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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.
What are the implications of our first-year experience for Aledade ACOs? We have measurably improved patient care through more intense, engaged, and informed primary care. Yet, we must critically examine our assumptions and take steps to improve our strategy and execution. Below are our conclusions:
Delivery transformation is hard—it takes time and commitment. Although we welcome the urgency imposed by the program design, we recognize that improved quality (eg, pneumonia vaccinations and cardiovascular risk reduction) may take years to bear fruit. Furthermore, the inertial drag of habits acquired through decades of fee-for-service medicine can be hard to overcome. It takes time and painstaking initial groundwork to understand and drive change when you are impacting an entire network for care. The experience of the MSSP and the Massachusetts Alternative Quality Contract reveals continued and growing savings from accountable care structures over time.11 Furthermore, we have seen large variability between the practices in our ACOs in terms of their ability and willingness to change practice workflows. ACO governance must include transparency and holding each other mutually accountable—up to, and including, ACO termination of practices that are not yet ready for the transformation required.
Care management must be funded. Our philosophy has been to eschew centralized telephonic care management in favor of the practices owning the care management process (with assistance in training, recruiting, and tools). However, it is not possible to simply demand more from the existing practice staff in most independent primary care practices; there must be a return on investment for practices to invest in care coordinators. In 2016, we are using chronic care management fees and the ACO Investment Model to make it possible for most of our ACO practices to begin this process. Ongoing care management fees from commercial gain-share contracts, enhanced chronic care management fees as proposed in the 2017 Physician Fee Schedule, and the Comprehensive Primary Care Plus program greatly increase the financial viability of this strategy.
Changing primary care practice is not enough. Accountable care centers on primary care, and independent primary care practices are best suited to lead the movement from volume to value. However, as we have seen, we need to reach beyond our primary care core to enlist key specialists and ancillary providers as allies and affiliates. The sequencing is important, and these partnerships must be based on transparent and objective claims-based utilization patterns, as well as the clinical consensus of our primary care practices. In 2016, we are creating tiers of specialists and launching an affiliates program for engagement and inclusion of high-value specialists.
Scale matters. The Aledade network now includes an additional 5 MSSP ACOs launched in 2016, and we have submitted applications for an additional 9 MSSP ACOs for 2017. We have also established several commercial gain-share agreements that extend the work of the ACOs to non-Medicare patients.12-14 This allows us to share investments in infrastructure and learnings across a broader network. A portfolio of ACOs also works to balance out regional and random variations. In addition, increasing local scale can bring positive network effects, where each additional practice benefits the existing members of the ACO through increased data and increased ability to influence the local healthcare ecosystem, including through contracts with commercial payers and downstream suppliers. Our Delaware ACO is growing from 9000 attributed Medicare lives to nearly 25,000 lives—over 20% of the Medicare primary care market in Delaware. This will be especially important as we move toward Advanced Alternative Payment Models (AAPMs) and 2-sided risk.
MSSP policies can be improved. Using regional inflation trends to calculate benchmarks will improve the fidelity and fairness of the MSSP. The most sophisticated academic analysis of the MSSP to date15 found systematic “underestimation of savings in the independent primary care groups (relative to the hospital-integrated groups) when savings were determined from comparisons with CMS benchmarks.”16 Aledade has the resources to continue to support our ACOs over the long term, but many ACOs that are high-value, and often hospital-independent, will not be able to continue in the program in markets with strong cost headwinds. Meanwhile, ACOs that have earned savings due to the peculiarities of the program may also be less likely to continue into 2-sided risk arrangements and AAPMs. To shorten the timeline to financial success for ACOs that achieve lower costs with better quality, CMS should continually strive to make the counterfactual approach the gold standard of ACO performance. Current policies make these adjustments over a period of 4 to 9 years, but not every ACO can wait that long, and we believe that no ACO should have to wait that long.

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