealth Fund analysis authors note, “The past four years have seen rapid growth in the number of ACOs, as various groups rush to promote or adapt to this new, risk-based payment model. Today, more than 800 ACOs cover an estimated 28 million Americans, a figure that some expect to quadruple over the next five years. While large, more mature commercial ACOs tend to score higher on quality measures and have more processes in place to improve efficiency than their noncommercial counterparts do, few ACOs of any variety report having rigorous quality monitoring processes or substantial financial incentives tied to quality. To ensure the rapid embrace of this promising model leads to desired improvements in healthcare quality and efficiency,” the analysis’s authors state, “ACO leaders and policymakers will need to focus on critical success factors such as organizational structure, health IT, physician engagement and incentives, and quality improvement.”

Now for a few fascinating drill-down results:

Ø  Commercial ACOs are far more likely—41 percent versus 19 percent—to be include one or more hospitals, and to be jointly led by physicians and hospitals (60 percent versus 47 percent). Commercial ACOs also had lower expenses per Medicare enrollee--$10,000 versus $12,000—and slightly higher overall quality-of-care scores.

Ø  Commercial ACOs tended to be more active in tying physician compensation to quality incentives, though overall, only half of ACOs reported even monitoring financial performance at the physician level. Commercial ACOs were also more likely to tie specialists’ compensation to quality metrics.

Ø  Overall, quality improvement activities were seen by the analysts as being modest across the board. Even among the commercial cohort, only 60 percent of those ACOs provide clinical-level performance feedback or use patient satisfaction data for quality improvement, while only 30 percent reported having well-established chronic care programs.

Ø  When it comes to IT, analysts found that just over 30 percent of commercial ACOs uses a single electronic health record (EHR) system, while fewer than 20 percent of non-commercial ACOs do so. And few ACOs of either type reported “being able to effectively integrate patient information between providers.”

As the Commonwealth Fund-supported analysis noted, “Both noncommercial and commercial ACOs need to make major investments in critical infrastructure if they are to support delivery system reform, the study’s authors say. “In particular, this his would entail coordinating quality improvement activities and related financial incentives for physicians. At the same time,” they add, the Health Affairs article noted that “the immature state of most ACOs’ information technology platforms may substantially complicate such efforts.”

So what can we take from all of this? A number of things. To begin with, it’s interesting that the researchers who have done the analysis for the Commonwealth Fund found that, while all ACOs have a long way to go in terms of broad elements such as tying physician performance to clinical and financial outcomes, providing physicians with clinical outcomes feedback, providing physicians with financial outcomes feedback, or creating unified clinical information systems (including EHRs) across their networks, they also found that commercial ACOs were ahead of publicly sponsored ACOs in some of these areas.

There are a number of possible explanations for such findings, including the fact that some commercial ACOs have been in existence considerably longer than some of the Medicare ACOs; the fact that the executives of private health plans have far more flexibility to develop the parameters of their risk-based contracts with providers; and the fact that some of the same providers now joining the various Medicare ACOs, including the Medicare Shared Savings Program, the Pioneer ACO Program, and the Next-Generation ACO Program, already had experience on the commercial side, and that those that did have that experience, are benefiting from it now, as they participate in the more rigidly architected Medicare programs.

Another very interesting finding was the divergence between the number of ACOS that included both hospitals and physicians, and especially whose governance included both physician and hospital leaders—on the private contracting side versus the government contracting side. The very fact of joint governance, with leadership from both physician group and hospital system leaders—is an obvious potential success factor in an ACO’s operations, given that reducing inpatient readmissions and ED visits through population health-based strategies is essential to bringing down costs and improving patient outcomes under accountable care. And that 60-47 percent disparity around governance speaks to some of the challenges that some ACOs will face going forward. That having been said, I found in my research for our September cover story on physicians taking on risk, that it isn’t all black-and-white when it comes to such things.

For example, Jeffrey LeBenger, M.D., the chairman and CEO of the Summit Medical Group, based in the northeast New Jersey community of Berkeley Heights, is leading an entirely physician-run and physician-governed medical group that is involved in very successful risk contracting with private payers in New Jersey. But Dr. LeBenger and his colleagues also know that smart strategy and governance go hand in hand, and that it is those elements that must drive the leveraging of technology. As he put it to me, “Infrastructure does not drive medical care. You have to have the physician buy-in and the program that manages patient care, and your infrastructure has to support the care, but not drive it.” And, finally, he says this about why physician group leaders can in some cases achieve what hospital and health system leaders struggle to achieve: “Often, when hospitals manage medical groups, the problem is that they use the wrong paradigm. Our paradigm is to take everything to the ambulatory sector, and do what’s right for the patient on the ambulatory side.”

