For ACOs Large and Small, Sharing Ideas With an Open Mind

December 12, 2014
Mary K. Caffrey

The American Journal of Accountable Care, December 2014, Volume 2, Issue 4

As the ACO and Emerging Healthcare Delivery Coalition gather in Miami, results are coming in, and it's time to figure out just what to measure.

Those who came to Miami, Florida, for the second live meeting of the ACO and Emerging Healthcare Delivery Coalition voiced these favorable assessments and more about their experience, which was shared among 50 attendees at the Marriott Biscayne Bay on October 16 and 17, 2014.

But if a single word could capture the response, it would be “opportunity.” The value of this gathering, as with the first one in May, will last well beyond the conclusion of the sessions. Small workshops and networking allowed members from a diverse group of accountable care organizations (ACOs)—large and small, new and well established—to share ideas, make connections, and perhaps form partnerships that will prove valuable in changing times. Learning together and learning from one another—both are reasons The American Journal of Managed Care created the Coalition, which has grown to more than 130 members in less than a year.

Typical meetings in healthcare involve only health plan leaders, or only IT people, or only providers. AJMC’s ACO Coalition stands apart because it puts everyone in the same room to share perspectives—in some cases, for the first time. “Feedback from our participants has been tremendous,” said Brian Haug, president of AJMC and event host. “Our meeting provides a rare opportunity for healthcare leaders from different parts of the system to come together. These exchanges are where meaningful change can occur.”

Engaging the Experts

“Tell us something we don’t know about you.”

With that introduction, moderator Leonard Fromer, MD, FAAFP, executive medical director of Group Practice Forum, set in motion each speaker’s presentation or panelist’s contribution, giving the room a sense of openness and informality despite the remarkable level of expertise present.

Among those taking part were Ira Klein, MD, MBA, FACP, chief medical officer, National Accounts Clinical Sales and Strategy, Aetna; Thomas Graf, MD, and Eric Newman, MD, both with Geisinger Health System; John Jesser, MBA, of LiveHealth Online at WellPoint; and Krista Drobac, who within a month of the meeting would form Sirona Strategies as the new home of the Alliance for Connected Care.

Based on feedback from prior sessions, many of the presentations and workshops in Miami concerned technology and data: how to collect it, how to use it, who owns it, and whether the data points being gathered are even the right ones. Fromer worked to put both speakers and panelists at ease, laying the groundwork for the workshops that would follow.

By October, some participants were starting to see results of interventions for patients with chronic conditions, which were required under the 2010 Affordable Care Act (ACA), and they were ready to start framing their own definitions for the term “population health.”

As speaker Bruce Bagley, MD, FAAFP, president and CEO of TransforMED, said, “Population health is code for identifying the 5 to 7% of people who are costing the most money and figuring out what to do.”

Bagley and other speakers said achieving this requires a reengineering of the primary care practice, including a concentrated effort to take certain tasks off the plates of primary care physicians (PCPs), not only for the purpose of focusing their attention on atrisk patients, but also to improve their quality of life. “We have to redesign the system so we don’t burn out the people trying to do good work,” he said.

As Fromer noted later on, the common denominator of the many stakeholders is “measurement.” All things—perhaps too many things—are being measured, but ACOs are in the midst of figuring out how to cope with that situation. A multitude of challenges exist in making the massive transition from a volume-based payment model to one based on value, Fromer said, but ACOs are starting to meet them.

“The biggest idea, or output, I think, was revolving around real movement in achieving better triple-aim results, and scores, for patients we take care of in ACO settings,” he said.

Expanding Telehealth

Among the challenges ACOs face is the need to improve healthcare measures despite a shortage of PCPs. The patient population is aging, yet many patients, especially those who are still working, are busier than ever. Drobac presented opportunities that could come with expanded use of telehealth, which would involve more virtual appointments via Web-based technology.

More than 14,000 Medicare patients tried telehealth in 2013, Drobac said, and data show that those who tried it overwhelmingly liked it. Yet regulatory limits on telehealth have curtailed its ability to boost access to care for rural Americans, those with disabilities, or employees who don’t want to lose time from work.

As Drobac explained, current constraints limit the ability of ACOs to receive Medicare reimbursement for telehealth encounters, even though evidence of its effectiveness justifies payment. Meanwhile, resistance from some state medical associations to changes that would allow physicians to practice outside their home state have also limited telehealth’s growth.

Momentum for telehealth is building with the arrival of “wearable” healthcare technology, which Drobac said consumers have embraced. “The opportunity is ripe right now,” she said.

The Breakout Sessions

The heart of the gathering—and a favorite of attendees, based on feedback—were small workshops gathering a dozen participants each, lasting roughly a half hour, which allowed for a rapid exchange of ideas. Topics were tied to the material in main presentations, but the looser format seemed more like a seminar; here, participants learned more about and from each other.

Financial incentives. Kelly Conroy of Triple Aim Development Group, West Palm Beach, Florida, began a session on financial incentives by describing the ACO landscape in her state. There are many organizations that are technically competitors, she said, but the staffs do not “feel like we [are] in competition.” Participants shared the lessons they’ve learned so far. Success of ACOs must be “outcome-driven,” and there must be a focus on developing good incentive structures that are fair and targeted toward those participants who have truly made changes in their practices. The worst thing to do, participants said, is to “give a big check” to physicians who have failed to change poor behavior. If an ACO wants to reward the best performers, data to determine who performs well will have to be collected at the ACO level.

