In the annals of the history of medical group management in U.S. healthcare, some industry observers may well look back on the years 2012 through 2014 as a turning point for medical groups. That’s because it was during that period of time that a number of large medical groups entered into the Medicare Shared Savings Programs for accountable care organizations (ACOs)—either the regular Medicare Shared Savings Program (MSSP), or the Pioneer ACO Program. At the same time, too, many medical groups nationwide entered into ACO contracts with private health insurers; indeed, a large number began participating in both one of the Medicare programs and one or more private-sector programs. (As of May 2014, there were 338 MSSP ACOs and 23 Pioneer ACOs.)
“How hard is it?” is the inevitable question many would like to ask. The answer, of course, depends on whom one asks—and perhaps even on what day one asks the question. Certainly, participating in these kinds of programs is not easy; indeed, in the last week of August 2014, the news went public that Sharp HealthCare had dropped out of the Pioneer ACO program. As reported online in California Healthline, executives from the San Diego-based integrated health system had actually informed the federal Centers for Medicare and Medicaid Services (CMS) of their decision to pull out of the Pioneer program on June 29; but the announcement was not made public until late August.
Alison Fleury, CEO of Sharp’s ACO, attributed the organization’s decision to drop out mostly to the financial model of Pioneer ACOs, telling California Healthline that, “Because the Pioneer financial model is based on national financial trend factors that are not adjusted for specific conditions that an ACO is facing in a particular region (e.g., San Diego), the model was financially detrimental to Sharp ACO despite favorable underlying utilization and quality performance.’”
What’s more, Sharp HealthCare’s departure follows by one year the departure of nine other original participants, among 32, in the Pioneer program. The other nine had left the program all at the same time, in July 2013, at the same moment that CMS had announced publicly that while all original 32 participating organizations had improved the quality of care, only about one-third had lowered costs significantly enough to create shared savings.
The Sharp departure seemed to signal an inflection point for the Pioneer program, and certainly led to industry commentary about the rigors of the Pioneer program, at least. Yet behind the scenes, a more complex landscape was becoming clear, one involving more nuance than at first met the eye.
[EDITOR'S NOTE: On September 25, after the print edition of the October issue of HCI, which included this cover story, had gone to press, it was announced that three more organizations participating in the Pioneer ACO Program--the Franciscan Alliance, Genesys PHO, and Renaissance Health Network--had dropped out of the Pioneer program, with two shifting to the MSSP program and one of them--Renaissance Health Network--dropping out of federal ACO participation entirely.]
A continuous learning organization in Massachusetts
Indeed, for all the challenges facing Pioneer ACO and regular MSSP program participants, some leaders of larger medical groups participating in those programs are feeling confident these days; and most of all, they are using the opportunity to participate in one of the two Medicare programs in order to engage in conscious learning. A great example in that regard is Atrius Health, a non-profit alliance of six community-based medical groups in Massachusetts. With more than 1,000 physicians and more than 2,100 other staffers, the six medical groups, based in Newton, Massachusetts, are taking care of 35,000 Medicare beneficiaries in the Pioneer program.
In joining along with the other 31 Pioneer organizations in January 2012, “We had very specific goals when we started,” says Emily Brower, executive director of accountable care programs at Atrius. “One goal was to move towards a population-based approach, and a single model of care for the Medicare population, which was population-based, as opposed to thinking about patients being in different service models. What being in the Pioneer ACO did for us was to help us think about the entire Medicare population in the same way clinically—we take an approach that serves that entire population.”
The other goals, Brower says, had to do with aligning all clinicians to work together, Atrius-wide, on care delivery improvement. “We want to think of ourselves as a system of care where we can share best practices, and to replicate, wherever we can find it, across all of Atrius Health, to create systems of care,” Brower says, and working within the Pioneer program is giving her and her colleagues the opportunity to do just that. “That’s been incredibly rewarding. We have a team of about 50 people who are working on our population health strategy, testing [strategies]; we call it our ACO team. It includes our Pioneer population, our Medicare Advantage population, another 30,000-40,000, and our dual-eligible population of about 5,000.”
