ACO Experts Weigh in on CMMI’s Bold Goal

Jan. 26, 2022
Leavitt Partners’ David Muhlestein said it's going to be very difficult to get all Medicare beneficiaries into accountable care arrangements by 2030

During the Jan. 24 Value-Based Payment Summit, several accountable care organization leaders and analysts spoke about the promise and challenges inherent in the CMS Innovation Center’s goal of having all Medicare beneficiaries in accountable relationships by 2030.

Melanie Matthews, M.A., president of MultiCare Care Connected, an ACO in Washington state, applauded CMMI for creating a bold goal around care transformation. “I think that we're working to systematically and fundamentally change our fee-for-service delivery model to one that promotes value and quality and keeps the patient at the center,” she said. “When I think about the lessons learned around the CMMI model maturation over the years, and the outcomes that I've seen firsthand, I see that we've really impacted more appropriate utilization.”

Matthews said the work that her ACO has done has put more focus on reaching out into the communities it serves and connecting patients to the resources that they need to stay healthy in the community. “We fundamentally see a shift from sick care to health care. I think the fee-for-service model is a sick-care model.” The lessons from Next Generation ACOs can be “building blocks for us to transform our healthcare into something better, which is what our communities deserve,” she added.

Phil Oravetz, M.D., M.P.H., M.B.A., chief population health officer at Louisiana-based Ochsner Health, also said he is excited about CMMI’s bold vision. “I think it's very achievable,” he said. “The reason I say that is this work is well under way. At Ochsner, we've had a long history of managing total cost of care and Medicare Advantage risk models. We are now seven or eight years into our Medicare ACO experience.”

Oravetz said it takes three or four years to build ACO infrastructure. “Our experience has been a very typical one, where we extended our learning, not only in time, but also in space. And what I mean by that is we are now extending our learning and our resources into the areas that were really on the sidelines in the early ACO movement, namely rural and underserved communities.” He said Ochsner’s ACO is now throughout the state and the region. “We're extending our expertise our technology infrastructure, and our resource platforms.” One example of that is their community resource network partnering with the Unite Us platform. “I think the initial learnings over the initial five to 10 years of the ACO movement now are well positioned to leverage across the entire region, and we're doing that at Ochsner Health.”

David Muhlestein, Ph.D., J.D., chief strategy and chief research officer at Leavitt Partners LLC, said that although he thinks it's a great goal, it's going to be very difficult to get all Medicare beneficiaries into accountable care arrangements by 2030.  

“There's a few ways that you can do it,” Muhlestein said. One way is just to create a really broad definition of what you mean by a care relationship or accountability. “This is like when they said all hospitals are at risk, because there's a hospital readmission reduction program. Well, they're kind of at risk, but not really at risk.”

  If you use a more targeted definition where the provider recognizes the responsibility for the patient, where there may be some risk involved and a population health focus, it's going to be difficult to get to everybody involved, Muhlestein said.

One reason, he said, has to do with just the adoption cycle. There are early adopters and laggards. The laggards have viable reasons why they can't do it. For many of them, it could be an issue of them going out of business if they started to focus on this, he explained. Other providers are nearing the end of their careers and say they just want to continue to do what they are familiar with. It's not worth the effort. The juice is not worth the squeeze. “There are going to be groups of providers who just refuse to do this, and frankly, they're going to have the ears of their members of Congress, and I think there's going to be a political barrier if you try to move everybody,” Muhlestein said. “Now that doesn't mean that having that goal and creating programs and strong incentives and maybe disincentives from staying in the traditional fee-for-service world won’t move many people. I do think that it's realistic that we could have a majority of patients that are covered under what I would call a true population-based model. But I think it's unrealistic to think that we can get 100 percent there, unless there is some major act of Congress that basically just forces it down people's throats. And we know how well that goes over.”

Oravetz also was asked about CMMI’s stated goal of decreasing health disparities.I think CMMI has already shown us the roadmap for how we're going to do better on this,” he responded. The root cause of the lack of diversity in the models is because the models were all voluntary, and provider groups and others who joined these models were going to play in certain areas and not in others, he said. “We had self-selection from the beginning, and that is being addressed. We were just mandated into the ESRD [End-Stage Renal Disease] Treatment Choices model, as an example.” Everyone in the country was eligible for that model, so there was no opting out. Then CMMI did a randomization to choose a third of the providers around the country to be the intervention group and the other two-thirds to be the control group. “The Treatment Choices model is the first of the CMMI models to specifically address health equity,” he stressed. “We know that many of our systems are now addressing race and the calculations of renal function. It's leading to dramatic changes in how we manage those diverse patient populations. I would suspect that as models move forward, particularly total-cost of-care models, you're going to see less ability to cherry-pick patient populations.”

Muhlestein gave more detail about the difficulty of the expected transformation ahead. “Whenever you make these transitions, there are going to be organizations that simply fail,” he said, “and we've seen that already with ACOs. It hasn't happened a lot, but we've seen some that have gone out of business. They're just not able to make that transition towards these alternative payment models. And we have to be comfortable with that. The reality is, communities hate to lose their providers, and if hospitals start to fail because of this or physician groups start to leave their communities, that's going to be a major barrier. And I know that will happen in certain areas around the country.”

He also stressed the importance of multi-payer alignment. “Medicare payment is necessary but not sufficient for this to happen,” Muhlestein said. If you have Medicare pushing really hard, but the large commercial payers in the market say no thank you, it's going to be really hard for people to make these changes. “You have to get some sort of alignment with stakeholders, and what we've seen is it’s really hard to get any group of stakeholders to come along and align. It’s not because they don't all agree that something should happen; it's that they don't have common pain. They have their own pain points from different directions. And that makes them say, ‘Well, we have very different solutions to our different pain points.’ What works really well in many of these forward-looking organizations may not work for others. What they've done to manage populations using technology systems or other mechanisms may simply not work. You are going to see organizations that try and just are not successful and not able to implement those changes.”

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