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The American Journal of Managed Care September 2016
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The Opportunities and Challenges of the MSSP ACO Program: A Report From the Field
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The Opportunities and Challenges of the MSSP ACO Program: A Report From the Field

Farzad Mostashari, MD, ScM, and Travis Broome, MPH
This article provides a detailed description of a Medicare Shared Savings Program accountable care organization (ACO)'s actions and results, to increase understanding of the challenges and opportunities facing ACOs-particularly those comprised of independent practices.
Quality improvement. All of our practices are users of certified electronic health record (EHR) technology, which we optimized with visit templates and order sets to increase consistency in provision of preventive services, screenings, and immunizations, particularly in the context of annual wellness visits. Although ACOs can earn full credit in their first year for successful reporting of their quality scores regardless of accomplishment, we believe that a focus on preventive services—particularly for cardiovascular health—will pay dividends over time, decreasing our patients' morbidity and mortality and improving longer-term cost trends.6 Consequently, we achieved rates of aspirin use for patients with ischemic vascular disease of 87%, screening and follow-up for elevated blood pressure at 90%, tobacco use screening and cessation counseling at 93%, and pneumonia vaccination status rose to 76%; all were substantially higher than applicable benchmarks.
Avoid unnecessary emergency department (ED) visits. We worked with practices to broaden access to same-day scheduling for urgent visits, improve after-hours telephone triage, and educate patients about appropriate use of the ED. In a Consumer Assessment of Healthcare Providers and Systems survey (obtained via confidential reports given to each ACO by CMS), 94% of patients reported that they could “usually” or “always” get an appointment for urgent care as soon as they needed it, and 88% reported being able to get a medical question answered as soon as they needed it when they called after hours. Rates of ED visits that led to hospitalizations fell by 5% and 4% in the APC and Delaware ACOs, respectively, while they increased by 1% in other MSSP ACOs.
Improve care transitions. Wherever possible, we established real-time notifications of hospital discharges through integration with health information exchanges, direct hospital Health Level Seven International (HL7) feeds, and optical character recognition and natural language processing of fax notifications.7 We developed a cloud-based workflow tool and training and feedback for practices to call patients within 48 hours of discharge and to see them for an appointment within 7 to 14 days of discharge. Our APC and DE ACOs saw a decrease in 30-day all-cause readmissions of 13% and 15%, respectively, compared with national benchmarks. Taken together, these interventions achieved a reduction in acute hospitalization utilization rates of 9% and 2%, respectively, compared with our benchmark.
So far, our physician-led ACOs have successfully increased primary care utilization (and revenue), and decreased ED and hospital utilization and readmissions. However, we failed to earn a return on our investment of practice time and Aledade resources in the first year of the MSSP program. In the following section, we explain what happened.
The first year of this multi-year journey toward better quality and lower costs creates 2 fundamental challenges for all ACOs. First, you cannot do everything at once; prioritization and learning is a necessary part of the first year as an ACO gains experience. Second, an ACO must learn how the rules that govern the measurement of better quality and the measurement of lower costs affect their specific population and their specific physician practices.
Specialty costs. Independent physician-led ACOs do not have to contend with the challenges of “demand destruction” that stymie hospital-led and multi-specialty ACOs,8 but they also cannot be complacent toward specialist costs. They must pay particular attention to specialist practices that have been bought and reclassified as hospital outpatient settings with facility fees that can double the cost to Medicare (and patients) of procedures and visits to specialists.9 These trends have resulted in a 5% increase in hospital outpatient costs nationwide, and increases of 13% and 7%—representing a total cost increase of 2.7% and 1.1%—in the APC and Delaware ACOs, respectively, thus erasing gains made elsewhere.

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