In health IT circles, most people probably know Farzad Mostashari, M.D., as the former National Coordinator for Health IT, a role he served in for more than two-and-a-half years before founding Aledade in 2014—a Bethesda. Md.-based company focused on physician-led accountable care organizations (ACOs). Since then, Aledade has formed ACOs in New York, Delaware, Maryland, Arkansas, West Virginia, Tennessee, Mississippi, Florida, Louisiana, Virginia, and Kansas, which collectively care for more than 100,000 Medicare patients.
Recently, Dr. Mostashari, and Travis Broome, Aledade’s healthcare policy lead, co-authored a report, published in the American Journal of Managed Care, that made the healthcare IT media rounds as it took a deep dive into how Aledade-initiated ACOs fared in the 2015 Medicare Shared Savings Program (MSSP) ACO class. The report also largely looked at ways the Centers of Medicare & Medicaid Services (CMS) could prove its federal ACO programs. Broadly speaking, the authors noted that “there is no magic bullet for ‘transforming healthcare’ overnight, and that the work of redesigning our delivery systems to meet the expectations of the outcome-based payment models will be slow, hard, and uneven.”
Indeed, in August, CMS released performance and financial data for more than 400 ACOs in the MSSP and Pioneer government-led programs, revealing more than $466 million in total program savings in 2015, although nearly seven in 10 of those ACO organizations did not generate enough savings to receive bonuses. It should also be noted that CMS paid $646 million in shared savings bonus payments to high performing ACOs, leading to a net loss of $216 million, or a loss of slightly less than 0.3 percent for the government. The mixed results of ACOs to date have been a popular talking point for many healthcare leaders as maybe wonder about their sustainability.
Mostashari recently spoke with Healthcare Informatics Managing Editor Rajiv Leventhal on a myriad of healthcare IT issues, including information blocking and drilling down on the results of ACOs to date. Below are excerpts of that interview, edited for formatting purposes.
What’s new with Aledade? What are you working on these days?
You know that whole technology infrastructure we put in place and the whole volume to value shift? We’re basically [trying] to connect those. You have new payment models, so let’s help smaller and independent practices with those value-based contracts. And you have the technology infrastructure, meaning EHRs [electronic health records] and HIEs [health information exchanges], so how can we put those together and create workflows that can help smaller practices succeed in these value-based contracts using the technology, the information, and the business process redesign, which is maybe the hardest piece of this all. You need to rewire the workflows around the patient and his or her needs even if the patient is not in the office today. Aledade is in 11 states going on 15, and is working with 500 primary care physicians, going on 1,000, across the U.S. We are partnering with them and bringing them together on saying, “Enough with compliance; compliance with pay-for-performance, compliance with meaningful use, compliance with patient-centered medical home [PCMH] requirements.” Let’s keep people healthy and out of the hospitals and share in the affordability in healthcare that we help create.
Farzad Mostashari, M.D.
You recently published an in-depth report on Aledade’s ACOs in the field. At a high level, what did you learn most from that?
The first takeaway is that these things take time and people get better over time. This is not an overnight thing; you cannot transform healthcare overnight. But on the other hand, you can do a lot in a short period of time. Just within a year, in our “freshman experience,” we were able to cut ER visits by 5 to 6 percent and reduce 30-day all cause readmissions by 14 to 16 percent, relative to national trends. That’s huge—if there was a drug that cut readmissions by 14 percent, that would be a blockbuster drug! We reduced acute hospitalizations by 4 percent and 11 percent against national trends. So those are big things you can change in a short amount of time, even in these small practices. We’re very proud of the hard work our practices did and the technology that helps them succeed.
What are the key strategies and IT elements of these ACOs?
Some of it is high-touch and low-tech, so changing what the primary care practice does in terms of things like same day scheduling, so putting up posters, and smiling when a patient calls on a Friday at 4 p.m. and says he or she isn’t feeling well. Instead of saying “go to the ER,” say “come on in, we’ll see you.” So some of it is relationship based, but there are also things that [these ACOs do] that they couldn’t do before.
