APG’s Susan Dentzer on the Future of ACOs

Oct. 19, 2022
Susan Dentzer, president and CEO of APG, America’s Physician Groups, shares her perspectives on where ACO development and value-based contracting are headed

The APG, America’s Physician Groups, one of the leading national associations representing physician groups involved in risk-based contracting, will be hosting its fall conference Oct. 31-Nov. 2 at the Grand Hyatt in Washington, D.C. Entitled “Transitions 2022: APG Colloquium,” the conference will bring together a roster of high-powered healthcare policy leaders, as well as representatives of hundreds of APG member organizations.

Among the speakers will be Anthony Fauci, M.D., Director of the National Institute of Allergy and Infectious Diseases; Chris Jennings, former Chief Health Advisor to President Bill Clinton, and president of Jennings Policy Strategies; and Thomas Insel, M.D., author and executive director of Vanna Health. What’s more, on Tuesday, Nov. 1, Susan Dentzer, APG’s president and CEO, will moderate a panel entitled “The Bumpy, Slow, and Circuitous Route to Value-Based Healthcare,” and whose panelists will be Adam Boehler, former Director of the Center for Medicare and Medicaid Innovation (CMMI); Patrick Conway, M.D., former Director, CMMI; Seema Verma, former Administrator of the Centers for Medicare & Medicaid Services (CMS); and Gail Wilensky, Ph.D., former director of the Health Care Financing Administration (now CMS). In addition, the various tracks will offer sessions that focus on the integration of primary and specialty care; creating, scaling, and sustaining behavioral health integration in primary care; integrating value-based oncology into primary care; innovations in care delivery; the future of advanced care at home; pharmacy in team-based care; caring for homeless older adults in value-based arrangements; geriatric and urgent care in the home; healthcare workforce recruitment and retention; and policy developments at the federal and state levels.

Healthcare Innovation Editor-in-Chief Mark Hagland spoke recently with Susan Dentzer about the program and more broadly about where value-based care contracting and accountable care organization (ACO) development are, right now. Below are excerpts from their interview.

Tell me about the conference?

We do a spring conference in San Diego and a fall conference in DC. We’re calling this “Transitions 2022,” to capture the fact that we’re in a bunch of transitions, including with regard to the upcoming elections, at the national and state levels, as well as the ongoing transition to value and transitions in terms of the delivery system, as well as who’s who and who’s doing what in healthcare. And we’ve just had several major acquisition announcements in the last few months, with new and new-ish players coming into healthcare. And also, transitions underway for APG.

For sometime within APG, we’ve had groups oriented around particular aspects of payment and delivery reform. We’ve had our ACO Reach Coalition; and we had something called the Risk Evolution Task Force, which we’ve renamed our ACO MSSP Coalition, focused on MSSP, particularly in light of the fact that, in the most recent physician fee schedule announcement, CMS indicated they’re going to make a lot of changes in the MSSP, to keep that program alive and keep the number of entrants a robust number; but they’ve also announced that they’ll create advanced incentive payments, to lure smaller practices into MSSP; and they also intend to inject some equity features into the MSSP. That could bring new members into APG, to join our experienced members.

And we have a joint meeting on October 31 of those two coalitions, and Liz Fowler will be addressing both of those. And before that, we have a lunch for our Clinical Quality Leadership Forum, our physicians who have been extremely highly focused on quality in their organizations. And Lee Fleischer, M.D., the head of the Center for Clinical Standards and Quality. The entity within CMS that focuses on quality; and Dr. Fleischer will speak to us. So, we have our joint session with Liz Fowler, and then the coalitions are going to split up and meet separately, and the ACO MSSP Coalition will meet separately, as will the ACO Reach Coalition. Purva Rawal works under Liz at CMMI, and will be speaking to that coalition.

I’d like to ask you your perspective on a situation that evolved forward during 2019 and 2020, involving the previous administration, and tension between CMS under Seema Verma and some of the provider associations, around how the Medicare Shared Savings Program (MSSP) was architected, particularly around benchmarks, as well as the timing of certain elements. Seema Verma was pressuring provider organizations to take on downside risk as fast as possible, and provider associations were pushing back, warning that huge numbers of providers might leave the MSSP. That tension between federal health authorities and providers seems to have eased somewhat in the past year-and-a-half—would you agree?

Yes; it’s eased because the policy’s changed, the administration’s changed, and the approach has changed. If you think about what the previous administration did, it did as you say—created a structure designed to push ACOs faster into two-sided risk while also creating a program, Direct Contracting—which, BTW, had bubbled up under the previous administration—and aimed at those ready for full or global risk, at least on the primary care side. So they did that, and created that important vehicle for those ready for that move. The current administration has seen a trailing off of new entrants into MSSP, and they’ve got this goal now of getting 100 percent of enrollees in traditional Medicare into accountable relationships by 2030; well, you’re not going to get there by setting the bar so high that you won’t get smaller practices into it. So this administration has shifted to the opposite side. And they’ve learned from the Advanced Investment Model that it’s not so simple to get into any element of any ACO simply by flipping a switch; you need to run your practice differently.

