Healthcare Leader on Possible ACA Repeal: “Accountable Care isn’t Going Anywhere”

March 2, 2017
The ACLC’s executive director recently spoke with Healthcare Informatics about the organization’s current work, how healthcare stakeholders are responding to a possible ACA repeal, and how this all might impact the future of value-based care.

In November 2015, Leavitt Partners’ Accountable Care Cooperative and the Brookings Institution’s ACO (accountable care organization) Learning Network merged to form the Accountable Care Learning Collaborative (ACLC), which its officials now call the largest accountable care collaborative in the world.

The ACLC, based at Western Governors University (WGU) in Salt Lake City Utah, quickly grew to about 70 member organizations that wanted to take part in this mission. These members are made up of providers of all shapes and sizes, as well as major national payers, industry associations, vendors, manufacturers, and population health enablers.

The core point, says John Poelman, executive director at ACLC, is “we believe that in order to identify for providers what competencies are most needed and what their priorities [should be], you need a cross-industry perspective.” Poelman says, “We have chosen as an organization not to speak directly to a specific payment model, as we are seeing so many different ones with lots of options. We also don’t know what’s coming next.”

Indeed, what the ACLC is truly concerned with is provider readiness for taking on risk, irrespective to different payment models, he says. “We want to give providers a roadmap. What do you need from an infrastructure and culture standpoint?” As such, Poelman recently spoke with Healthcare Informatics about the ACLC’s current work, how healthcare stakeholders are responding to the new administration’s thoughts about the Affordable Care Act (ACA), and how this all might impact the future of value-based care. Below are excerpts of that interview.

Tell me about the ACLC and what its core mission and goals are?

The ACLC is a nonprofit organization with the mission to accelerate the readiness of the industry to adopt accountable care. The founders are Mike Leavitt [former Utah governor and Secretary of Health and Human Services under George W. Bush], and Mark McClellan [former administrator of the Centers for Medicare & Medicaid Services (CMS) under Bush and former FDA administrator].

So both founders have strong policy backgrounds and a lot of the payment reform is being driven from the policy side. There are lots of policy and market pressures on providers to enter into risk-based contracts, and providers are starting to get into these risk-based payments, but they’re not changing the way they are delivering care. So they are not doing a whole lot different, despite getting paid differently. The concern is that people are failing, and you can’t then turn back the clock on the movement as a whole. But the problem is that providers didn’t know where to start or what to prioritize. The vendors out there say they have the right tools and the most important next steps, but they don’t [provide] a great, unbiased roadmap out there to transition your practice to one that assumes risk.

With the member organizations in the ACLC, we have created seven workgroups, each one tasked to identify core care delivery competencies. These workgroups were: government and culture; financial readiness; health IT; care coordination; patient risk assessment; quality; and patient-centeredness. Representatives of these organizations were sent to these workgroups, and they each came up with an itemized list of competencies that providers need in each of these areas. They compiled a large list and they now have over 150 competencies that we have identified and published. We have a membership model to stay funded, but everything goes into the public domain. We are creating a glide path from those competencies and learning from those who are trailblazers, and then translating into a glide path for organizations who are earlier on and trying to figure out the next steps in changing their care delivery models.

One of the ways we are sharing learnings from trailblazers is through our Case Study Brief (CSB) Program, an initiative aimed at distilling real world examples of successful care delivery transformation into targeted and tactical lessons for providers. We just released our inaugural CSB series with 20 case studies. The amount of positive feedback we’ve received from the provider community since the release has been reaffirming of the importance of this work. Providers are looking to find proven strategies and solutions in a digestible and actionable way, and our goal is to help them.

John Poelman

You have mentioned that many providers are ill-equipped to succeed under value-based payments and lack a map of how to move forward. What particularly are they struggling with most?

This is subjective; I can’t speak for ACLC, but we are now identifying the biggest weaknesses. Anecdotally, we are seeing organization culture as an issue so far. A CEO or vice president might talk about value-based care, but the board of the organization might not be talking about it. That permeates down to physicians practicing. That’s a big one. Aside from that, getting more into the technology, people are underestimating the time and resources it takes to connect all of their data with disparate organizations. Sharing information is really important and really hard to do. Providers are stalling or not adapting fast enough, and that is part of the concern as well.

With this in mind, do you think the alternative payment model goals that HHS has put out there are too aggressive?

It depends how you define value-based care. Last year, HHS said they hit [their target] early [of having 30 percent of Medicare payments for hospitals and physicians come via alternative payment models such as ACOs and bundled payments by the end of 2016], which included 10 different alternative payment models in that calculation. CMS has a lot of different programs beyond those included in the HHS alternative payment model goal. In fact, we recently shared new research analyzing Medicare’s 74 care and payment initiatives. They are trying to make something for everyone, so everyone can get into it one way or the other, and MACRA [the Medicare Access and CHIP Reauthorization Act of 2015] does do that with different options. But there are going to be providers that, as time goes on, and as there is a greater incentive to take on risk, can’t accelerate the volume of their risk-based payments.

The post-election landscape leaves key regulatory areas such as the Affordable Care Act facing significant uncertainty. How do you see the future of value-based care playing out? Are the major pieces of it still on track to move forward?

I can’t speak on behalf of the ACLC, but I can speak to a lot of the conversations we have, and there are a couple of key points: the overall belief is that accountable care will keep marching forward. On the market side, we have had this economic pressure to change the way we are delivering care, and the pressure for more cost-effective care. This goes back to the early 1990s with managed care; there have been multiple iterations. This isn’t new. Republicans were even pushing and experimenting with delivery reform before Obama, and that’s responsive to a market pressure and an economic pressure to reduce costs.

And on the policy side, there’s at least one good reason to expect accountable care to move forward, and that’s MACRA—a bipartisan law with lots of Republican support. The element that will be helpful about MACRA is the MIPS [the Merit-based Incentive Payment System] side, so you have different quality programs like Meaningful Use and PQRS [Physician Quality Reporting System], and then there is the APM [alternative payment model] side, where you have a chance for a 5 percent payment bonus. That is really attractive. The CMMI [the Center for Medicare & Medicaid Innovation] has put out many of these programs; they are the organization which provides those avenues to achieve those APMs, and they are making tweaks to make them more attainable. The pressure will be on the new administration to preserve that type of activity and [continue] that momentum towards the accountable care transformation.

Do you think ACOs could be in any danger if a repeal or replace happens, given that many of them stemmed from the ACA?

Accountable care, speaking globally to value-based payments, is not going anywhere. These different payment models, like an ACO, will continue to evolve in a variety of different structures. ACOs, as they are now, don’t even mean one type of program; they have evolutions. Providers we have talked to intending to get into the MSSP [Medicaid Shared Savings Program], for instance, have hit the pause button given this political uncertainty, but we fully expect that this will not freeze inevitably or fall apart. It might be a slow pause, but there are enough signals that this is the way forward.  

What advice can you give to those who are stuck in this uncertain period?

Do not ignore it. By not paying attention, you can really put yourself in a bad situation. Take time to learn about what’s going on. Pay attention to new programs and what’s going on in your market, and start learning from as many sources as you can.