As the Centers for Medicare & Medicaid Services (CMS) launch the revised rules for the Medicare Shared Savings Program (MSSP), I am grateful to have a few years of one-sided risk under my belt, as well as having navigated many of the early struggles that are inherent to the process from its original format. “Pathways to Success” is the new shared savings program that redesigns the federal Accountable Care Organizations(ACOs)participation options and encourages, moreover requires, ALL to evolve to two-sided risk models, increasing savings and mitigating losses, and encouraging “regulatory flexibility and free-market principles”. The new process moves to five year agreement periods, away from the previous three year contracts we were accustomed to, and will “glide” ACOs through different levels of risk with everyone eventually participating in the Enhanced (highest risk-highest benefit) Track, previously called Track 3.
ACOs have demonstrated a significant increase in numbers from only 58 participating contracts in 2011 to 1477 in first quarter of 2018. Commercial ACO contracts still exceed the 561 MSSP contracts. Even so, nearly 40% of all Medicare beneficiaries are now covered under an ACO (though many of them are unaware of this fact).While nearly 60% of these 561 MSSP ACOs saved money relative to their benchmark, only about a third saved enough to qualify for shared savings. This means that 40% lost money and would have been in a potential payback situation if they were in a two-sided risk model. Critics of “Pathways for Success” fear that the accelerated glide path will encourage risk-averse groups, or those with a poor track record, to dissolve, markedly increasing the only 2% of ACOs that quit their contracts in these early years. I am personally afraid that fear mongering will drive people to the CMS created MIPS program (Merit-based Incentive Payment System), which I see as an even more dangerous, cloaked risk vehicle.
"My first recommendation to any ACO would be to ensure that you have a good data analytics platform and train EVERYONE how to use it, whether or not you have a management company"
Without a doubt, the changes to the MSSP tracks are significant and will likely “thin the herd” as the strongest excel and the weak limp away. The good news is that I truly believe the ACO model can be successful with two-sided risk and can improve population health, reduce medical costs, and provide minimal financial risk to providers and organizational members.
Every ACO is unique. Some cross state lines and cover over 100,000 lives. Others may encompass more rural communities, and still others are partnered with large commercial insurance entities. We are part of a hospital-sponsored primary care only ACO that includes an academic medical center, many Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs), private practices, and a for-profit hospital. Initially, our ACO struggled to balance the historical “need” for revenue from admissions (to our partner hospital) versus the goals of a shared savings program which encourages providers to better manage patients in an effort to prevent those very admissions. To a great extent, we have surpassed this fear and achieved success and financial rewards as we head into year three. We initially utilized an ACO management company but parted ways due to struggles with data analytics, communication, and physician engagement. These three items have been our primary challenges but a new day and a new director has brought solutions and enthusiasm back to our board of directors. Now we just have to prove to our members that we have good reasons for optimism even with the significant changes to the MSSP Program.
W. Edwards Deming, a renowned statistician once said, “In God we trust. All others must bring data.” It is no secret that data from CMS lags by months, making adaptions and changes difficult to institute or measure in a timely fashion. Additionally, volumes of great data exist outside of claims information that is vitally important to ACOs. We assumed that our management company was providing us with good data---the problem was, no one knew how to utilize the extensive spreadsheets and fact checking soon brought concerns to the table.
My first recommendation to any ACO would be to ensure that you have a good data analytics platform and train EVERYONE how to use it, whether or not you have a management company. When you can drill down to an individual patient visit or provider, you can make changes. ACO’s are difficult and the data within the ACO is complex. It is important that everyone have a decent level of knowledge of the platform as education is contagious. Providers are easier to engage when you can show them real-time, as well as, historic data. It is also very important that you have processes or informatics overlays that allow the ACO to capture data from a multitude of different resources. Sadly, the dream of a true Healthcare Information Exchange (HIE) does not yet exist. Data is in many places but is useless without bidirectional sharing.
Aggregating the data into clear, concise messaging is key to ACO success. All the information in the world is pointless if you do not have a way to share it with both administrators and providers of your member organizations. Whether this is in the form of high risk patient names, missing Medicare Annual Well Visits (AWV’s), or a daily list of ER/Urgent care visits, data that is 3 – 6 months old is essentially unusable and unattainable. Communication can take many forms but I strongly believe that multiple methods must be employed to be successful. This is includes face-to-face visits with training on how to read reports and utilize data analytic platforms, group sharing of successful initiatives pertaining to quality metrics, and quarterly report cards with recommendations and ways to improve before the next evaluation. Keeping the board meetings transparent is also a key to good communication, along with utilizing appropriate board committees to allow the directors to maintain the “big picture” focus.
Perhaps the most important and definitely the most challenging strategy of ACO success is provider engagement. Engaged physicians have better patient relationships, better achievement of quality metrics, and thus healthier and satisfied patients. This results in overall improved costs to the ACO. This is unfortunately easier said than done. There is a dearth of physicians across the spectrum taking care of an ever enlarging aging population. Physician job satisfaction is at an all-time low, and “burnout” is the new buzzword at every medical forum. Organizations, and specifically an ACO board of directors, must have a well-developed strategy for engagement, recruit strong physician leaders, and continually provide leadership opportunities to our “boots on the ground” providers. Strong data connecting clinical information, performance, and outcomes to financial performance is embedded in all ACO goals but not well executed. Evaluating motivations while providing leadership and educational development opportunities will help to bring providers on board.
I still firmly believe that the ACO model is here to stay though the new rules are likely to result in a shift of the current players. Are ACO’s the best system to help improve patient care and reduce healthcare spending? No, but they are the best of the current available options and with proper care can certainly be beneficial to patients, providers, insurers, and hospital systems.