ACO Success Is Possible: The Leaders at Castell Accountable Care Explain How

Oct. 12, 2021
The leaders at Intermountain Healthcare’s Castell Accountable Care describe how their ACO has been able to achieve sustained, exceptional quality outcomes and cost savings in the MSSP

When the Centers for Medicare and Medicaid Services (CMS) have announced the 2020 results for Accountable Care Organizations (ACOs) participating in the Medicare Shared Savings Program (MSSP) in early September, Intermountain Healthcare’s Castell Accountable Care organization was revealed to have received a quality score of 97.03 percent and to have generated $11.5 million in savings for Medicare. The amount of savings Castell and Intermountain Medical Group have generated for Medicare has increased each year since the Castell ACO was formed.  This was the ACO’s highest savings generated to date, up from $2.5 million in savings from 2018 and $10 million in 2019.

In a September 2 press release, the leaders of Castell Accountable Care posted that “Castell’s ACO managed to grow savings year-over-year and maintain a strong quality score despite the challenges of the COVID-19 pandemic. The organization attributed this success to strong collaboration with partnering providers and the speedy development and implementation of innovative methods for delivering care.

“The COVID-19 pandemic required our accountable care organization to be nimble and evolve how we delivered care. The fact that we maintained a high quality score and reduced expenditures during the pandemic is not only encouraging when we look at the savings, but it’s proof that our value-based model of care works, and can withstand unforeseen changes in the future,” said Nick Bassett, Castell’s vice president of population health services and president of Castell Accountable Care,” in a statement included in the press release.

“Intermountain Medical Group providers and Castell care coordinators showed incredible dedication and flexibility in the way they helped care for patients. Our teams worked collaboratively to assure patients about precautions taken at Intermountain clinics and screening centers to keep them safe from COVID, while conducting wellness calls and proactive outreach to patients to look after their preventative care,” said Dave Henriksen, vice president of clinical operations said in a statement in that press release. And Eric Cragun, executive director of government programs for Castell and administrator for Castell Accountable Care, added, in a statement on his part, that, “As an ACO, we can continue to improve each year. We showed statistically significant improvement in our breast cancer and colon cancer screening rates. We helped patients access care in more convenient, less costly ways. And we improved the savings we achieved. Our ACO’s work helps patients, providers, and taxpayers.”

As articulated in the press release, “Castell is a comprehensive health services company that helps healthcare providers, payers, health systems, and accountable care organizations achieve success in value-based care. Castell’s impactful analytic products and innovative care solutions are designed to accelerate organizations’ transition from volume to value and improve outcomes for patients while keeping costs more affordable. Castell is an Intermountain Healthcare company.” And, the press release noted, “Intermountain Healthcare is a not-for-profit system of 25 hospitals, 225 clinics, a Medical Group with 2,600 employed physicians and advanced practice clinicians, a health insurance company called SelectHealth, and other health services in Idaho, Utah, and Nevada. Intermountain is widely recognized as a leader in transforming healthcare by using evidence-based best practices to consistently deliver high-quality outcomes and sustainable costs.”

Shortly after the performance results were released by CMS, Castell’s Bassett and Henrisken spoke with Healthcare Innovation Editor-in-Chief Mark Hagland regarding those results and the broader context of their organization’s ongoing evolution. Below are excerpts from that interview.

Tell me a bit about the context of these excellent performance metrics?

Nick Bassett: Castell Accountable Care is a wholly owned subsidiary of Intermountain Healthcare. We’ve got about 50,000 lives in our Medicare ACO, mostly made up of people attributed to our employer-owned ACO. 2020 was our third year; 2021 is an extended year. So these were our third-year results. They’ve improved every year. We were among the about one-third of ACOs that generate savings in their first year. And we’ve generated savings every year.

The 50,000 lives are Medicare beneficiaries who are attributed to the Intermountain Medical Group. As we look at the 2020 results, one, because Utah is a low-cost state, that generally helps our benchmark performance, because of the way the program sets benchmarks; however, in a COVID year, that had an inverse impact, so we’re particularly proud that we maintained our very high score; we were almost 99 percent in 2019, so we’re pleased to be able to maintain that. Castell’s role—the reason Intermountain Healthcare built Castell was to be able to go into any medical group, whether employed or affiliated, and to provide resources and support to be successful in value-based care. And that’s the work that Dave’s been leading, to support the employed groups.

What been the secret sauce of your team’s success to date?

Dave Henriksen: As with any good “secret sauce,” there are lots of ingredients. People are looking for silver bullets, but there aren’t any. But variables that have impacted our performance in a positive way: we have some very sophisticated algorithms that our analytics team uses that helps us identify the people who need to be seen. We have a team of individuals we call our care traffic control team, 150 care coordinators that do a lot of proactive work to get people in, using phone and also a MyHealth Portal tool, to get them scheduled and seen.

You’re starting with population risk stratification, then?

