What Stephen Nuckolls Knows About Accountable Care—and Why It Really Matters

Feb. 23, 2015
Stephen Nuckolls and his colleagues at Coastal Carolina Health Care know that they can make accountable care work—and do it outside the markets already best known for risk-based innovation

It was great to interview Stephen Nuckolls late last fall, and to reflect on what he had to say about accountable care organizations (ACOs), the Medicare Shared Savings Program for ACOs (MSSP), and the broad shift towards accountable care-based care delivery and payment in U.S. healthcare more generally, as I wrote recently.

Nuckolls, the president and CEO of Coastal Carolina Health Care, P.A., based in New Bern, North Carolina, two hours east of Raleigh, has been helping to lead his colleagues through significant transformation work around care delivery processes. The 45 physicians and 20 mid-level providers at Coastal Carolina have been engaged in intensive processes to improve outcomes and cost profiles for the 11,000 Medicare enrollees attributed to them through the MSSP program, as well as for all of their patients.

In the process, they have significantly reduced emergency department visits, hospital readmissions, and average costs per patient, while dramatically increasing preventive screening rates and such key outcomes indicators as blood sugar control among diabetic patients.

And what is really significant in all this is that all of this improvement has been taking place in a market that has not been one of the densely urban, highly managed care-driven markets that have had decades’ worth of experience with risk-based contracts. So the fact that Coastal Carolina ended up being one of the top-ranked MSSP participant ACOs last year is quite remarkable and worthy of note.

Among other accomplishments, the Coastal Carolina clinicians have reduced ED visits by 10-15 percent in one year; reduced hospital readmissions by 10-15 percent in one year; reduced average costs per patient by 19 percent in one year; increased preventive screenings to levels among the highest of all MSSP-participating ACOs; and dramatically improved the hemoglobin a1c levels of diabetic patients.

Asked how he and his colleagues had achieved these accomplishments, he told me, “A number of things; the key one was having care coordinators work with our sickest patients. We spent more than 85 percent of our advanced payment payments from CMS was spent on creating a care coordination department,” he noted.

Among the top lessons learned so far? “I think that the incentives of the program can work. To me, the big lesson is that, despite assertions to the contrary from its critics, and even in low-cost areas, the program can work,” Nuckolls told me, despite the problems inherent in the metrics and measures that the Centers for Medicare and Medicaid Services has employed thus far, and about which Nuckolls and his colleagues argued strenuously for reform from CMS, earlier this month.

So, given the right parameters and guidelines, accountable care really can work, and it can work as executed by medical groups and other patient care organizations in smaller cities and towns outside the healthcare markets that everyone knows about already, in terms of their having high levels of managed care and risk contracts.

So yes, the MSSP program needs to be tweaked, in some ways, rather seriously. But we must collectively refuse to allow the Debbie Downers and Negative Nancys of healthcare to discourage the pioneers of accountable care from accomplishing everything they can. Only time will tell how robust the ultimate returns are on the ACO investment; but what’s clear is that it is absolutely far too early to be naysaying accountable care right now, and the noteworthy innovations of groups like Coastal Carolina prove that.

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