must be prioritized for these populations based on specific market conditions.
Steward Integrated Care Network in Massachusetts managed over 66,000 Medicare beneficiaries in 2014 under the Pioneer Model but is moving to the Next Generation model. It is innovating Medicare care management outreach, moving from a traditional coordination-of-care model to a model of patient activation and motivation, care planning and engagement. “The engagement of a senior today will be greatly different than the senior of tomorrow due to technological innovation — we are balancing today’s traditional engagement methods with the technology advances of tomorrow,” said John Minichiello, executive director of accountable care solutions at Steward.
Optum ACO in Arizona took specific steps to better serve high-risk Medicare Advantage patients in its market, focusing on those with a history of multiple admissions. Optum did not participate in earlier ACO programs, but it has a history of taking on risk. From the beginning, its Medicare Advantage program was at 100 percent financial risk.
“It was very tough going in the beginning,” said Garell Jordan, president of Optum Care Delivery. “We started with a large facility and planned on seniors coming in for care, but we quickly moved to a patient-centric model to meet the patients where they needed care.”
Optum ACO tailored its approach to focus on navigation points in the market, listening to Medicare patients to understand all of their health needs rather than concentrating on episodes of care. This understanding of the market allowed it to innovate strategically, adding social workers and care managers and increasing in-home physician visits. As a result, it was able to reduce hospital admissions by 70 percent for high-risk patients.
In Michigan, Henry Ford recognized the importance of winter weather conditions in its market — especially for the senior population. It responded with innovations that enhanced access, such as expanded home visits and telemedicine services, as well as improved support for caregivers.
Cornerstone innovated in its market by creating a duals-eligible clinic that integrates a consulting psychiatrist into the care management team. The clinic was formed in response to the high proportion of chronic mental health disorders in the population it serves.
Plan for an evolution, not a big bang: The transition from volume- to value-based models requires organizations to manage course corrections so they can effect clinical and financial transformation. “It’s a maturity — you have to have air traffic control, and balance scope and resources across all the different value-based contracts the organization has entered into,” said Minichiello, describing Steward’s evolution. “Organizations must focus on core competencies while stimulating breakthrough progress.”
Cornerstone had three goals when it embarked on its evolution: Get paid differently, allow physicians to practice differently and integrate information throughout the system. The journey has taken more than five years. Getting paid differently was the biggest challenge as the payer market was not ready to move to a shared-risk model; over time, the market has matured to allow Cornerstone to achieve its goals.
Optum ACO’s decision to abandon its if-you-build-it-they-will-come plan is another good example of an evolutionary approach. “Our initial care model had to evolve,” said Jordan. “Expecting patients in a 9,500-square-mile area (about the size of the state of Maryland) to come to us to get the care we thought they should have was the wrong model for the market. Now, we’re taking care to them, focusing on what they consider important.”
The cost of redesigning care must also be considered. For example, Triad invested over $8 million in start-up costs, with a large portion of that for coordination and management of home care. The investment was considered essential to creating a population health system with its needed infrastructure.
Approaching population health as an evolution benefits the organization as well as patients. A gradual approach allows health systems to pace new investments and activities as they take on more risk for targeted populations, ensuring an appropriate reward for the value created. Jordan outlined Optum ACO’s approach: “Phase one was learning. Phase two was making it scalable. Phase three is continual improvement without ego.”
Focus on partnerships. Organizations cannot improve quality and reduce costs by addressing acute care or ambulatory care exclusively. Successful organizations are forming partnerships that support care within the entire ecosystem.
Since care transitions can substantially affect quality, cost and patient satisfaction, Triad organized a “transition in care” summit with more than 25 stakeholders to identify problems and develop integrated processes to support Medicare patients.
Both Triad and Henry Ford have built partnerships with emergency medical service providers to help deliver appropriate care outside the hospital. Triad has contracted with EMS providers to handle medication changes for heart failure patients, based on protocols and physician oversight. EMS providers can also perform medically cleared evaluations. Over a six-month period and with congestive heart failure alone, the program saved $250,000, reduced emergency department visits and admissions, and improved patient satisfaction.
Similarly, Henry Ford and Optum ACO have created partnerships with skilled nursing facilities as their population health models have matured. For Henry Ford, the effort includes telemedicine, data integration, ACO-deployed medical directors at skilled nursing facilities, and support from attending physicians — all with the goal of providing better care in the appropriate setting, thus avoiding unnecessary higher-cost care. Optum ACO, using a premium skilled nursing facility network, reduced readmissions from 33 percent to 18 percent.
Both Cornerstone and Steward have put in place relationships with urgent care centers to integrate information, but more importantly to offer care in more locations and during extended hours. In addition, Cornerstone physicians and care coaches have partnered with Rite Aid pharmacists to help manage patients with chronic and multiple chronic conditions.
Reaping the benefits
In the early phases of the ACO program, providers focused on organizing physicians and implementing targeted high-risk population health programs. As providers progressed, they continually innovated in organizational structures, clinical models and partnerships.
As a result, providers have gained the confidence to take on more risk. At the same time, CMS has made changes to the Next Generation model, allowing ACOs to take on up to 100 percent risk and receive a greater share of the savings.
There will be important lessons as the program proceeds. But there is already much to be learned from the performance of the 21 selected Next Generation ACOs. Ultimately, these lessons can serve as a valuable guide, helping all health care organizations meet the challenge of providing high quality care, improving health and reducing costs.
Cynthia Kilroy is a managing director at Huron Healthcare in Chicago.