Taking the time to track individual physician performance will likely prove worthwhile: many participants said that doctors are highly competitive with one another and will change their behavior if they know how their performance ranks within the ACO.

Rewarding “physicianship.” The group spent some time discussing physician “citizenship,” also called “physicianship.” Measures of physicianship include, for example, how willing the doctor is to be part of a practice team, or to cover a shift for another doctor etc. There was some discussion about how this would relate to the ability to improve patient satisfaction ratings.

Attendees offered ideas to persuade physicians to participate in committee work that will be needed for the transition to value-based care, including financial incentives. One metric to track—and one which must be rewarded—is noting which doctors are willing to stay late at a practice to see a patient who would otherwise head to the emergency department. To build this willingness, one speaker said, the ACO must be sure that if the doctor stays, there are also specialists on call to consult, imaging services available, etc.

Addressing challenges. Patient engagement continues to be a challenge. Participants discussed the importance of engaging PCPs first, because unless that happens, “We have no chance to engage the patient.” Throughout the meeting, the need to engage PCPs, and the difficulty this presents, came up repeatedly.

Data flows. Drobac led this session, which began with the observation that the focus on Big Data in healthcare IT should perhaps be a focus on gathering the right data; some attendees wondered whether the data points typically gathered in an electronic health record always make sense. When there are too many “bells and whistles,” medical practitioners who are trying to use the data can be overwhelmed.

ACOs are still working to figure out what data are needed to properly run their organizations without asking so much that doctors feel bombarded. Requests from pharmaceutical companies complicate matters, with varying requests from each. As ACOs step into specialty pharmacy, they are greeted with all the data requirements for post marketing research, which is required by the FDA. Meeting these requests, and sharing data to achieve desired outcomes, have to be balanced with HIPAA requirements.

A key test is ensuring that data can be gathered in the course of normal work flow; staff, software, and procedures must be properly coordinated so that data are not being pulled from records after the fact.

Questions about data. The world of Big Data in healthcare is still unfolding, and many policy questions remain unsettled. Who pays for data gathering? Who owns the data? Once questions of how to share are resolved, how much do you share? Are the answers the same for practices owned by an ACO compared with those that are only affiliated? Drobac asked whether there should be a Choosing Wisely for data, referring to the well-regarded American Board of Internal Medicine initiative that seeks to reduce wasteful, harmful practices across medical specialties.

The Geisinger Model

Friday’s sessions exemplified the valuable professional opportunities offered by the ACO Coalition: Graf, chief medical officer for population health and longitudinal care service lines at Geisinger, first gave a detailed keynote address outlining one of the best known models for value-based care. Then, he led one of the small workshops on the patient experience, a wide-ranging discussion that took turns into such details as workers’ compensation.

Geisinger, which operates throughout central Pennsylvania, uses technology and automation to help providers cover much of wellness care; the more a patient suffers from chronic conditions or comorbidities, the more “hands-on” the model becomes. The model offers a variety of settings for patients to receive primary care treatment. Great emphasis is placed on collecting data and teaching office staff to use it, Graf said, so the PCP has 2 core functions: handling complex medical decision making, and maintaining patient relationships.

In the process, Geisinger has not only shown profitable results—Graf pointed to data showing return on investment is $1.70 for every $1 put into the system—but healthcare measures have also improved sharply over 8 years. For example, more patients with diabetes are receiving vaccinations; more are at goal for blood pressure, cholesterol, and glycated hemoglobin; and more are documented nonsmokers.

“We’ve moved from providing great care one patient at a time, to great care 1 patient at a time to an entire population,” Graf said.

How Today’s ACOs Are Different

When ACOs were created by the ACA, they were intended to do more than simply provide insurance coverage. ACOs are vehicles designed to keep track of patients’ healthcare experiences, and to reward those entities that provide the better ones. Thus, if ACOs work as designed, even though they seek healthcare savings, they should not give doctors or hospitals incentives to cut corners or deny care, which was the complaint about the health maintenance organizations (HMOs) of the 1990s.

Quality of care and patient satisfaction measures exist alongside savings—the so-called “triple aim.” Putting these patient-centered measures on equal footing with financial performance is a meaningful break from past efforts, according to speakers and participants at the meeting who took part in 1990s reform efforts. Twenty years ago, HMOs formed to aggregate risk without a clear understanding of how to take on that risk. Today’s efforts are not just about managing risk, in contrast to the 1990s when some patients were left out of networks or denied coverage.

Effective ACOs have the ability to engage PCPs, especially by helping them make positive changes in the way they run their practices. Helping physicians free up their time and better deploy staff in both care and decision making should, in time, improve the bottom line and the quality of life for PCPs, who are in short supply. But first, PCPs have to be firmly convinced that ACOs are for their benefit.

“Without primary care engagement, we are simply spinning our wheels,” said Richard Lubicella, MS, MBA, the CEO of Accountable Care Options, LLC, a Florida ACO. “The primary care physicians will engage the patients for you if they are engaged.”

Thus, future ACO Coalition topics will include patient incentives to select PCPs, as well as the challenge of “attribution,” which is the matter of deciding which patients are assigned to the ACO in the first place.

To learn more about the ACO and Emerging Healthcare Coalition, contact ACO_Coaltion@ajmc.com or visit http://www.ajmc.com/acocoalition.Author Affiliation: Mary K. Caffrey is the managing editor of the Evidence-Based series at The American Journal of Managed Care.

Address Correspondence to: Mary K. Caffrey, 666 Plainsboro Rd, Suite 300, Plainsboro, NJ 08536. E-mail: mcaffrey@ajmc.com.