In Michigan, Prime ACO is in the Risk Game, with Eyes on the Big Picture

May 17, 2018
Still in a one-sided risk model, the Michigan-based ACO is working its way toward taking on downside risk

Three years ago, when the Southfield, Michigan-based Prime Accountable Care was created, organizational leaders had a mission to focus on independent physicians. The creators of Prime Accountable Care, a company that serves communities all across metro Detroit while also covering a large portion of mid-Michigan, all come from a place where large institutions “gobble up the independent practice physician,” says Diane Blackburn, Prime ACO’s executive director. “So we wanted to make sure they could remain independent, while also being able to give them a venue to explore every facet that is afforded to them under the ACO (accountable care organization) umbrella,” she says.

Then in 2016, Prime ACO began its first CMS (Centers for Medicare & Medicaid Services) ACO contract, entering in the MSSP (Medicare Shared Savings Program) ACO Track 1 model. This specific model is “upside-risk” only with no downside potential—meaning that the ACO shares any savings with CMS, but if it overspends past its benchmarks, the government is on the hook for any financial losses all on its own.

Blackburn notes that Prime ACO, which as of last year, had 150 providers managing 11,000 patients, is planning on extending the MSSP contract with CMS, with the goal to stay in Track 1 for at least another year, and maybe for another three years. However, forthcoming policy could potentially thwart those plans. As Healthcare Informatics reported last week,  there is an ACO rule that was sent to the Office of Management and Budget (OMB) on May 1 and is currently pending review. The proposed rule will likely call for changes to the duration of one-sided risk models and force people into two-sided risk, according to at least one person in the know, Farzad Mostashari, M.D., CEO of Aledade, a Bethesda. Md.-based company that helps create and operate physician-led ACOs, and former National Coordinator for Health IT.

In an interview with Healthcare Informatics, Mostashari said he thinks CMS will propose that if the ACO’s contract period is over, and it is in a one-sided risk model, it cannot renew that contract. “You would have to get out or get up,” Mostashari said.

As it stands today, CMS limits one-sided risk ACO contracts to six total years, or two contract terms of three years each. But the upcoming rule could also propose to limit new ACOs entering MSSP Track 1 to just one three-year term each. Nonetheless, Blackburn says she has not heard anything about policy changes that could impact upside-only ACOs. “I had a call [last week] with the CMS liaison assigned to our ACO, and this topic didn’t come up, nor did she mention anything about it. We are ending our third year, so we have to renew [the contract] for our second three-year term, and we had that conversation without [the liaison] suggesting that something might change. So it’s not coming directly to me from CMS,” Blackburn says.

Looking at the bigger picture, though, Blackburn says she understands what CMS is thinking if the agency were to propose something like this. “We totally appreciate it and agree. Track 1 ACOs were never meant to be a model that someone was going to live in forever and ever. It is [similar to] training wheels—you have to start with them, but then you get off at a certain point,” she says. Blackburn adds, “We understand it, we’re welcoming it, and we have the right people and processes in place. We are comfortable. But at this point, CMS hasn’t mentioned to me that the three-year period might be shortened.”

Picking the Right Partner

Blackburn says the reason why Prime ACO hasn’t evolved into a downside risk model is due to early struggles that could be tied to picking the wrong health IT vendor. “We didn’t pick the right people, and that pulled us behind a little bit because we didn’t get off to a quick or strong start,” she says candidly.

The big-picture goal of Prime ACO, Blackburn attests, is to “delve into risk and into value-based reimbursement models. We’re all on the same page with that. There is not enough output or positive outcome in a one-sided model, and we didn’t envision being here for very long. But we had to make big changes our first year, we adopted those things in our second year, and now, going into the third year, we just know that it will give us a better foundation staying in a one-sided model staying for at least one more year before delving into something like Track 1+ [an ACO model with limited downside risk],” she says.

Diving into some of the specific challenges that Prime ACO had with its technology vendor, Blackburn says that when she started working there, she was looking for certain pieces of key performance indicators, such as dashboards and exchanges, but the back-and-forth dialogue with the vendor was porous.  “I was asking the questions I would normally need to ask in order to run the ACO, and the vendor just couldn’t provide simple information early on. Dashboards weren’t there [in real time]. We just weren’t on the same page. They wanted to focus on different areas than I did; I wanted to get back to key indicators and having dashboards [available] so I that I could validate the numbers every month. But they just couldn’t deliver,” she asserts.

Needing to go in another direction, Blackburn and a colleague went to the National Association of ACOs (NAACOS) Fall 2016 Summit, and spoke to every population health management vendor at the event. From there, Prime ACO decided to partner with The Garage, an Orlando-based population health management vendor. “They were adaptable to what we wanted; it was a partnership rather than them treating us like a client,” Blackburn says. She notes that the vendor had everything built and ready in a month so when Blackburn had to give her year-end presentations for physicians, it was all ready. “Picking the right partner, who you want to share vendor risk with, is key,” she contends. “Who do you want to entrust your patient lives with? You need that partner who has your back as much as you have theirs as you move into risk-based contracts. If not, you will fail.”

Now, Prime ACO leaders can use the population health management technology platform to accurately pull and understand critical data. “We are looking at the data on regular basis, analyzing it, and identifying areas that are vulnerable points. And we’re doing this by looking at patient claims data,” says Blackburn.

Once such area that the ACO is focusing on is chronic care management. When Blackburn’s team looked at the data, they saw that more than 70 percent of the ACO’s patient population had two or more chronic conditions, meaning they were eligible for chronic care management. “We knew that if we were going to make changes to the appropriate use of resources at patient or practice levels, [we had to] adjust those costs accordingly and get better outcomes. We had to start somewhere, and chronic care management was a clear identifier for us,” she says.

Indeed, being able to look at data, and then put in protocols and plans in place for “stratifying our own practices if you will, like you would risk—and going to those practices to talk to them about what needs to be done, why it needs to be done, and pulling them into a strong chronic care management program—has been a wonderful approach for us,” Blackburn notes.  

Some of the improved outcomes that Prime ACO has realized include: increased patient compliance and adherence to physician directives; increased patient visits with their physicians; better use of resources by those patients; lower inappropriate ER usage, lower admissions; and lower readmissions, Blackburn attests. “We’re even seeing better patient satisfaction and engagement. And of course, costs are following all of those positive outcomes, so this has been a worthwhile endeavor,” she says.

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