Oncology ACOs offer innovation for high-cost populations

As accountable care organizations (ACOs) gain footing, a few innovators are finding ways to enhance the prevailing models. The disease-specific ACO, still rather nascent, is now on the radar.

In May 2012, Blue Cross and Blue Shield of Florida (Florida Blue), and two providers, Baptist Health South Florida and Advanced Medical Specialists (AMS), built the Miami-Dade Accountable Oncology Program. AMS is a multi-specialty physician group focused on cancer care.

Jonathan Gavras, MD, senior vice president and chief medical officer for Florida Blue, says cancer care was ripe for attention. Oncology is the top disease category account for 80% of Florida Blue’s medical spend.

“We knew we needed to do something different to achieve the triple aim: save money, improve outcomes and deliver patient satisfaction,” he says.

Dr. Gavras says the three organizations studied costs associated with cancer treatment, projected trend and set a target for an appropriate reduction in expenses. He anticipates that if all quality measures are met, there will be savings to share among the two provider organizations and the insurer. Providers are paid fee-for-service along with a shared savings agreement.

The program focuses on six types of cancer: breast; digestive system and peritoneum; female reproductive organs; lymphatic and hematopoietic tissue; male reproductive organs; and respiratory and intrathoracic organs. Thus far, the ACO’s services have reached 500 members.

In the population identification process, the three organizations chose active cancer patients attributed to AMS during the prior year and calculated the average per-member, per-year expense within the population. They established financial targets for them in order to reach the medical Consumer Price Index, shared savings percentages among the organizations and an effective date for the agreement.

Key to the delivery of accountable care, says Dr. Gavras, has been an onsite clinical coordinator, along with after-hours care that allows for post-chemotherapy follow-up to prevent emergency room visits. Although there are not yet any firm results, Dr. Gavras says the ACO is on target to reach or exceed its goals: decreasing readmissions, reducing ER visits, increasing medication adherence and improving quality of care.

The ACO also has increased connectivity among the partners through information exchange and streamlined utilization, pharmacy and care management services, while implementing a total cost-of-care, value-based model to target a larger population. In the private market, accountable care models are proving more innovative than the Medicare ACOs because they are more nimble. However, ACOs in general are designed to raise the bar on care across all populations.

Dr. Gavras says the oncology ACO is beginning to take a closer look at palliative care as a means to avoid inappropriate treatment, such as chemotherapy for a patient with a life expectancy of 30 days. Difficult end-of-life care continues to be a challenge from a cost and quality-of-life perspective.

Along the way, Dr. Gavras says the ACO has learned a few lessons:

• Pick committed and aligned partners with common goals;

• Streamline data exchange early in the process; and

• Realize that a small population of patients can lead to large variations in data from one reporting period to another.

In fact, Florida Blue has learned so much that it launched another oncology ACO a year ago with Moffitt Cancer Center in Tampa, a National Cancer Institute-designated facility. He expects the Tampa ACO to target a larger population to reduce variability.

This year, the insurer hopes to develop four more single-specialty ACOs.

Bundled Payment

While the Miami-Dade Accountable Oncology Program represents an ACO that is disease-specific, others are contracting with different provider specialties to take advantage of their services.

Elliott Fisher, MD, director, Dartmouth Institute of Health Policy & Clinical Practice, says bringing specialists onboard in an ACO is the typical arrangement. He sees the role of the specialist as one who designs care pathways around a certain condition and provides support and knowledge to enable primary care physician teams and patients to deliver appropriate care.

To be successful, he says, an ACO needs to coordinate care among all providers targeting a defined population, share data and reduce costs.

Dr. Fisher says that a bundled payment arrangement might make more sense in the long run than forming a chronic disease-based ACO.