Published Online: June 20, 2014
Kelly Conroy, executive director, Palm Beach Accountable Care Organization, CEO Triple Aim Advisory Group
The world of healthcare is no longer changing: it has changed. Embracing that change and understanding what it means is at the core of Palm Beach Accountable Care Organization’s (ACO’s) success in its first year participating in the CMS Medicare Shared Savings Program, earning a total of $22 million in shared savings. Palm Beach ACO, which has about 30,000 Medicare beneficiaries and 275 participating primary care physicians and specialists, is one of the 29 ACOs in the nation that earned shared savings in the first performance year.
Achieving this success required laser focus on simple steps proven to make measurable differences. We quickly learned that building a large, expensive infrastructure was not going to bring the results that would be necessary to earn shared savings. Instead, a grassroots approach was taken that centered on physicians and their patients. Our strategy started with gaining a clear understanding of the rules, and then engaging physicians in real and meaningful ways to create a belief that this approach to healthcare would work.
That belief in the ACO model began with the realization that the government is a partner in this process—CMS’s goal is to create a collaboration that is good for both physicians and their patients. Treating patients as consumers who are willing to pay for quality outcomes is the ultimate mission, which means that the reimbursement system must change. Yet, we believe that the concept of rewarding quality makes sense and can work.
Success also means a huge cultural shift, but one that has the potential to return medicine to its roots. Our physicians began to believe in the ACO model because it put them in the driver’s seat. Making doctors part of the solution is critical, as no one is better able to improve the delivery of healthcare and redefine population health management than doctors. Thanks to the experience and insight of Hymin Zucker, MD, chief medical officer at Palm Beach ACO, it quickly became clear that success would hinge on the creation of strong patient-doctor bonds and a full knowledge of the population, as they exist both inside and outside the doctor’s office.
This completely changes the image of population health management in today’s healthcare model. With primary care physicians managing the process, medicine takes care of itself and the practice of medicine returns to what it was always meant to be. In turn, knowing and building close ties with everyone surrounding that physician can lead to better healthcare for the patient.
We concentrated on defining expectations and improving coordination with all stakeholders, including specialists, hospitals, home healthcare agencies, and skilled nursing facilities. We didn’t try to control where the patient went, but instead created a competition among providers in the community. We communicated about those who got results and it had a positive domino effect; that improvement in work flow and collaboration moved the needle in measurable ways.
Everything we did tied back to the overarching goal of understanding each patient’s experience and building enduring connections between doctor and patient. We continually measured our progress against the 33 quality measures and looked for ways to achieve ongoing improvement in each area.
We realized that dissatisfied patients could mean as much as 25% in lost savings, so it made sense to spend time in this area. One surprising discovery was the substantial number of patients who walked out of the office without follow-up appointments. That loss of control over a patient’s healthcare often resulted in the loss of the patient altogether, which means lost revenue and decreased shared savings.
So our team spent countless hours engaging physicians and navigating them through the cultural shift and the environment of constant measurement. We held both group and face-to-face meetings to demonstrate how even just a few simple changes could result in tremendous savings and improved quality measures, all without creating additional work for physicians.
Once the message was delivered, the results became increasingly clear. Dr Zucker made tremendous strides in helping physicians and their teams see the importance of quality patient-physician interactions. He helped physicians remember the value of creating a constant state of “wow” for each patient. Physicians were encouraged to create systems, hire staff, and do whatever was necessary to create positive patient experiences by treating those patients as they would treat their own mothers, for example. Patients who winter in Florida but live elsewhere the rest of the year were called and asked how they were doing; follow-up visits were scheduled before patients left the office; and patients who hadn’t been seen for a while were called and reminded to schedule wellness visits. These closer relationships resulted in more—and better—transitional care management, fewer emergency department visits, and increased overall satisfaction for patients. In short, we worked to create a culture where physicians are involved with their patients.
It didn’t take long for the physicians to see the value of their role as patient advocates, and the pieces began to fall into place. The successful physicians made changes in their offices, whether it was staffing, extended hours, or increased patient outreach. As a result, patients enjoyed the benefits of more detailed care plans and of the shared decision making with their doctors regarding their individual health issues, and their overall satisfaction increased. That satisfaction translates into real savings when those patients give their doctors high marks on satisfaction surveys.
When doctors solved the access issues and created happier patients, they realized the value in truly taking care of their population. We went as far as creating “The Big 7” patient satisfaction tips and posting them in physician offices. We determined that the areas with the best potential for improvement were:
1. Providing patients with timely care, appointments, and information
2. Ensuring effective communication with the doctor
3. Creating an environment that encourages patients to rate their doctors favorably
4. Providing easy and convenient access to specialists
5. Offering health education
6. Finding ways to involve patients in shared decision making
7. Staying current on each patient’s health status.
Simply being more proactive in getting patients in for wellness visits and preventive screenings covers 11 of the required 33 quality measures. Increasing clinical outcomes and improving revenue translates into a win-win for the patient and physician.
The primary lesson learned on the path to shared savings was that small changes make big differences. Improving patient outcomes and experiences, all while reducing unnecessary expenditures, creates a better healthcare system for everyone. Our bottom-up approach allowed us to help physicians to more thoroughly understand and thus manage their population, and help earn shared savings.