September 22, 2014

It is unusual to open a health policy periodical without seeing the words “Accountable Care Organization,” or, more frequently, “ACO.”  Are these entities as successful as they are visible?

According to recent estimates, there are some 500 ACOs operating in the US today.  More than 360 Medicare ACOs have been established, serving over 5.6 million Medicare beneficiaries, since passage of the Affordable Care Act in March 2010.  There are two distinct categories of Medicare ACO:  the Pioneer Model ACOs, which are on a faster track toward value- and population-based payment, with higher levels of shared savings and risk, and the ACOs participating in the Medicare Shared Savings Program (MSSP).  Together, the ACOs reduced Medicare spending by approximately $817 million in 2013.

The 23 ACOs that participated in the Pioneer program in 2013, and for which CMS has just released performance data, generated estimated savings of $96 million and qualified for shared savings of $68 million.  They also increased their average quality score by 19 percent, showed improvements in 28 of 33 quality measures and had average improvement of 14.8 percent across all quality measures.  These measures included screening for fall risk, screening for tobacco use and cessation, patient experience in health promotion and education and controlling high blood pressure.

While 2013 was the second year for the Pioneer ACOs, it was the first full year of participation for 220 ACOs enrolled in the MSSP program.  The MSSP ACOs saved $254 million and generated $126 million.  Fifty-three of these ACOs held spending $652 million below their targets and earned performance payments of more than $300 million as their share of program savings.  The top-performing ACO in the Medicare Shared Savings Plan netted CMS $57.83 million in savings.  The six highest-performing ACOS accounted for fully one-half of the savings—at least in part because of their location in Texas, Florida and other states with historically high utilization, according to Cheryl Clark’s review Few Winners Among MSSP Participants in the September 19 online edition of Health Leaders Media.  The six were:

• Memorial Herrmann ACO in Houston, TX;
• Palm Beach Accountable Care Organization in Florida;
• Catholic Medical Partners Accountable Care IPA in Buffalo, NY;
• Southeast Michigan Accountable Care Inc. of Dearborn;
• Nevada Primary Care Network ACO in Las Vegas; and
• Triad Healthcare Network LLC in Greensboro, NC

An additional 52 ACOs reduced health costs compared to their benchmark, but did not qualify for shared savings, as they did not meet the minimum savings threshold.  Overall, the MSSP ACOs improved on 30 of the 33 quality measures.  Quality improvement was shown in such measures as patients’ ratings of clinicians’ communication, beneficiaries’ rating of their doctor, health promotion and education, screening for tobacco use and cessation, and screening for high blood pressure.

While they are doing well on the whole, the Medicare ACO programs are not an unqualified success.  CMS named the original 32 Pioneer ACOs in December 2011, and upon the release of first year performance data in July 2013, nine Pioneers departed from the program. In August 2014, San Diego-based Sharp Healthcare left the Pioneer program, leaving only 22 of the original ACOs in the program.  As for the MSSP ACOs, only 53 of the 220 participating ACOs will receive bonus payments from CMS.  One out of the five ACOs following the Track 2 payment model, which provides not just for shared savings but also for shared losses, ended up reporting losses that amounted to nearly $4 million.  Most ominously, a poll of ACO Executives conducted by the National Association of ACOs (NAACOS) in April 2014 showed that 2/3 of the MSSP ACOs were unlikely to renew their three-year contracts with CMS.

NAACOS has suggested a number of changes that would improve the CMS ACO programs, most of which have to do with the program design and the setting of formulae for savings targets and risk adjustment—issues that bear on aspects of  CMS management of the ACOs and not on ACOs’ potential for managing the quality/cost equation.  Some ACOs are certainly on the path to success.  Allina Health in Bloomington, MN for example, is among Becker's Hospital Review’s “100 ACOs to watch.”

