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:
----------------------------------------------------------------------------------
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

----------------------------------------------------------------------------
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.

--------------------------------------------------------------------
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.

------------------------------------------------------------------------------

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.