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The 32 Pioneers asked CMS to delay the move to pay for performance in 2013
The first official results from the Pioneer ACOs aren’t due until this summer, but early data from at least one ACO is encouraging.
Banner Health Network, which serves 57,000 patients primarily in Maricopa County (Phoenix), Ariz., shows a 7% reduction in readmission rates, a 10% drop in inpatient admissions and a 7% decrease in high-tech imaging, according to Matt Horn, operations director for Banner Health Network.
Pioneer ACOs are considered the cutting edge of the accountable care organization movement. The nearly three dozen organizations selected represent many of the most well-respected provider organizations in the country. In February, however, the 32 Pioneers asked the Center for Medicare and Medicaid Innovation to delay moving from reporting-only status to pay for performance in 2013. Reasons cited include lack of benchmarking methodology for a majority of measures, and benchmarks that are set higher than current best-of-class performance. In the same letter, the ACOs reiterated their support for the program.
“The Pioneers are providing high quality care but are struggling in their ability to send that information to Centers for Medicare and Medicaid Services (CMS),” says Michael Gleeson, senior vice president of product strategy at Arcadia Solutions. The company works with five of the Pioneers to improve the performance of electronic health records, capture the right data and share it with providers.
In early May CMS indicated it would not in fact change its methodology for collecting and evaluating Pioneer ACO data.
Believing instinctively that outcomes are improving is not the same as reporting it. A strong EHR creates a consistent data repository that ACOs can use to study populations, disseminate data to providers and track progress. But getting at that data can be a challenge, especially for certain patients. Unlike true managed care, patients are free to seek treatment outside an ACO network, which can stymie efforts to track comprehensive patient data and manage the health of the population.
“We believe that engagement of providers and beneficiaries is a key issue,” Horn says. “The model allows patients active roles in their health and wellness.”
Undergirding patient and provider engagement is a robust electronic health record. Banner Health’s 23 hospitals are connected to the system, allowing physicians, nurses and other providers to view a common medical record that reduces test duplications and medical errors. The system incentivized physicians to adopt a common EHR platform.
“It’s not just about the patient record,” Horn says. “It’s about having a common EHR strategy and bringing in tools to predict population trends, as well as the data registry to serve [patients] best.”
Banner uses employed and contracted physicians in its network.
Bringing on the right providers and engaging patients are among the overarching goals of Heritage Medical Systems, an affiliate of the Heritage Provider Network, the organization that runs the Heritage California ACO and-through its affiliated medical groups and independent physician associations-provides care to nearly 1 million lives in three states. Other goals focus on data and how to parse it correctly, says President Mark L. Wagar.
“It’s very important that physicians understand that participating is a commitment to a different way to practice medicine that’s not present in fee-for-service,” says Wagar. “They must be much more involved with patients-both those with complex illnesses and in catching emerging conditions.”
Social interventions are just as important as medical ones, says Wagar, who believes the primary care physician office is the pivot point around which patient health revolves. But engagement should involve every medical and nonmedical provider who interacts with the patient. Like other ACOs, Heritage has placed a large emphasis on engaging patients following discharge from the hospital. The handoff from acute to post-acute care is critical to ensure every patient continues progress made in rehab, for example, has the correct medications, a follow-up physician visit and the proper societal or family resources needed for proper recuperation at home.
For Banner, teams also focus on case management, using mainly RNs with social work backgrounds, “with the added skill of being able to connect with someone and make a difference,” Horn says. “They manage prescriptions, go over the discharge schedule and go into patient homes, when necessary, to proactively manage their patients.”
As a result, Horn says the ACO has been able to reduce readmissions and hospital length of stays.
Another key element of the success is Banner Health’s decision to partner with many insurance providers that work with Banner to provide a highly coordinated patient care experience, one that Horn says emphasizes wellness, prevention and the close monitoring of chronic illnesses. The Pioneer ACO is actively looking to deploy patient-centered medical homes and an intensive ambulatory care program that would harness the power of telehealth to give high-risk patients the tools to monitor their health at home.
One reason ACOs may have difficulty hitting targets is how often CMS provides data on patient populations, says Gleeson. Patient panels change regularly, but updates often lag, giving ACOs an inaccurate view of its population, Gleeson says. Not only can patient turnover affect how an ACO reacts, provider turnover also can be a stumbling block, as can provider consolidation.
Horn agrees that finding the right talent can be a challenge in patient-centered care models. The organization must not only find talent with the right skill sets, those clinical employees must also thrive in a culture of change.
“Especially in a large organization, it’s hard to flip the switch and focus on value,” Horn says. “And in moving from volume to value, you have to have the right leadership to carry out the mission.”
And in this environment, every patient counts. ACOs can’t just focus on the high risk populations, they have to focus on the entire patient panels and all the associated providers, Gleeson from Arcadia Solutions says.
“I’m optimistic for ACOs to work,” says Gleeson. “Through the enhanced concepts of accountable care and shared savings, I think all of these organizations will get through these reporting challenges in some shape or form.”
A successful ACO will have both the right programs to manage risk and help patients care for themselves and the right technology platform to measure results and help providers proactively deliver care, says Horn.
“ACOs will need both to coordinate care on a real-time basis, with the right technology for caregivers, case managers and physicians,” Horn says.
Looking longer term, Heritage wants to compile a baseline measure of every patient from both medical and social standpoints, such as whether patients have children or other relatives close-by who can step into a caregiver role and have adequate transportation to make medical visits.
“Ultimately, we want to engage those in a good state of health and them help them do the right things to keep them healthy,” Wagar says. “If we manage the population in this way, they will be better off overall, healthier and cost less in the long run. It’s a worthwhile goal, and we have to be patient.”
This article was updated May 8, 2013 to reflect the CMS methodology.
Banner Health Network
Bellin-Thedacare Healthcare Partners
Beth Israel Deaconess Physician Organization
Brown & Toland Physicians
Fairview Health Systems
Healthcare Partners Medical Group
Healthcare Partners of Nevada
Heritage California ACO
JSA Medical Group, a division of HealthCare Partners
Michigan Pioneer ACO
Mount Auburn Cambridge Independent Practice Association
OSF Healthcare System
Park Nicollet Health Services
Physician Health Partners
Plusâ¨(formerly North Texas ACO)
Presbyterian Healthcare Services
Primecare Medical Network
Renaissance Health Network
Seton Health Alliance
Sharp Healthcare System
Steward Health Care System
Trinity Pioneer ACO, LC
University of Michigan
Source: Centers for Medicare and Medicaid Services