And that is a perfect segue to the Commonwealth Fund-affiliated researchers’ conclusions about information technology. Because while it is absolutely clear that improving EHRs and other clinical information systems, and making them more interoperable and more responsive to ACO-driven needs, including health information exchange-related needs (such as the need to alert primary care physicians of inpatient admissions and discharges and ED visits), all of those advances need to be strategically driven in order to maximize the opportunities offered by the present moment in ACO evolution.

But the core points made by the Commonwealth Fund do seem highly valid to me, particularly given the greater flexibility that private plan-contracted ACO development offers to physician groups and hospitals. And that reinforces a core point I make often these days: now is a wonderful moment for healthcare organization leaders to learn from one another. We’re still the very early stages of creating true accountable care in healthcare, and the leaders of pioneering organizations can share and are sharing tremendous learnings with one another. And some of those will definitely be around the strategic architecting and deployment of key clinical information systems, financial systems, data analytics, and data and information sharing, to support accountable care- and population health-based initiatives. So I would take this analysis as a “glass-half-full” kind of situation, and examine its findings, for all the opportunities it can provide the countless ACO and population health efforts being developed right now—and in the near future.

 

 

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Kaiser Creating Evidence-Based Complex Care Models

January 17, 2019
by David Raths, Contributing Editor
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Work aligns with recently published ‘Blueprint for Complex Care’

The National Center for Complex Health and Social Needs recently published a “Blueprint for Complex Care” to develop a collective strategy for promoting evidence-based complex care models. Recognizing that many patient issues have root causes that go beyond the medical, the Blueprint seeks to identify best practices for breaking down silos between the social care delivery system and healthcare.

Perhaps no health system has devoted as many resources to complex care as Kaiser Permanente. Its Care Management Institute, a joint endeavor between the Permanente Medical Groups and Kaiser Foundation Health Plan, has established Complex Needs as one of its national quality initiatives. It has named regional complex care leaders, created common quality measures across regions and established a complex need research arm called CORAL. (Kaiser Permanente has eight Permanente Medical Groups and regions, more than 12.2 million members, more than 22,000 physicians and 216,000 employees.)

In a Jan. 16 webinar presentation, Wendolyn Gozansky, M.D., vice president and chief quality officer, Colorado Permanente Medical Group and national leader for complex needs at the Care Management Institute, described Kaiser Permanente’s efforts and used some personal anecdotes to explain their goals.

She said Kaiser Permanenteis working on the concept of developing core competencies and tools to support a longitiudinal plan of care for patients with complex needs. “These are the folks for whom the usual care is not meeting their needs,” she said. “How do you recognize them and make sure their needs are being met?”

Gozansky gave an example from a patient she had just seen the previous wekend. This women had fallen and broken her hip. She had several chronic conditions, including significant asthma, yet she was not on an inhaled steroid.

“One concept I love from the Blueprint is that this field is about doing whatever it takes to meet the needs of the person in front of you,” she said. In speaking to the woman, she came to understand that singing in a church choir was the most important thing in her life, and the inhaler medication was making her hoarse and unable to sing.  She was fairly isolated socially except for church. “My goal was to get her rehabbed and leverage the patient-defined family that is supportive. Her goals are to sing, so we need to do what is possible to get her back to that. We have to capture that information, put it into a long-term plan of care. The goal is not to get her out of rehab but to get her singing in choir.”

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The health system has to work on care that is preference-aligned. The woman is not on a steroid inhaler but her care is preference-aligned. How does the health system assure that everyone knows they are doing the right thing?

Gozansky said the beauty of Permanente Medicine is that its setup involves an employed medical group focused on value, not volume. They can interact with health plan partners in delivery of new systems of care. “It is a virtuous cycle about value and person-centered care. This is what our complex needs team is trying to understand.”

She described the journey so far: In 2015 there were pockets of work being done across the eight Kaiser Permanente regions. In 2016 they established complex care as a national qualitiy iniative. “We knew we were not meeting these patients’ needs. We had to figure out the right way to do that.” They also realized that most of the previous research on the topic involved examples that were not in integrated systems such as Kaiser Permanente. “We had to figure it out in an integrated system,” she said.

 In 2017 they started working on cross-regional learning — for instance, taking a program from Colorado and trying it in Southern California. Then they sought to align quality measures. In 2018 they got funding to create CORAL, the complex needs research arm.  

The Care Management Institute has created a “community of practice” on complex care to break down silos within the organization and bring together research, operational and administrative executives. They also want to work with external stakeholders to make sure what they are developing is scalable, Gozansky said.

Mark Humowiecki, senior director of the National Center for Complex Health and Social Needs, also spoke during the webinar. He said one of the goals of the Blueprint was to get a clearer definition. Some people get confused about terms such as “hotspotting” and complex care, he said. He said there is a recognition that these patients’ needs are crossing traditional silos, so “there is a need to connect care for the individual but also at the system level.”

