They came to praise ACOs
With the recent news that four more participants in CMS's Pioneer ACO program are dropping out, the future of this important piece of the Patient Protection and Affordable Care Act is in doubt, now that just half of the original 32 sites remain.
Former Utah governor and HHS Secretary Mike Leavitt, a Republican who is no fan of the ACA, said at last week's inaugural Healthcare Analytics Summit, hosted by data analytics company Health Catalyst in Salt Lake City, that the future of Medicare ACOs may well depend on whether the remaining 16 Pioneer ACOs renew their contracts next year.
In fact, Leavitt, who now runs the consulting firm he founded, did something that current Republican members of Congress seem to avoid: acknowledge that the conservative Heritage Foundation proposed the idea of insurance exchanges — which he said are "here to stay." Pilots around risk-based payment grew out of ideas he championed during the Bush administration, he added. Leavitt also placed much of the blame for healthcare's woes on the dominant fee-for-service paradigm, which encourages high-cost services rather than effective, efficient care.
Leavitt's issue was with how much say government should have in reforming American healthcare.
Whether CMS is involved or not beyond next year, an increasing number of health systems are finding that accountable care is the right way to go, thanks in no small part to analytics. Leavitt himself predicted that 20 million Americans would be part of risk-based care contracts in the next 10 years, a significant number, but still less than 10 percent of the nation's population.
The move to accountable care will happen "slowly but surely," affirmed Health Catalyst founder David Burton, MD, who now serves as senior vice president for future product strategy.
Regardless of the direction of ACA implementation after November's midterm elections and the future of the Pioneer ACO program, health systems nationwide are seeing the necessity of becoming more accountable for the care they deliver.
"We're not an ACO," said Gene Thomas, CIO of Gulfport Memorial Hospital, Gulfport, Miss. "But I submit that we need to act like an ACO." That means turning to analytics.
Thomas said that if it were feasible, it would be better for patients and less expensive for payers to pay for doctor visits for chronic care, make those with congestive heart failure take their medications and have clinic staff personally walk each person two miles a day than to admit them through the emergency department. Indeed, Leavitt said that the most important competency of an ACO is the ability to change patient behavior
"What's best for the patient is lower cost," Thomas added, invoking the "Triple Aim" of safer care, improved population health and reduced spending.
However, in fee-for-service, as hospital margins fall, insurers still pay the same for the life of their contracts. But Big Data done right can shift the dynamics, giving providers stronger negotiating power with payers. "This is where shared savings come in," Thomas said.
"If you're looking for a marker for a bad outcome, you can look at high costs," agreed Geisinger Health System CEO Glenn D. Steele Jr., MD.
Steele said he had an "epiphany" after reading the seminal 2003 Rand Corp. study in the New England Journal of Medicine showing that patients only received 54.9 percent of recommended care for dozens of conditions, including chronic care.
But he said it took Geisinger close to seven years to get financial validation of accountable care. The change happened when cost-conscious Walmart started sending many Pennsylvania employees to Geisinger facilities for cardiology treatment.
Geisinger has been held up as a national example for health reform because it has properly aligned incentives by owning both a health plan and a care network. Still, Steele said that the organization's ACO "sweet spot" is not incentive alignment, but rather data sharing and aggregation.
Minneapolis-based Allina Health System has had similar experiences, according to Chief Clinical Officer Penny Wheeler, MD, who labeled cost a proxy for quality. Wheeler, an OB/GYN, cited Michael Porter of Harvard Business School, who said that quality improvement is the most powerful driver of cost containment. "Quality improvement is a science in itself," Wheeler said.
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There was just one problem. "I was trained in delivering care, not in improving it," Wheeler noted. She said that her fellow physicians needed opportunities for professional improvement, so the health system set up the Allina Advanced Training Program, which seeks to ameliorate care through better communications and more collaboration.
Allina doctors had expressed a desire for quality improvement tools, such as how to run an improvement cycle and the knowledge they need to deliver better care. They also wanted leadership development.
Data infrastructure is the "common foundation that has to be in place," Wheeler said.
Allina's data-driven "quality roadmap" includes being a Pioneer ACO and building accountability into commercial payer contracts, according to Wheeler. The organization is one of the 16 remaining Pioneer ACO participants. Among those, about half are making money and the rest are about breaking even; Allina is in the latter category, Wheeler said.
For now, that is just fine. "Our organization went into the Pioneer to learn," Wheeler said. "CMS has been a good partner," she said, while not tipping her hand on whether Allina would re-up next year.
"If we don't do this with CMS, we will do another program that focuses on value," Wheeler said.