At last week’s meeting of the National Association of ACOs (NAACOS) in Washington, D.C., a panel was convened to respond to the recent report from the U.S. Department of Health and Human Services (HHS) Office of Inspector General on lessons learned from the Medicare Shared Savings Program.
Meredith Seife, deputy regional inspector general for the Office of Evaluation and Inspections at OIG, led off by describing some of the report’s findings. “The good news is that physicians are quietly changing the way they do business,” she said. The report evaluated the first three years of the shared savings program and found some high-performing ACOs that led to reductions in hospitalizations and had top marks in quality measures.
The report, she said, tried to better understand what these high performers were doing to achieve those results and identify common strategies deployed by successful ACOs. It examined a sample of 20 ACOs, chosen for geographic diversity, as well as physician- and hospital-led and those taking on varying levels of risk. The report identified seven strategies these successful ACOs had in common:
1. Focused on better supporting physicians.
2. Improved patient relationships, including increasing the number of annual wellness visits.
3. Doing a better job of managing beneficiaries with costly or complex care needs. This includes using care coordinators and providing care outside the physician office through services such as remote patient monitoring.
4. Managing hospitalizations, working to reduce avoidable hospitalizations, and finding alternatives to the emergency department, such as extended hours, same-day appointments, and telemedicine. In addition, there is an increased focus on improving care coordination at hospital discharge to ensure smooth transitions between settings.
5. Managing relationships with skilled nursing facilities (SNFs) and home health by creating lists of preferred providers and doing warm handoffs into and out of post-acute care.
6. Behavioral health and social determinants: ACOs are working to address behavioral health needs, some by integrating behavioral health providers into the ACO network and bringing them into the primary care setting, Seife said. For social determinants, they are incorporating non-medical staff into practices.
7. Using technology to improve care coordination and overcome interoperability issues. Some ACOs are moving all providers onto a single EHR system so they can seamlessly share data, according to Seife. Others are using HIE data to send providers real-time alerts on ADTs.
Among the report’s recommendations are that CMS should adopt more outcome- based measures and better align measures across programs.
“We believe CMS should support these strategies,” Seife said, “and they apply not just to ACOs but to all providers committed to transitioning the health system to value. It is not just budget makers, but patients who will benefit.”
Chairing the panel response was Stephen Nuckolls, chief executive officer of Coastal Carolina Health Care, PA, and their ACO, Coastal Carolina Quality Care Inc. His responsibilities include the direct management of the 60-provider multi-specialty physician-owned medical practice and its ACO that was selected by CMS in the initial round in April 2012 and is currently in a two-sided risk model.
He noted that the report highlighted reducing unnecessary hospitalizations as a key to success, and asked panelists to comment about that.
First to speak was Rich Feifer, M.D., president of Genesis Physician Services and chief medical officer at Genesis HealthCare, one of the nation's largest skilled nursing and long-term care providers. He leads more than 550 clinicians in the transition from fee-for-service to value-based care.
In the skilled nursing setting, Feifer said, having more nurse practitioners, physician assistants and physicians on site is key. In studying its own experience, Genesis found that evenings and weekends were a problem, because staffing was thinner. The default was to send complicated patients to the ER. “When a complicated patient hits the ER, they are going up the elevator,” he said. Genesis has worked to add a telemedicine service that allows staff to engage a physician trained in long-term care to do a patient assessment on site safely.
“Reducing unnecessary hospitalizations is central to our success,” Feifer said. “We have to identify and evaluate patients who might be decompensating by doing testing on site and getting lab results quickly, including ultrasounds. The scope of services we provide on-site now is much more complex.” He said they also spend more time talking to patients about their goals of care. “For many people, we find that their preference is to be cared for on-site rather than being transitioned to the ED. Hospitals can be dangerous places. Sometimes bad things happen. They want care in a more nurturing setting sometimes.”
Feifer also noted that there has been a dramatic reduction in average length of stay, and goals of rehab have changed. “Previously they had a goal of restoration of function before returning home. It is different now. Now they say the goal is to get you well enough to go to next level of care, which is outpatient care,” which is good, he said. “But as length of stay gets shorter, in some cases, we see increases in rehospitalizations, and that concerns us, because we are directly penalized. We have to find that balance.”
Nuckolls asked how ACO leaders were engaging both physicians and patients in new ways.
“Actionable data is a key component,” said Sandra Van Trease, group president for BJC HealthCare. “Our team has provided physicians with greater levels of specificity and something actionable. We have scorecards that show how many attributed patients are in their panel.” A scorecard might show how many patients have had annual wellness visits. “Doctors tend to be competitive,” she said. “They know where they rank in quality metrics.”
Van Trease leads the BJC Collaborative LLC, an association of Saint Luke’s Health System (Kansas City, Mo.), CoxHealth (Springfield, Mo.), BJC HealthCare (St. Louis, Mo.) and Memorial Health System (Springfield, Ill.). In 2012, she was appointed president of BJC HealthCare’s ACO and leads BJC’s overall efforts in population health and virtual health.
In terms of engaging beneficiaries, she said that each situation is different. “I don’t think engagement is sending them a letter telling them they are in ACO, she said to applause from the audience. “We work to understand who would benefit from direct engagement to help them lead a healthier life. That may be talking to a pharmacist, a dietician or a social worker. It takes the data to identify people and then the work of care managers and clinicians to stay connected. That is why it is expensive. But stories suggest that is the way to change behavior and improve outcomes.”