One example is around consistently reducing readmissions, and we now have the results from the five new ACOs that we started, and readmissions are down in all of them. The way we reproducibly and scalably get those results is by using event notifications from hospitals. So from the HIE, it’s an HL7 ADT [Admit Discharge Transfer] message that goes from the hospital to the HIE or to us, or from the hospital to us directly, or in some cases we create a real-time notification system for primary care practices to let them know when patients got admitted and discharged from hospitals. We get these to them quickly, within 48 hours, and have them contact the patient, see what’s going on with the patient, review medications, and schedule a visit with him or her within the next 7 to 14 days. That works; it’s what you would want for your mom, and most primary care practices don’t have the information, tools, and workflow to pull that off. We help them pull that off.
With Medicare ACOs, there are plenty of naysayers and Debbie Downers saying how poorly the programs are doing. Others are more optimistic. What’s your perspective?
We pointed out in our piece that there are some policy headwinds that Medicare has put in place particularly for physician-led ACOs that are hurting the success of program. I am a realist when it comes to saying this program needs to be improved. As currently constructed, it makes it hard for people to see the fruits of their efforts. I have the conviction that CMS wants to and will do the right thing, and they have shown a commitment to making the adjustments that will be necessary to make this program succeed. This comes slower than many would like, including me. Over the long run I think they will make the program work.
What improvements do you think are needed?
One of the most obvious things, and this is what every single Medicare Advantage and commercial contract does, is becoming more of what these other programs are like. There are two features that these contracts have that the MSSP doesn’t have: comparison into your regional trends and risk adjustment. So for example, if in Delaware we saw 5 percent year-over-year Medicare cost growth, but nationally the cost growth was totally flat the last few years, which means holding costs flat in Delaware is a huge accomplishment, but you get no credit for that. But in other parts of the country where costs are coming down, they are applauded even though they are just surfing the regional trend, rather than changing the regional trend. It’s an inaccuracy in calling balls and strikes that has to be fixed.
The second thing is around risk adjustment. Every single other program recognizes that patient populations can get sicker as well as healthier. But Medicare thinks it only goes on way; that your risk scores can only go down. That evaporated several millions of savings we accomplished based on that policy. So these are two changes Medicare can make to make the program more aligned with that others are doing, and keep folks more in the program who can see that their efforts are paying off.
From an IT standpoint, what other pain points are you hearing from providers in the trenches?
This is [an area] that I think your readers will find of interest. First, there is the real world data blocking that we’re seeing. The first example is EHR vendors—in order to fully develop that picture and really know your patient, and to know who needs your help, you need to do predictive modeling with the clinical data. It’s about getting clinical data out of EHRs that the practices have paid for and spent tens of thousands of hours putting data into them. Wanting to get your own data out is way too hard, expensive and slow. It’s neither cheap, easy nor fast; you get zero out of those three, and honestly I would settle for getting two out of those three. So that needs to be fixed.
The part that galls me the most is that the vendors can’t or won’t do what they pledged to do as part of the certification program for EHRs. These EHRs got tested in a lab to be able to produce batch downloads of patient care summaries, but in the field they either can’t or won’t do it. Some vendors actually implemented their technical solution in order to past the certification lab test, so it’s as if they “hardcoded” it to their lab test. It’s like knowing what the questions would be, they hardcoded their answers to that. But you can’t have a conversation with them in the field. They played a compliance game to pass the test, but they knew they didn’t actually have to have it working in production. That needs to have consequences. There needs to be a robust surveillance program response from ONC. If vendors don’t comply with the certification requirements they should be at risk of having their certification revoked. Or the vendors will charge you, say $40,000 for an interface engine that they didn’t originally say was needed as part of the certification program’s transparency requirements. They said it was a complete EHR.
The second part of information blocking is not on the part of vendors, as many vendors say they are just responding to what customers want. It’s on the side of hospitals. We have seen multiple hospitals—and it is a minority, thank goodness—refusing to share this lifesaving discharging information with primary care physicians. It’s a way to keep patients in their own network, to encourage doctors to join their ACO, rather than an external ACO, out of concern there might actually be fewer admissions, maybe? I don’t know what it is, but we are seeing very conscious and active information blocking on the part of hospitals.
Some stakeholders seem to outright deny that information blocking takes place. What do you make of this?
These people are not walking in the shoes of the people who are in the field trying to get data across networks. There is increasingly information flow within networks, such as within an ACO. One hospital CIO [recently told me] that the organization views information as a strategic asset. That’s not ethical in my view. I am not a huge believer in compliance thinking, but for this, there has to be regulations and carrots and sticks that say you have to have to comply, especially if you are a hospital that took federal money or is getting low income pool patients. You have to share this information back with the patient’s primary care provider since it is right for the patient.