Building Accountable Care, Block by Block

April 10, 2013
Healthcare industry expert Joe Damore of Premier Health Alliance is helping hospitals and health systems nationwide to move forward on the development of accountable care organizations (ACOs). Not surprisingly, key lessons are already being learned by those organizations at the head of the pack.

In 2010, the Charlotte, N.C.-based Premier Health Alliance created two working groups to assist its hospital and health system member organizations to prepare to participate in the Medicare Shared Savings Program for accountable care organizations (ACOs), one of the voluntary programs created by the Affordable Care Act (healthcare reform) in 2010. As Premier’s website explains, the ACO Implementation Collaborative is designed to help Premier member organizations “pursue ACOs for patients today, leveraging existing payer partnerships and a tightly aligned, engaged physician network.” Meanwhile, “The ACO Readiness Collaborative is designed for health systems that must first develop the organization, skills, team and operational capabilities necessary to become ACOs and ultimately joint the Implementation Collaborative. Altogether, nearly two dozen health systems, representing several dozen hospitals, are already actively participating in the collaborative.

One of the key Premier executives involved in helping the organization’s hospital and health system member organizations to prepare for ACO development has been Joe Damore, whose title is vice president for the implementation collaborative. Damore, who spent about 30 years in healthcare management, as a senior executive in numerous hospitals and health systems nationwide, joined Premier in January 2011, and has been deeply involved in ACO development support there ever since. Damore will be addressing these issues in an educational session at HIMSS12 in Las Vegas on Feb. 20 (“A Capability Framework For Accountable Care”).

Damore spoke recently with HCI Editor-in-Chief Mark Hagland regarding his leadership in this area and the lessons being learned about accountable care work in the collaborative and across Premier to date. Below are excerpts from that interview.

Tell us a bit about how your professional background dovetailed with the needs you are now addressing at Premier?

I’ve spent about 30 years in management, first, with several different hospitals and health systems, and including about 20 years as a CEO. My philosophy was, I tried to build integrated health systems. The model that I thought was the most logical model was creating regional integrated health systems, and I went to Greenville Hospital System in Greenville, South Carolina, because Bob Toomey was trying to build integrated care there; that’s what I did at several different organizations, in fact. Now at Premier, I get to work with really progressive organizations, to manage, measure, and improve the health of populations all across the country. I get to work with organizations like Fairview in Minneapolis, Presbyterian in Albuquerque, Banner Health in Phoenix, and AtlantiCare in Atlantic City, New Jersey, WellStar [Health System] in Atlanta, and Baystate Health in Springfield, Mass. Those are members of our collaborative, and I would rank those among the most progressive organizations in the country. I visited at least 40 organizations across the country the last year.

Joe Damore

What are the biggest lessons that you and your colleagues have learned so far?

One of the first things we’ve learned is that you’ve got to build an integrated care model, encompassing the full continuum of care, at the local level; you’ve got to figure out how to integrate hospitals and physicians across the full continuum. For instance, how do you integrate private physicians into such networks? We’re calling them clinically integrated networks (CINs), or clinically integrated PHOs [physician-hospital organizations]. The big difference between these organizations and the PHOs of the 1980s and the 1990s is that these clinically integrated PHOs are fully integrated. The FTC [Federal trade Commission] actually developed criteria around this in 1996; in fact, not many places adopted those criteria at that time. Now, many are interested. So this first area of effort involves clinical integration at the local level.

Generally speaking, there are three broad areas of initiative involved here. There’s development of the clinically integrated network; development of the partnership with physicians; and then the development of care management techniques, including the patient-centered medical home [PCMH]. And I would tell you that the early research I’m seeing on the patient-centered medical home is extremely positive. The data we’re seeing is showing about a 7 to 8 percent drop in costs. Three sources: Geisinger [Health System, Danville, Pa.] has done an analysis, and by the way, they’re one of our members, and an early adopter of the PCMH concept. A second source is [Seattle-based] Group Health Cooperative; and the third I’ve seen is Cigna’s experience in employing PCPs [primary care physicians] in the Phoenix area. They’ve developed 23 patient-centered medical homes in Phoenix, and their experience is the same.

I was on a panel in Phoenix with a medical director for the Cigna program; this was at an Arizona chapter meeting last year of the ACHE [American College of Healthcare Executives].

How do you get the physicians to integrate with you when in most markets there has been a history of mutual mistrust?

First, it’s all about trust-building. And my father used to say, you build trust by doing what you’ll say you’ll do. Second, physicians are thinking through their options for the future. And one of the things we do for organizations is, we do a little talk for them; we call it “level-setting.” And when you see the facts, most people agree that the current system of healthcare in the United States is not economically sustainable. And I do a lot of physician retreat work where they bring me in, and when you start with that premise, then what are the options? I try to point out to people that the options that make the most sense are the ones in which we change the payment system in the U.S. from paying for more volume to paying for value.