The classic illustration of this is, let’s say you’re a primary care doc in fee-for-service: what do you care about on a day-to-day basis? You care about the patients who show up, because you treat them and then they go away. If patients aren’t coming in, they’re fine. But of course, we know that’s not true. And so now if you’re required to manage the health of your diabetic patients, you have to move into being totally proactive, and that involves a whole different set of capabilities, with bigger and better infrastructure, and new and different staff, to act proactively; and that takes investment. And if you’re the average primary care provider out there in the community. So the Advanced Investment Payment, AIP, will be a new feature. You’ll get $250,000 now as a small physician practice if you go into MSSP. Is that enough? Probably not; but it’s enough to stimulate practices to get into the MSSP. And Doug Jacobs, Chief Transformation Officer at CMS, will speak to the ACO MSSP group. Technically, of course, the MSSP is not under CMMI’s umbrella, but CMS’s.

Can you speak to this moment in healthcare, when hospitals and health systems have become financially fragilized by the challenges they’ve faced during the pandemic, and their leaders are in some cases now more anxious about moving into value-based contracting than before. How will some of this play out?

I think the next few years are going to be a real Rubicon for the nation’s hospitals and health systems, even for the ones that have already dipped their toes into value-based care. It’s the cliché; they’re definitely the organizations with feet in two canoes. But they also understand the imperative, and that over time, the future of the U.S. healthcare system is going to rest in taking better care of patients to keep them as healthy as possible and out of the hospital; and that means that plenty of people will still end up in hospitals. And the biggest single driver will be demographics; and we know that. But we have proof of concept now, that it’s possible to take better care of people, and minimize their hospital stays and intervene in terms of primary prevention and secondary prevention, keeping people from getting sick in the first place, and then keeping people from getting sicker. And all levels have to be addressed. We’ve starved primary care and under-invested in primary care. People understand that.

Your members are going to show the leaders of other patient care organizations nationwide the way, correct?

We are; and that’s been the bedrock of APG’s groups already. But if you look at the commitment on the part of CMS to get 100 percent of Medicare recipients into accountable relationships by 2030; and then you have the 28 million in Medicare Advantage. Now, not everyone in Medicare Advantage is in an accountable relationship. So we don’t think that MA always means a really accountable relationship; but, could it be? Of course it could be. And what everyone at CMS and CMMI want to do is to push accountability forward in the Medicare program; and once you do it in Medicare, it’s hard to resist elsewhere.

And also on one panel, we’ll have two former heads of CMMI and of CMS: Adam Bohler and Seema Verma, and Gail Wilensky, and Patrick Conway. And we’re going to have a big discussion with them on the transition to value.

That should be really interesting!

Yes, we’ll ask them what worked, what lessons were learned, where we are now, where we have to go. And we titled that “The Long, Slow, Bumpy Road to Value,” because that’s how it’s been. But have we made some headway? Of course we have. And there are a lot of people who are frustrated with the pace and look at the averages. And it’s possible to look at the average accomplishments and get really depressed; but we argue that you’ve got to look at what’s going on; people are showing proof of concept every day. And what’s anyone’s better idea—that we stay in fee-for-service? Really? And there’s been a lot of pushback on the progressive left, which wants Medicare for All; and they’re entitled to that position. But they don’t drill down below that, into value-based for all. And they’re militantly opposed to Medicare Advantage. Are a substantial percentage of Americans voting with their feet, and going into Medicare Advantage? Yes. And if you’ve got 28 million people in the program, that provides a very big platform for creating change.

Would you say you’re more optimistic, or pessimistic, in the moment, about where things are at?

I would say that I feel hopeful; and our members are all hopeful. And their hope is not a fantasy-based hope; it’s based in reality, because they know what they’ve accomplished, and there’s much more to be done. And if the policy environment remains helpful, they’ll continue to move forward, and will share their knowledge and learnings forward. And of course there are huge challenges, including workforce, and mental health, and we have sessions on both. We have Tony Fauci coming to speak, because the pandemic obviously posed huge challenges, and it’s not over. And even if this one is ebbing, it’s time to get ready for the next one. And none of that goes away, just because you’ve been transitioning to value. Everyone has worries, but our members are 100-percent confident that they’ll be better able to confront future pandemics based on what they’re doing. If you were getting population-based payments, you survived the early months of the pandemic much better.

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