The goal, he added, is to create a complex care ecosystem by developing in each community system-level connections between social care delivery and healthcare, which in the past have operated too independently.  The five principles are that complex care is person-centered, equitable, team-based, cross-sector and data-driven. One of the Blueprint’s recommendations is to enhance and promote integrated cross-sector data infrastructures.

 

 


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NIH’s All of Us Program Teams with Fitbit for Data Collection

January 16, 2019
by Heather Landi, Associate Editor
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The All of Us Research Program, part of the National Institutes of Health (NIH), has launched the Fitbit Bring-Your-Own-Device (BYOD) project. Now, in addition to providing health information through surveys, electronic health records, and bio-samples, participants can choose to share data from their Fitbit accounts to help researchers make discoveries.

According to All of Us research program officials, the project is a key step for the program in integrating digital health technologies for data collection.

The All of Us Research Program, established by the White House in 2015, aims to advance precision medicine by studying the health data of 1 million diverse Americans over the next five years. One aim of the project is to include groups that have been historically underrepresented in research. As of September 2018, more than 110,000 people have registered with the program to begin the participant journey, and more than 60,000 have completed all elements of the core protocol.

The participants are sharing different types of information, including through surveys, access to their electronic health records and blood and urine samples. These data, stripped of obvious identifiers, will be accessible to researchers, whose findings may lead to more tailored treatments and prevention strategies in the future, according to program officials.

Digital health technologies, like mobile apps and wearable devices, can gather data outside of a hospital or clinic. This data includes information about physical activity, sleep, weight, heart rate, nutrition, and water intake, which can give researchers a more complete picture of participants’ health.” The All of Us Research Program is now gathering this data in addition to surveys, electronic health record information, physical measurements, and blood and urine samples, working to make the All of Us resource one of the largest and most diverse data sets of its kind for health research,” NIH officials said.

“Collecting real-world, real-time data through digital technologies will become a fundamental part of the program,” Eric Dishman, director of the All of Us Research Program, said in a statement. “This information, in combination with many other data types, will give us an unprecedented ability to better understand the impact of lifestyle and environment on health outcomes and, ultimately, develop better strategies for keeping people healthy in a very precise, individualized way.”

All of Us participants with any Fitbit device who wish to share Fitbit data with the program may log on to the All of Us participant portal at https://participant.joinallofus.org and visit the Sync Apps & Devices tab. Participants without Fitbit devices may also take part if they choose, by creating a free Fitbit account online and manually adding information to share with the program.

All of Us is developing additional plans to incorporate digital health technologies. A second project with Fitbit is expected to launch later in the year, NIH officials said, and this project will include providing devices to a limited number of All of Us participants who will be randomly invited to take part, to enable them to share wearable data with the program.

The All of Us research program plans to add connections to other devices and apps in the future to further expand data collection efforts and engage participants in new ways.

Related Insights For: Population Health

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NorthShore to Lead “Largest Primary Care-Based Genomics Program in U.S.”

January 14, 2019
by Rajiv Leventhal, Managing Editor
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The Chicago-based NorthShore University HealthSystem and genomics technology company Color are partnering on a new initiative that will aim to deliver the power of genomics to routine primary care at population scale.

Known as "DNA10K," the initiative will engage more than 10,000 patients and will be the largest known primary care-based genomics program in the U.S., according to officials who made an announcement last week.

The approach will build on NorthShore's years of experience in genomics and actionable electronic medical records (EMR) information, while providing access to Color's clinical-grade genetic testing and whole genome sequencing to inform patients about their risk for certain hereditary conditions, according to company executives.

“The knowledge will help patients learn about their genetic makeup, including risk factors for certain disease types such as common hereditary cancers and heart diseases. This insight will help NorthShore personalize care for each patient to support improved outcomes, prevention and overall health,” officials noted.

The announcement comes on the heels of a recent pilot between NorthShore and Color that looked to unlock the benefits of genetic information in routine care.

As officials explained, in less than two months, more than 1,000 patients signed up for the Color population health program as a part of their primary care visit, an adoption rate of more than 40 percent of those eligible and significantly beating expectations of the pilot program. “This is a strong indicator of patients' interest in understanding genetic factors that can influence health and the opportunity to work with NorthShore care providers to make more informed treatment or prevention decisions,” they attested.

Overall, the DNA10K initiative supports NorthShore's efforts to improve patients' health outcomes at a population level, with genomics as a foundation for informing individualized healthcare.

Patients who take advantage of the "DNA10K" offering will provide a blood sample, which is then analyzed in Color's CLIA-certified, CAP-accredited lab, and results are returned to healthcare providers and their patients. In addition to their NorthShore primary care provider, patients will also have access to board-certified genetic counselors and clinical pharmacists from Color and NorthShore, officials explained.

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