Thursday, March 6, 2014

What decides the success of ACO, population health models?

Not all health systems, hospitals, or physician practices succeed at implementing accountable care organizations.
More recent results published by the Centers for Medicare & Medicaid Services (CMS) showed returns within range of the federal agency’s expectations for the first year of the Medicare Shared Savings Program (MSSP) and the Pioneer ACO Program. However, that news came nearly half a year after CMS revealed that nine accountable care organizations (ACOs) would be leavingthe more aggressive Pioneer ACO Program, two for good with the other transitioning to MSSP.
So what determines the likelihood of a healthcare organization and its providers making a successful goal of an ACO? According to the leaders of the MMSP ACO, TriState Health Partners (THP)-Meritus ACO, the answer to that question is a combination of two elements: a physician culture of accountability and an organizational structure built on collaboration and data sharing.
Historically, THP has had strong physician engagement as a result of its setup as a physician hospital organization (PHO) owned jointly by more than 200 physician and Meritus Medical Center. What’s more, its physicians were well versed in care coordination and clinical integration well in advance of ACO programs being made available.
“We’ve had data presented to the doctors so when the ACO opportunity came on the radar physicians felt that they had an understanding of what the global ideas were,” says THP CMO Robert Cirincione, MD. “There was very little ‘sell’ that had to be done. We went to our physicians were already part of THP and presented them with the various contracts.”
As a physician himself already espousing alongside his fellow physicians the key components of accountable care in his practice, Cirincione encountered little resistant when selling the concept of an ACO.  “From the physician’s standpoint it is: what does it cost to join (nothing); what is the downside risk (none); what do you want me to do (practice more efficient and patient-based medical care and achieve increased outcomes)?” he adds.

According to ACO Program Director Shelley Grant, the organization was likewise primed for embracing the MSSP ACO model. “We were very well positioned from with our Tristate Health Partners organization — from a governance structure to a network of providers to reach out to — so we had more of an infrastructure already in place because of some of our previous work that we had done around clinical integration,” she reveals.
Because of the ownership structure of THP, many of the initial hurdles facing other aspiring ACOs were simply not there. “Unlike organizations that are starting out and just trying to pull providers together to educate them on the concept and then gain the trust to do the actual contracting, we already had a foot in the door,” Grant notes.
The challenge for the organization actually centered on its health IT infrastructure and the data being used to manage a patient population.
“We knew right away that the solution that had been in place was not going to be sufficient moving into the Shared Savings Program, and that’s where we really started to venture out,” Grant explains. “Through years of doing this, the technology that we had been using was solely claims-based and claims-based solutions will only get you so far in the management of a population and also when you’re looking at the overall performance of the healthcare provider community.”
The organization needed to be able to integrate its patient and provider data in a fashion similar to how THP had been coordinating and integrating care among its physicians for close to two decades. “We needed a system that would pull in those disparate data systems and be able to map those quality data elements and provide a more unified picture of how we were performing as an ACO,” says Grant.
While these two components are key to a successful ACO, they must be driven by the right philosophy — one that recognizes the value of the individual patient within the entire patient population.
“When we talk about population health, we tend to use very broad buckets — five percent of people in this bucket, twenty percent of people in that bucket,” Cirincione observes. “Practicing physicians tend to glaze over with discussions like that at some point because they really want to know about their patients who are in one of the buckets.”
What’s important to physicians in ACO or population health management is aligning views of a population with the needs of the individual. “Our challenge is to take what we can know from the segmenting of risk and then translate that into what that means to patients as they are going through the care so that the primary care physician or medical specialist is focusing on that patient relative to an evidence-based protocol and meeting the needs of the patient,” concludes Cirincione.

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