And what does that mean? It means you won’t get paid more to do more to people, but you’ll be paid for improving their health, like using HEDIS measures [from the Healthcare Effectiveness Data and Information Set, sponsored by the Washington, D.C.-based National Committee for Quality Assurance, or NCQA] to improve outcomes; and you’ll get paid for doing this in the most economical way.

So we’re talking here about episodes of payment. And in order for things to move forward, changes in the payment method have to occur simultaneously with changes in organization. So we point out to leaders of member organizations that there’s a natural shift to shared savings and per-capita payments, along with changes in organization. To share a comment, one of the leaders of CMS [the federal Centers for Medicare and Medicaid Services] with whom I’ve had a personal friendship for a long time, said to me, ‘Joe, we’re just really blessed to have organizations like Banner Health and Fairview to help lead the change.’ And I think we’re blessed to have 32 organizations step up; those are two. I’ve worked with Texas Health Resources, Banner, Fairview, and Presbyterian, I’ve worked with those four of the 32.

What do those organizations do right?

First, I’d start with their vision and leadership. They recognize that the  current system is not sustainable; they recognize that they can lead their organizations forward in this way. Second, they get a plan together to decide how to do this, and I just gave you three elements that are important—building a clinically integrated system, establishing hospital-physician alignment, and developing care management and PCMH concepts. In addition, there’s payment system change; and there’s the development of the electronic patient record. Finally, the fifth element in what these organizations do right is that they have visionary leadership. Those are things those organizations are doing well. For example, Fairview has brought in 120 care managers; those guys are very serious about care management.

And that care management needs to be clinician-led, correct? 

At Premier, we have six core values, and one is that [development work] has to be physician-led and professionally managed.

How would you articulate this need to be clinician-led?

We have an assessment tool here involving 170 operating activities that we believe you should have when you have an accountable care organization. And we’ve used this in about 100 health systems across America; and I’ve had the pleasure of doing 40 assessments.

Can you offer any examples?

Under the PCMH, for example, one operating activity in the form of a question is, has the PCMH been developed in a team-based model that includes a mental health component? In IT, for example, do you have an electronic patient record that covers the full continuum of care? Another IT one that we talk about is, is there a patient portal that allows patients to access their electronic record? Those are three examples of the 170 activities that we review with member organizations.

What’s more, our team was led by Dr. Rick Gilfillan, who is now the acting director of the Center for Medicare Innovation. So a lot of what’s in pioneer and the shared savings program came out of our work; and clearly he has the intellectual knowledge.

What are your key pieces of IT-focused advice for healthcare leaders?

I try to keep these to a small number. And I’m not an IT geek or anything. But the first piece is creating an electronic record at the hospital and in the physician practice, as a base. Then you’ve got to build that record so that it crosses the continuum of care. And you can either do that by creating an HIE, as Bon Secours Health System in Richmond, Virginia, has (in fact, they’ve just been selected by the state of Virginia to create Virginia’s statewide HIE), or through an integration engine. Most organizations do not have the capital to create their own integration engine; and UPMC [the University of Pittsburgh Medical Center health system] has created their own. The third piece is what we call a population health data management engine. You’ve got to be able to measure population health and the effectiveness of your tools. One area we look at is diabetes; and in that area, you want to be able to measure in your PCP practices, what percentage of patients are in the diabetes registry; what percentage are keeping their hemoglobin a1cs below 7; and the total cost of care per diabetic per year. And that would tell you, are certain physicians having to hospitalize their diabetics. So that’s population health data management.

The fourth IT-related element for success is predictive modeling: can you identify based on like claims, which people in your population are most at risk. And AtlantiCare in New Jersey has created a chronic disease center; they’re one of our members, and I visited them recently; they’ve been doing a wonderful job. The fifth element is the consumer portal, so that patients can ask physicians questions.

How should our audience  of healthcare IT leaders focus their energies? They have gigantic to-do lists right now.

As a CEO, I always said, address the things you need to do first to get other things done. So to me, addressing meaningful use would be first, because if I could get the funds from meaningful use, that would help me move forward in the other areas. So, help physicians achieve meaningful use. And I’ve been to communities recently where 20 percent of the physicians, mostly in one- and two-doc practices, still are not yet billing electronically. I was in the Detroit area and South Florida recently, both areas in which some ‘onesie-twosie’ doctor practices still aren’t doing so. And that’s one reason we’re seeing such a rush towards physician employment right now, because how am I going to become a patient-centered medical home and implement an electronic medical record in the current environment, when I’m already working as hard and as long as possible?

And people will call me, who’s really doing the PCMH? And I’ll say, Geisinger, and another is Ce ntral Maine Healthcare, based around Central Maine Medical Center in Lewiston, which has established 20 PCMHs. I try to link these organizaitons together so they can learn from each other. And I’m going up to University Hospitals in Cleveland, and they’re moving ahead with the PCMH and chronic disease management; it’s wonderful.

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