Yes, absolutely. And our team has put forward a pretty sophisticated risk-scoring algorithm, which predicts who is likely to be high-cost.

Can you drill down one level on that?

Yes, we’ve been evolving that algorithm forward for nearly ten years, and it’s been refined with physician feedback and input. So defining just the right individuals is one component of the secret sauce; the second component is who we hire to do this outreach work. We have some of the friendliest, brightest people you’re going to find. No clinical background required; we hire for personality.

Is it a customer relationship management type of approach, then?

That’s a big component of it, for sure. And it allows our providers to have a team to support them. And supporting getting people to the places they need to go. Otherwise, it’s very hard for physicians to accomplish that kind of work.

What have been some of the biggest challenges in this work so far, and how have you overcome them?

Obviously, COVID has been a pretty big one this year; and more generally, it’s people wanting to stay away from healthcare; people not wanting to come in for their mammograms, and so on. So, bringing people in. And staffing for care management, care coordination. It’s hard right now: unemployment is super-low; it’s a good problem for the state to have, but it makes recruitment challenging.

Bassett: One of the additional challenges—we’re talking about MSSP ACO results—and one of the challenges we feel is prioritization of how we spread our resources across more than half a dozen risk arrangements spanning Medicare, Medicaid, commercial, and this MSSP product. And we can say, we’ve got this handful of people in Medicare Advantage, other high-risk patients in the ACO. And we don’t have unlimited resources. So it’s where we see the biggest financial impact per intervention. And that gets pretty deeply into how the model and constructs work. So it’s about prioritization. And with this particular population, given the way the MSSP is built, and given the retrospective nature of the program, understanding the need and prioritizing the right way, and continuing to improve even upon the results we’ve got, is important.

What have been the biggest lessons learned so far in the program?

Bassett: That’s a great question. One lesson is that the more patients on a provider’s panel who are covered by a risk arrangement, the easier it is to get them to engage around behaviors. We’ve got a non-employed group involved, and while they’re engaged, this population for them represents 2 percent or 5 percent, a relatively small percentage of their population. But when patients covered by risk-based contracts represent 50 or 100 percent of their population, that accelerates the energy in this work.

The “one foot in the boat, one foot on the shore” problem is often cited as a major challenge for the leaders of patient care organizations.

Yes, and that’s what Castell is doing, we’re trying to get people off the dang boat and get them going. How do we bring commercial payers and government payers along? We’re just trying to get more people into these risk arrangements; it’s kind of tough to be able to pay for these investments unless you’re in a risk-based arrangement.

Henriksen: Nick and his team have been doing a great job working with providers. And we’ve accelerated the percentage of providers in the state with risk-based panels; one-third of them now, after this year, have completely dedicated at-risk panels—that’s in the employed group.

Bassett: It’s been a really deliberate strategy that Dave has been leading with the Intermountain Medical group, so that their entire panel is risk-only.

Henriksen: And the more risk you have, the easier it is to exhibit these behaviors over and over again, and work as a team. These is a team-based sport; you can’t do this by yourself. The level of analytics needed, of bringing together care coordinators, pharmacy managers, house calls, care management—it’s not just the provider and MA [Medicare Advantage] trying to see 25 patients a day and trying to do value-based care as well—that doesn’t work. You’ve got to surround the teams with the right tools and resources, and be in the workflow. This can be made to work, if you hold the risk. In fact, Nick and I are betting on it. And we’re seeing it in this ACO performance.

What do the next two years look like for you?

Bassett: Just continuing to grow our risk arrangements, increasing the number of lives and the amount of risk, specifically around the Medicare ACO. 2021 will be our last year in the shared-savings model; we’re migrating to direct contracting, where we’ll basically be in a capitated arrangement with the federal government. And per that, the more real-time we can deliver data and information to people, the better we can do. And the tough thing with MSSP is that we didn’t really know our final performance until eight months after the contracting period ended. We believe that Direct Contracting will move us a little closer to what we think is the right approach to providing care. So I would say in the next couple of years, on the payer-construct side of things, we definitely see an acceleration not only towards more lives involved, but closer and closer to capitation-type models across the board.

Henriksen: Nick, you’re spot on. And the thing that’s been fun is to see the number of ideas that have surfaced around value-based care. If we’re trying to save money, how about a renal clinic that treats people with stages 1 and 2 kidney failure, so that it averts dialysis? And Nick and I don’t have to sit at our desks perusing journals; ideas are percolating up from the teams that can improve our performance. And we’re going to see more and more of those. And there’s certainly no shortage of great ideas for new offerings and products that can improve quality and lower the cost care.

Is there anything that you’d like to add?

Henriksen: Our vision, our hope for what we’re trying to accomplish here is much greater than Salt Lake City or even Utah; we think what we’ve been doing here in the Utah and in the western United States, can really be a conduit to moving forward in value-based care.

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