Allina Health has 60,000 Medicare members in its own ACO and is also part of the Northwest Metro Alliance, an ACO that covers more than 300,000 people.  The Allina organization encompasses 11 hospitals, some 90 clinics, 24,000-employees, and 5,000 physicians.  In 5 Keys to ACO Excellence (Becker’s Hospital Review, September 12, 2014), Karen Tomes, Allina Health’s Vice President of Care Management and Coordination identified five keys to ACO success:

1. Install a comprehensive EHR system. The need for a comprehensive EHR system is obvious because ACOs are managing the health of the population, which requires patient care records on every patient in the system…. Allina has an EHR from Epic that allows the physicians to see the past history of each patient.  The EHR includes clinical, demographic and other data that Allina uses to give a full picture of each patient's needs. Eventually the information will be used to gather data on each patient's total cost of care.
2. Identify patients who need specialized care.  The EHR can help all providers identify those patients who need specialized care, such as those who are the frail elderly, for example. …
   
   Allina Health has a number of preventive care resources to identify patients who may need some level of extra care or attention to prevent a healthcare crisis or sharp increase in utilization.
   
   A more difficult challenge for ACOs is identifying those patients who need specialized care for chronic conditions before their need for care becomes acute.  Allina has interviewed patients about their needs and worked closely with them to develop a care model that supports the delivery of preventive health services.  In addition, the ACO uses patient registries to track each patient's needs and to allow providers to design care plans to improve each patient's overall health.…
3. Use data to help providers manage care.  Data collected in each patient's EHR allows Allina to run predictive models on what costs providers can expect for the population.  Allina has a readmission prediction model, for example, that it uses to calculate the likelihood of a patient requiring multiple hospital stays. … One way we can reduce readmissions is by standardizing discharge planning throughout the system and providing that information to the patient when he or she leaves the hospital.
   
   Other data we use to manage care includes information we collect on patient satisfaction … in various settings.
4. Build a network that supports the delivery of care.  Just as every other health care delivery model needs a widespread and diverse network of providers who can deliver care to each member, so too do ACOs.  The basis for any delivery network is a core group of primary care physicians who supervise patient care using the data Allina has collected on what these patients need. …
   
   Allina also has a senior care transition team that provides services in transitional care units or skilled nursing facilities to patients who are moving from one site of care to another.  For those patients needing long-term care, Allina has a geriatric service. …
   
   It's important to note that in care management we are seeing patients in their homes, the hospital and in skilled nursing facilities, but we also are doing some telehealth in which a physician or other provider conducts video visits with patients.
   
   Allina also has what it calls care guides, who are laypersons trained to develop relationships with patients to help them improve their health by supporting them in making changes in their lives.
5. Develop educational strategies for workforce development. … Following protocols is an important element in many healthcare settings today, and standardized online workforce development allows us to deliver standardized care to a large number of patients efficiently and consistently. …
   
   Using online training coupled with continuing education credits, we can train care coordinators to achieve high ratings in patient quality measures.  Also, we can use this form of workforce development to elevate the core competencies of care coordinators and social workers involved in all cases in the hospitals and in many of the cases concerning patients who are not hospitalized.  In this way, we are improving patient outcomes and transitions of care, reducing readmission risks and improving claims management.  We also are cutting the number of avoidable delays, which reduces length of stay and overall costs.
   
   While these five strategies are important, there are many others that ACOs are implementing as they deliver care based on increased value to patients, meaning lower costs and better outcomes.  Accountable care, after all, is a reflection of what patients, providers, and health care payers want from the system: better care at lower costs.

These five strategies were among the factors that allowed Allina's expense trend to grow at less than one percent in 2012 while delivering high quality care.  If single-digit percentage accomplishments seem modest, remember that ACOs have a very short history.  That makes it hard to predict their form, their characteristics and even their number very far into the future.  What we do know is that interest is extremely high.  NAACOS is two years old and already counts organizations representing more than 120 ACOs from more than 20 states among its members.  This week, 400 ACO leaders will be attending NAACOS’ two-day conference on “valuable care coordination and cost management strategies for all accountable care organizations, whether they are new or more established.”

Where do anesthesiologists and nurse anesthetists fit in to this development?  As numerous observers have commented, among them Kash, Cline, Menser and Zhang in The Perioperative Surgical Home (PSH) A Comprehensive Literature Review for the American Society of Anesthesiologists, “the movement toward ACOs creates an opportunity for anesthesiologists to expand their practice through the perioperative surgical home.”  The PSH will be featured in future Alerts.

With best wishes,

Tony Mira
President and CEO