Accountable Care Organization (ACO) Accelerated Development Learning Program

I just came back from a conference organized by Medicare for Accountable Care Organizations (ACO) in Minneapolis.

These are some of the interesting ideas/thoughts/tips that I got there:
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Don Berwick, MD, MPP, Administrator, Centers for Medicare & Medicaid Services:

- You don't need to lock patients to reach the Triple Aim of the ACO. Triple Aim is the business plan of the ACO.

- We need medical boards that celebrate when hospital beds are empty. We need to move away from an acute care system

- Medicare got 1200 comments on the Medicare ACO proposed rules.

- ACOs need to change health care delivery - this is not negotiable.

- Medicare is offering different options for ACOs with levels of experience. Using a skiing metaphor: Black diamond - Pioneer ACO. Blue Square - Track 2 Shared Savings ACO (takes risk on all 3 years). Green circle - Track 1 Shared Savings (takes risk only on third year).

- ACOs need to emulate best practices. For example, there are medical groups that have almost 0% complications on hip replacements and send most patients home after 2 days

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James Rogers, MD, St. John’s Health System, Springfield, Missouri

Dr. Rogers has experience working with Medicare on a Medicare ACO Prototype — Medicare's Physician Group Practice Demonstration.

You can read more about this program at the New England Journal of Medicine

As you can see in this NEJM table, St. John's received no money on year 1 or 2, received $3,143,044 on year 3 and $8,185,757 on year 4.

One of the focus on this group was heart failure and nursing home transitions. Also putting nurse case manager on the ER was very important for their success during PGP. That prevented some hospital admissions related with "social" reasons.

There were able to decrease COPD admissions by vaccinating all COPD (they even send nurses to patients homes to give them shots) and worked on a smoke cessation program. An "emergency box" with prednisone and antibiotics was given to COPD patients. When the patient was short of breath, he could call the doctor and get permission to take the meds. Dr. Rogers found out that sending a prescription to the pharmacy of a patient with a COPD exacerbation would take an extra few hours and by then patient would be too short of breath and come to ER.

Dr. Rogers also found out that with direct phone calls between the hospitalists and the PCPs ("warm transfer"), the hospital readmissions drop significantly.

This group had experience already with the Medicare Advantage program and they translated some of this experience into the PGP demonstration program.

St. John's had no EHR initially and they used a homegrown registry to keep track of patients. Their initial billing system was IDX and they used it to track all the diagnosis and visits. The registry produced a "Visit Planner" with lists of all tests that patient is missing at the time a patient visits a doctor.

The PGP Medicare bonus was distributed the following way: Medicare got 20% savings and group got 80%. The group divided 50% to providers and 50% to system to pay for investment.

St John's managed 29000 medicare patients under the PGP. St. John Clinic changed job descriptions to some of their staff and it was able to only spend an extra $0.5m during first year and then $250-350k on the following years with infrastructure. St. John realized 3% savings on Medicare total costs.

There was a 30% change between year 3 and 4 on the Medicare population under PGP.

It is very important to keep track of the patient in almost real-time. Claims data sent from Medicare to St. John's was not used to track patients. St. John's used their own billing data. Around the 4th year, St. John's made a transition to an EHR and they lost some of the tracking abilities for a few months. For example, nurse care managers were not able to track CHF patients. That may affect their bonus payments for PGP year 5.

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Barbara Walters, MD
Senior Medical director, Dartmouth-Hitchcock Medical Center

Dr. Walters also had experience with the PGP program at Dartmouth-Hitchcock Medical Center.

Dartmouth received no money on year 1, received $6,689,879 on year 2 and $3,570,173 on year 3 and $378,798 on year 4. They attribute the later decrease on the PGP bonus amount to a transition to an EHR.

Interesting, Marshfield Clinic, another PGP group (they didn't present their data on this meeting) made $4.5M on year 1, $5,8M on year 2, $13,8M on year 3 and $16,2M on year 4. This Wisconsin group already had an EHR before joining the PGP.