Still, despite that enthusiasm, Brower concedes that there have been challenges along the way, particularly “a couple of challenges around the way the Pioneer model is structured that’s very different, in terms of how accountability is measured,” Brower says. “Just the fact that it’s different from the way things are structured with a regular health plan,” has been challenging, she says. “The way that financial accountability is set and measured is very different from within the Medicare Advantage program or certain health plans. We’re working within it, but something that is very different is always a bit hard. We’re a very data-driven organization,” she emphasized. “We’re used to tracking things ourselves, but in this situation, we have to rely much more on Medicare.”
Toughing It Out: a FQHC Alliance Joins the MSSP
Interestingly, it’s not only clearly well-positioned medical groups that are participating in one or the other of Medicare’s ACO programs. One of the ACOs participating in the regular Medicare Shared Savings Program is an alliance of three federally qualified health centers (FQHCs) in New York. And the story of its participation is fascinating. Family Health ACO was formed by the Institute for Family Health, the Open Door Family Health Center, and Hudson River Community Health. Altogether, the three medical group organizations serve patients in 50 locations in lower New York state, including in New York City, and see 180,000 patients overall, with about 800,000 patient visits a year.
Family Health ACO joined the Medicare Shared Savings Program in January 2014, and, says Neil Calman, M.D., president and CEO of the Institute for Family Health and board chair for Family Health ACO, he and his colleagues pursued Medicare ACO status because “We all realized we needed to do practice in the new world order of reduced cost, outcomes-based, value-driven, and we decided this would be a good idea for the three of us to get together on a clinically driven initiative, to deal with some clinical improvement issues, keeping people out of the emergency room, etc.” Calman says that “We thought this was sort of the best-organized of the programs, and that it would give us an opportunity to look at Medicare claims data; we’re using that data to improve our outcomes and costs, and we believe working with it will help us in our private-sector contracting.”
Unfortunately, some challenges dogged the Family Health ACO from the beginning. “FQHCs have very few Medicare patients,” Calman notes, “so we’re struggling to get to 5,000 members, the minimum required for participation. You’d think we’d have about 7,000-8,000 members,” he adds; “but we’re struggling with the attribution number now. We’re struggling to find people who should be attributed to us but who are not,” he says. Unfortunately, he reports, “There’s no mechanism to go back to Medicare and find out about “lost” people; you only get the claims data on people who are attributed.”
Participating in the MSSP has turned out to be far more difficult than expected, Calman says. But the benefit for the three medical groups under the Family Health ACO umbrella is clearly this: the opportunity to work with clinical and claims data to try to improve clinical outcomes and cost-effectiveness—even as those FQHCs are already treating patients as cost-effectively as humanly possible.
Optimism and a Steep Learning Curve in Arizona
A couple of thousand miles to the southwest, the operational landscape is totally different from at Family Health ACO; and yet the medical group development intentions are remarkably similar, at Banner Medical Group, a Phoenix-based, 1,100-doctor group, and at Banner Health Network, which is one of the Pioneer ACOs. (Banner Health Network encompasses Banner Medical Group, which employs its physicians; as well as two independent practice association-type networks, Banner Physician Hospital Organization and Arizona Integrated Physicians.)
Banner Health Network, which is providing care for 300,000 attributed covered lives, encompasses 3,000 providers, and was accepted into the Pioneer MSSP program in November 2011 and began operating as a Pioneer ACO in January 2012. Banner Health Network and Banner Medical Group are in turn affiliated with the vast Banner Health, which operates more than 25 hospitals in seven states.
Clearly, Banner Health Network is better resourced than is Family Health ACO. Yet some of the same intentions are present among the Banner physicians and physician leaders, in terms of using the MSSP experience as a learning lab kind of process.
