Scott Fowler, J.D., M.D., is president and CEO of Holston Medical Group (HMG), a large multispecialty, independent medical group located primarily across eastern Tennessee and southwest Virginia. He recently spoke with Healthcare Innovation about why the accountable care organization he leads, Emergent ACO, built their own health information exchange and analytics tools.
HCI: You wear a lot of hats. Besides leading Emergent ACO, you head up the Holston Medical Group and a related tech-services company. Is that right?
Fowler: Yes. HMG is a multi-specialty group working in a more rural area, so coordinating care and maximizing our effectiveness was really important. That's why we were multispecialty. It's why we adopted urgent cares and diagnostics. But when I came in, we really didn't have all of the pieces we need. We needed to really get big enough to manage the actuarial issues and also be able to be the anchor point. One of the things we needed was the technology stack. What we needed was to bring together the data from all these patient encounters. We built One Partner, the health information exchange technology that allows us to easily and efficiently and with low expense connect all the data sources together. On top of that, we built an analytics piece.
HCI: Most organizations probably don't build their own analytics tools or HIE. Did you look at the marketplace and make that build vs. buy decision?
Fowler: We did do a buy versus build analysis. There wasn't anything available in the market. At the time, EHR systems were viewed as the end-all. They were just going to get bigger and bigger. I guess Epic is one of the final stories in that. But we realized right away that the EHR was not going to be ubiquitous across all the places where these patients interacted. A lot of these places are not even medical service places. They're health clinics that are associated with nonprofits, and they use different systems. So there was nothing really in the market for us to get everything we needed. We did go through a few iterations of the HIE technology, and we did not build our own HIE technology. We built the data centers and the programming competency, but we actually bought a product called dbMotion that we use. Then we built the analytics on top of that.
HCI: Could you talk about Emergent ACO and what you saw as the opportunity in the ACO space? Is there a huge overlap with the Holston physicians?
Fowler: There is some overlap. HMG is probably still the largest group in there, but they are rivaled in size by other groups. It's geographically located in southwest Virginia, northeast Tennessee and a large component in North Carolina. It’s actually in seven states. It's grown to 1,000 doctors and will probably grow to 1,200 next year. It’s 40,000 Medicare lives. There would be an equivalent number in Medicare Advantage if we expanded to MA, which we do plan to do.
Value is a bottom-up, transactional sort of system where you're establishing relationships. It is very personal, context-rich stuff. So you want tools at the top, but you don't want leadership and management at the top telling the bottom what to do. We understood that we needed to get all the data to the right people at the point of care. That's why we built our technology stack, but it's also why we chose to build a model where you could get big enough with multiple groups using the same operational playbooks to get bigger and bigger populations so that you could do the actuarial work. When we bring a group in, we can tell what risk corridor it ought to be in. We can just look at its data and say you shouldn't be in full-risk contracts. Whereas I think smaller groups don't have that ability. And if they find somebody that's willing to give it to them, they usually keep the vast majority of the profit, too. We realized we had to push 80-plus percent of the savings back into the point of care, rather than have it get bled off in these different models. There wasn't really wasn't anything in the market like that.
HCI: On Emergent’s website, it makes the point that many ACOs have a lot of overhead. So how do you distinguish yourselves as having lower overhead?
Fowler: For one thing, we have been able to subsidize through grants most all of the technology that's available, so when somebody comes into Emergent, what they're getting is no barrier to entry and a place to start doing value. This is something I suppose that other ACOs do as well, but I think we're focused as providers on a couple of issues. One is low cost, low barriers. The second is low expenses overall, so we can return as much as possible to them, because quite frankly, it's an expensive and scary proposition to get the providers to convert into something that has risk associated with it. So the ACO was intended to keep the barrier to entry low, return as much as possible, to take the risk as much as possible, and make it rational and understandable.
HCI: Has Emergent done well in the Medicare Shared Savings Program over the last couple of years?
Fowler: We've never lost money. We have usually been in the 6 to 8 percent savings rate range. That's including all these different groups. Some of them are just starting value and some of them are further along. We perform 99-plus percent on our quality. We return 80 percent of the money back to the practices. In 2021, we had $21 million in savings out of the ACO. We do this by providing less of the care that churns in a negative way. In other words, care that actually reduces quality because it's the result of multiple labs or multiple diagnostic studies being done because they're uncoordinated. The patient had a CT last month and they're going to get another one and get admitted because the ER doctor has no idea of the previous results.
HCI: Are there other alternative payment models that are attractive or that you are considering working on?
Fowler: One of the keys to this whole value thing is to understand it's a relatively small group of patients where there really is low-hanging fruit, and it is the area where we spend all of our money. I mean, the vast majority of patients we spent very tiny little bit of money on in healthcare. Medicare rises to the top just because it's where there is the most reward, but every single contract has opportunities in it. Medicaid has some opportunities to it. In commercial we can see good savings rates if we isolate patients to the ones that really need coordinated care. Every population does have some opportunities, but obviously some are much bigger than others.
HCI: Are there roles for the specialists in all that?
Fowler: Yes. We believe in a multi-specialty version of value. We do not believe in a PCP-only version of value. Now, I'm not saying that you can't make money that way. I'm saying it is not optimized. It's not maximized. You maximize your care model when you coordinate, whether it's internal to your group or whether it's through an ACO amongst everybody touching that patient coordinating. So, we do share savings back with the specialists. The specialists do have things they can do. Our models do look at a geography and say: Are we using the lowest-cost, highest-quality labs? Are there diagnostics available in this geography that are low-cost and high-quality? Another example: orthopedic treatment can vary hugely based on where the procedures actually get done. You're replacing a hip or knee in a hospital, you're talking $40,000 to $60,000; you do it in an ASC [ambulatory surgery center], you might get away with an $8,000 spend. Well, these are huge amounts of improved quality and reduced cost in a system that you need specialists for.
HCI: Do you have any recommendations for CMS or CMMI?
Fowler: I think CMS is on the right track. They have got to figure out how to improve the quality while they still drive down the price as the population grows. They are doing some experimentation, which makes some sense to me because there's so much variation in terms of how adoption is occurring. I would say stick with what you’ve got. We didn’t’ go to ACO REACH. We think we can do just as well with the standard program that has been around forever. It does complicate things, because everybody in our ACO gets letters saying, ‘Hey, come in, we're going to pay all this money. We’ve got better benchmarks.’ That was very confusing. We just need good benchmarks that accurately pay us for the improvements that we offer. Then we need consistency over time, so that we can build the organizations and the technology stacks that we need without having too much disruption. So that would be my feedback to CMS. Let's stick with the basic program.