Dr. Walters thinks that another factor on the success under PGP is related with population size. It seems that no PGP group was able to get a bonus by managing Medicare populations below 15,000 patients. Dartmouth managed 32,000 patients and St. John's managed 29,000 patients.

Dartmouth also a focus on managing patients with CHF.
They selected high risk patient populations based on:
3 comorbidities, > 7 E&M visits, >10K on total Medical expenses or patients on 3 different classes of medications. They marked this patients as "Goldstar".

Dr. Walters had a practical way to define patients that are attributed to the Medicare ACO/PGP program- if >3 visits with the group doctors, they belong to the group.

Dartmouth also used commercial software to define high risk populations ("Episode Treatment Groups") and they got the same results by just asking medical offices about who were the high risk patients. Medical offices were advised to give same day appointments to anyone on the priority list (Goldstar patients) that called.

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Craig Samitt, MD, Chief Executive Officer, Dean Health

Dr. Samitt talked about his experience of doing a transition from a volume based healthcare system to a value based system. He previously worked with Harvard Pilgrim and with Fallon Clinic in Massachusetts.

PCPs are essential on this transition. Interestingly, PCPs only earn 4% of total medical expenses (TME). Dean gave a 15% payment increase to PCPs (with a negligible effect on TME) and saved a lot of money.

Dean moved to a Value system by paying doctors based on Access/Growth (the doctor can choose new patient growth or appointment availability), patient satisfaction, quality (doctors can choose quality measures on the first year, then improve quality on second year) and achieving meaningful use.

They reward doctors with a blend of corporate performance (total cost of care), department level performance (quality) and individual performance (patient satisfaction).

They measure performance first then link to compensation. They offer a menu of options to make transition palatable.

Dean System made the incentive small initially (1-2% each) with low thresholds and then changed the metrics, increased the weights, decreased the options and raised the thresholds over time.

Received $18,000 check from Medicare for Meaningful Use Attestation with Care360 EHR

I submitted my Medicare EHR Incentive Attestation with Care360 EHR on April 18, 2011
I got a $18,000 Medicare check today:



"CMS FAQ on Payment for the Medicare EHR Incentive Program:

Question: I am an eligible professional (EP) who has successfully attested for the Medicare EHR Incentive Program, so why haven't I received my incentive payment yet?

Answer: For EPs, incentive payments for the Medicare EHR Incentive Program will be made approximately four to eight weeks after an EP successfully attests that they have demonstrated meaningful use of certified EHR technology. However, EPs will not receive incentive payments within that timeframe if they have not yet met the threshold for allowed charges for covered professional services furnished by the EP during the year.

The Medicare EHR incentive payments to EPs are based on 75% of the estimated allowed charges for covered professional services furnished by the EP during the entire payment year. Therefore, to receive the maximum incentive payment of $18,000 for the first year of participation in 2011 or 2012, the EP must accumulate $24,000 in allowed charges. If the EP has not met the $24,000 threshold in allowed charges at the time of attestation, CMS will hold the incentive payment until the EP meets the $24,000 threshold in order to maximize the amount of the EHR incentive payment the EP receives. If the EP still has not met the $24,000 threshold in allowed charges by the end of calendar year, CMS expects to issue an incentive payment for the EP in March 2012 (allowing 60 days after the end of the 2011 calendar year for all pending claims to be processed).

Payments to Medicare EPs will be made to the taxpayer identification number (TIN) selected at the time of registration, through the same channels their claims payments are made. The form of payment (electronic funds transfer or check) will be the same as claims payments.

Bonus payments for EPs who practice predominantly in a geographic Health Professional Shortage Area (HPSA) will be made as separate lump-sum payments no later than 120 days after the end of the calendar year for which the EP was eligible for the bonus payment.

Want more information about the EHR Incentive Programs?
Make sure to visit the CMS EHR Incentive Programs website for the latest news and updates on the EHR Incentive Programs."