Smart, Effective Advocacy: Clif Gaus’ Vision for Value-Based Care

For former and current interim CEO of the National Association of ACOs (NAACOS), Clif Gaus, ScD, MHA, his journey in health care administration and leadership began with a deep interest in improving the system for patients and providers alike. It was after his first year at Jefferson Medical College in Philadelphia¹—founded in 1824 and now known as Sidney Kimmel Medical College—which was a path his parents wanted him to take, that he decided to “go the route of administration.” At about the same time, President Lyndon B. Johnson signed into law on July 30, 1965, the legislation that established the Medicare and Medicaid programs.²

“I got really intrigued with what that aspect of health care was, and I wasn’t enjoying medical school much,” Gaus told The American Journal of Managed Care^® (AJMC^®). “I decided to jettison my medical school training after the first year and couldn't figure out exactly what the next would thing would be, but I made the decision to go the route of administration.”

From Medical School to Health Care Administration

He completed the 2-year Hospital Administration program—now the Health Administration program—at University of Michigan, following that up with a year of residency at Presbyterian University Hospital in Pittsburgh, Pennsylvania, and a Doctor of Science degree in health care at Johns Hopkins University. He became a faculty member at Hopkins soon after and would eventually go on to run the Agency for Healthcare Policy and Research (AHPR)—now the Agency for Health Care Research and Quality.³ He was also intrigued by the development of the health maintenance organization model that was in its infancy and the concept of organized medical groups taking responsibility for patients by providing a continuous set of services that were coordinated from the physician’s office to the hospital and beyond.

“Those were the days of a kind of freewheeling, unencumbered, innovative decision-making,” Gaus said. “Those definitely were sweetheart days.”

While at AHPR, he helped to create the Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys, which focus on matters the patients themselves say are important to them and for which patients are the best and/or only source of information, Gaus explained.

“There was not a person on the staff who said their customers were the patients,” he said. “There was no sense that all this research and analysis the agency did really went back to the patient, and so we created a different culture there. And one of the really big initiatives was to create the CAHPS survey.”

Championing Value-Based Care

His experiences at organizations like Wellpoint and Kaiser Permanente—both good and bad he told AJMC—provided valuable insights into managed care, operations, and innovation, lessons that would go on to shape his leadership at NAACOS. Those 2 organizations, where he reported to the CEOs, had extraordinarily different cultures, goals, and management styles, he explained. Kaiser had a team approach whereas Wellpoint had a top-down approach.

“Both experiences kind of convinced me of the value of nonprofits in health care. Really, my experience with Wellpoint added to my skepticism that big for-profit insurance companies really didn’t have the patient’s welfare as a top priority,” he stated. “It was a grueling experience that kind of filled in a real-world experience for me outside of government that I just take with me today.”

Since its founding in 2012, NAACOS has evolved under his guidance, sharpening its focus on supporting accountable care organizations (ACOs) as they navigate the complexities of value-based care. What started as a group of 30 members has grown to 477 ACO members covering 9.2 million beneficiary lives through both the Medicare Shared Savings Program and the ACO Realizing Equity, Access, and Community Health model.⁴ Gaus takes pride in having built an organization that champions collaboration and sustainable health care models, driven by the core principles of accountability, cost-effectiveness, and quality, and he emphasizes the importance of leadership, data-driven decision-making, and a steadfast commitment to patient-centered care.

Throughout his tenure, the founding goals have not much changed for this organization that has upheld its mission as a group formed, governed, and focused on ACOs. It continues to be guided by a desire to provide high-quality care while simultaneously lowering population health costs. However, there is a broader change that is under way around value-based care, Gaus said, explaining that ACOs are not the only entity in health care that focus on value.

Over the next 3 to 5 years, NAACOS will start to broaden its umbrella—“There’s, I think, a cultural and a broader change that’s under way around value and value-based care,” Gaus explained—by incorporating non-ACO entities.

“During my tenure, we pretty much stuck to ACOs, as they are the only voting governing members,” he added. “This will now change to a much more broader segment of health care, but with organizations only that have value-based care contracts.”

Of his proudest moments as CEO, he refers to keeping the ACO bonus alive, fixing and improving benchmarks to ensure ACO success, mitigating the impact of the “incredibly high number of hospitalizations” from the COVID-19 pandemic (“If something wasn’t done, the industry would have imploded,” Gaus explained), and negotiating with CMS on the fallout from the more than $3 billion in fraudulent catheter claims that were identified in 2023.

Looking to the Future

During our conversation, as he reflected on what makes an ACO successful, he also provided a framework for ACOs to follow:

1. Have a patient-centered organizational culture: optimize patient care, not revenue
2. Engage patients better in their care: serve your patients
3. Find the clinical leadership who can do 1 and 2: you want leaders who are dedicated to implementing value-based clinical practice changes
4. Provide continuity of care: know that your job does not end when the patient leaves your office, as you are responsible for the patient’s whole journey of care
5. Have current and actionable data and analytics: give your physicians the tools to track patients throughout their care and to track care costs as they occur
6. Apply Medicare ACO principles to your other payer patients: try to engage those payers in value-based contracts

“ACOs are just the beginnings of the value-based care movement," Gaus said. "I think there will be many more private payers contracting with full-risk capitation or with shared savings models for their insured population. I see the industry just continuing to grow at a pretty significant rate as there’s more Medicare.

"We really need the next administration to take a hard look at how Medicare can spur the growth of ACOs. We have been somewhat flat here for the last few years, and the trouble is, it's still not a good enough business model for ACOs; it's a complex, capital-intensive process to form an ACO. So, more incentives to build into attract new ACOs, less complexity, and probably some much expanded loans for new ACOs.”

References

1. Sidney Kimmel Medical College. Thomas Jefferson University. Accessed December 15, 2024. https://www.jefferson.edu/academics/colleges-schools-institutes/skmc.html

2. History: CMS’ program history. CMS. Updated September 10, 2004. Accessed December 15, 2024. https://www.cms.gov/about-cms/who-we-are/history#:~:text=for%2050%20years-,On%20July%2030%2C%201965%2C%20President%20Lyndon%20B.,the%20Medicare%20and%20Medicaid%20programs

3. Agency for Healthcare Research and Quality. Federal Register. Accessed December 15, 2024. https://www.federalregister.gov/agencies/agency-for-healthcare-research-and-quality#:~:text=The%20Agency%20for%20Healthcare%20Policy,299%20et%20seq

4. NAACOS. Accessed December 15, 2024. https://www.naacos.com/