Early ACO results: First steps prove challenging

August 08, 2013
by Diana Bradley, Staff Writer
Experts from a diverse group of health systems referenced a white paper analysis during a webinar on Tuesday. They cited some of the first examples of quality cost, patient experience and utilization improvements among the nation's earliest accountable care organizations (ACOs) and the challenges that came along.

Joe Damore, vice president of population health at Premier Research Institute, which supported the paper along with the Commonwealth Fund, said the best way to help people better understand the challenges, barriers, motivations, strategies and best practices was to hear directly from the organizations implementing them. In this case: Fairview Health Services of Minneapolis, Minn.; Memorial Healthcare System of Hollywood, Fla.; Presbyterian Healthcare Services of Albuquerque, N.M.; and AtlantiCare of Egg Harbor Township, N.J.

"[The Premier Research Institute] has had the pleasure to work in over 120 communities across the country and learn from many organizations," said Damore. "...The paper really focuses on what this journey is all about and what we are learning in this journey."

The Premier Research Institute conducted on-site interviews in October and November 2011 with executive leaders and applied Premier's Population Health Capabilities Framework to inventory the building blocks needed to transform delivery from volume-based to value-based health care.

At the time of analysis, two of the four organizations were engaged in ACO contracts with commercial payers; three of the four were working with their own self-insured employee plan; and Fairview and Presbyterian Healthcare Services were participating in the Medicare Pioneer program. Currently, all four organizations are engaged in ACO contracts with state or federal governmental agencies (Medicare Advantage, Medicare Pioneer, Shared Savings Program or Bundled Payment for Care Improvement, or state Medicaid programs).

Individual successes
Each of the four organizations showed significant improvements in quality and reductions in cost and utilization, according to the paper.

From 2009-2011, Fairview Health Services outpaced the market in improving optimal vascular care from 35.1-48.9 percent, and patient experience scores with 88.1 percent of patients saying they would recommend Fairview clinics. Further, inpatient utilization also dropped by 13.7 percent comparing 2010 to 2011 hospital volumes.

Meanwhile, the Florida State Health Department was spared $20 million by the Memorial Healthcare System, which coordinated care for 4,000 special needs children over three years.

Analysis showed Presbyterian Healthcare Services reduced average length-of-stay and operating room volume for procedures formerly in the top utilization statistics. In addition, Presbyterian improved care management and reduced costs via reporting and oversight encompassing the entire episode of care.

Hospital admissions and emergency department visits were reduced by 40 percent by AtlantiCare, who also cut per member per month insurance costs by $174-$200 for its own employees and large payer groups through its Special Care Center by better managing patients with chronic conditions. Further, AtlantiCare achieved a two-fold patient satisfaction increase, according to the paper.

The white paper shed light on the fact these four organizations are tackling payment reform and delivery system reform head-on and in parallel, according to Dr. Anne-Marie Audet, vice president of Health System Quality & Efficiency for the Commonwealth Fund.

"These are key ingredients to success," she said during Tuesday's webinar. "...We can't wait for payment reform to change the delivery system and we can't wait for the delivery system to change to figure out how we are going to pay for value."

Challenges
In the paper, all four organizations identified working successfully with providers and payers, a delayed return on investment and determining the ideal speed at which to implement accountable care as the most challenging aspects of transformation. Current state and federal regulations regarding the storing, sharing, and use of patient-related data were barriers to swift development of population health management capabilities.

Implementation speed was a particular challenge for Fairview, which chose to move rapidly over the course of one year to minimize time straddling the fee-for-service and ACO payment models, noted Dr. Patrick Herson, the organization's senior executive medical director during the webinar.

"A key challenge was aligning clinical and population health models with our payer and business models," he said. "The speed of how quickly you can move an organization our size can also be challenging."

For example, Fairview had a corporate graphic called the "messy yellow box", placing the organization between two operating systems: business and clinical models. Some people might be exiting the messy yellow box with their work, while others enter from another part of the organization. This results in a mix of people sandwiched together in a variety of different emotional, business and alternative operational spaces at the same time.

Herson also mentioned straddling different payment models proved a challenge for his organization. But they fought back with a great deal of focus and support from senior leadership, and by looking to the former professional ice hockey player Wayne Gretzky for inspiration.

"We are in the state of hockey, so we always talk about how Gretzky was a great hockey player not because he went to where the puck was, but because he could anticipate where the puck would be," said Herson. "And we need to have that same kind of virtuosity to the work we are doing."

Lessons learned
The white paper reveals several lessons for policymakers, payers, providers, and others interested in the feasibility of accountable care going forward.

Legal reforms will be required for successful movement to accountable care, along with novel policies supporting expanded primary care services, care coordination, the utilization of health IT, improved data availability and greater patient engagement, according to the paper.

Payers should encourage the leveraging of multiple payment and delivery reform models, like bundled payments and medical homes, along with ACO participation, the authors wrote.

Meanwhile, providers should consider how to best leverage their care improvement investments across their entire population.

"This [white paper] represents the early phases of ACO development," Audet said during the webinar. "First steps are the most important steps to set the stage for success and to be resilient to the changing environment under which health care lives today."

The white paper is titled: The Many Journeys to Accountable Care: 4 Case Studies.