Robert Groves, M.D., vice president of health management at Banner Health, and Anton Decker, M.D., chief medical officer of Banner Medical Group, both have thoughts about the physician leadership learnings currently taking place at Banner. “The way that Banner Health is structured, I am not the lead of the medical group, that’s Dr. Decker,” says Groves. “But my vice president of health management title is essentially director of population health. And one of the key learnings we’ve had around population health,” he says, has to do with “the need to centralize al of the support services involved, and to create centralized resources and to support processes. One needs to centralize a lot of those support services, do it early, and go big,” he says. That’s particularly important in creating processes that support the shift from fee for service-based payment systems to value-based payment systems.
With regard to collective physician learning around accountable care, Decker says that “It’s a steep learning curve, and absolutely fascinating, and a lot of fun. The first thing that comes to mind for me,” he says, “is data. So, physicians and hospitals and medical groups are historically not used to seeing data that was the privy of insurance companies. Now that we’re seeing that data, it’s creating a beautiful opportunity and a lot of engagement.” Fortunately, he notes, physicians in practice are far more open to data-driven care delivery improvement.
What have been the biggest collective learnings around data and IT among Banner physician leaders? “One is that it’s hard,” says Groves. “The number of disparate sources of data that must be integrated is a huge challenge—claims data, pharmacy data; we have 20-some different EMRs in our Banner Health clinics. So there is a real challenge in being able to pull all that information together and pull meaningful data out of it. The second biggest challenge is the delay in obtaining data in a timely way from government—and it is not a small problem either, with our private payers. But that’s been a process. And having everyone on the same point-of-care EMR is helpful.”
Nationwide, Learning How To Do Team-Based Care
Looking at all this from a national level, Jerry Penso, M.D. believes that medical groups across the U.S. are absolutely doing important collective learning through their MSSP and Pioneer ACO program participation. Penso, the chief medical and quality officer at the Alexandria, Va.-based American Medical Group Association (AMGA), says, “What they are learning is how to truly implement team-based care. And that involves figuring who should do what, and what information they need in order to do that,” he says. “The old days of, we’ll just take the claims data, do some analysis, and produce some reports, are over. You have to get the right data and information to the right people at the right moments. You have to do this in a population health context, to figure out which services you’ll provide to which patients, at which levels.”
Among the most difficult elements, Penso says, is ”developing the point-of-care tools with the right information available. From an IT perspective,” he says, “that can mean recreating structured fields within EHRs, and training everyone to use them. Getting those gap reports or care alert-type reports, into the EHR, and you have to get the physicians and others engaged, and to do that, you have to create workflow that fits with where they are and doesn’t screw up their lives,” he adds. There is also a fundamental cultural shift that has to take place within medical groups in order to make all this work, he emphasizes.
Penso has an interesting take on the Sharp HealthCare departure from the Pioneer program, by the way. Indeed, he was a senior executive at Sharp when the organization applied to become a Pioneer ACO, and helped write that application himself. His perspective on the departure this summer? “I don’t think that anyone expected all the Pioneer organizations to succeed; I think people realized they would learn over time. The challenges in restructuring care management, in delivering the utilization improvement, in restructuring EHRs, those are challenges, yes,” he adds. “But the [more intense] challenge they’re finding is in the benchmarking for performance. And depending on the market you’re in and the benchmarking system involved, even if you’re hitting all the benchmarks involved, that can be tricky.”
In the end, says Atrius’ Brower, “One of the things that the Pioneer ACO, or really, any PPO population, because Medicare really is our country’s largest PPO, can teach you, is that it really brings you face to face with the fragmentation of care. This is a population with high needs, and using a lot of services, and these patients are getting them from a very broad network of providers, hospitals, specialists, etc.; so when we started to look at the data, we really stepped back and said, wow, if there ever was a population that needed coordinated care, this was it; and for those patients, it’s really all about providing a great experience.” And, she adds quickly, “If you think about Medicare patients with multiple chronic conditions and who are on multiple medications—well, if we can do this with one EHR and one medication list, we can make the experience a safer one for patients.”
