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Year: 2017

Evaluating ACO Performance, 2016 Edition

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By DAVID INTROCASO

(A review of 2015 ACO results appeared on The Health Care Blog on October 1, 2016.)

The Medicare Shared Savings Program (MSSP), or Accountable Care Organizations (ACOs), continue to be CMS’ flagship pay for performance (P4P) model delivering care via 432 MSSP ACOs located in every state to over nine million, or 16%, of Medicare beneficiaries. This year the agency did not announce 2016 performance year results. Instead, CMS posted without notice in late October a Public Use File (PUF) or spread sheet summarizing 2016 performance. What analysis CMS did provide was by CMS’ vendor, the Research Triangle Institute (RTI), several weeks ago to ACO participants via webinar. RTI’s slides are not made publicly available.

Like performance year one (2013), two (2014), and three (2015), performance year four (2016) once again produced limited positive results. As stated last year, CMS does not evaluate the ACO program, therefore, ACO participants and Medicare policy analysts are left to decipher how success was achieved, what performance results mean for the MSSP program and in context of the agency’s overall efforts to reduce Medicare spending growth.

2016 ACO Financial Performance Results

Here is a bulleted summary of 2016 financial performance based on the PUF and RTI’s slides.

  • In 2016 there were 432 ACOs that had their performance year results reconciled.
  • Of these, 410 were Track 1, six were Track 2 and 16 were Track 3.
  • Of the 432, 134 earned shared savings or 119 out of 410 Track 1s, six out of six Track 2s earned shared savings and nine out of 16 Track 3s earned shared savings. Four Track 3 ACOs owed $9.33 million in shared losses. Only 129 actually received shared savings checks because five of the 134 owed CMS for advanced ACO payments.
  • Physician only ACOs once again were more successful than ACOs that included a hospital, or 41% versus 23% respectively.
  • Also again longer tenured ACOs were more successful. Among the 2012-2013 ACO class 42% were successful compared to 18% of the 2016 starters.
  • The 134 2016 ACOs earned in sum slightly more than $700 million in shared savings. Actual savings paid out was close to $650 million because imperfect quality caused ACOs to leave money on the table and because of Medicare reimbursement or sequestration cuts required the 2011 Budget Control Act.
  • For 2016 30% of participation MSSP ACOs will receive a shared savings check compared to 29% in 2016, 26% in 2015 and 27% in 2014.
  • Earned shared savings were again highly concentrated. The 15 highest performing ACOs received $265 million total in shared savings as compared to the 15 lowest performing shared savings ACOs that received $20 million in total.   An August DHHS Office of Inspector General (OIG) report made note of this dynamic, i.e., about half of the spending reductions during the first three years of the program, or $1.7 billion, were generated by 36 ACOs and three ACOs in that group generated a quarter of the amount.
  • Of the remaining 294 2016 ACOs, 107 fell within their positive Minimum Loss Ratio (MLR) corridor, 105 fell within their negative MLR corridor and 82 fell outside their negative MLR corridor. This last group, the worst performing ACOs, was 19% of all 2016 ACOs, significantly less than the 24% of the worse performing 2015 ACOs.
  • Again, success was largely determined by an ACO’s financial benchmark. ACOs that earned shared savings in 2016 had a reconciled benchmark 10% higher than all other ACOs, or respectively $11,614 per beneficiary versus $10,563 per beneficiary, or a benchmark 7% higher than those within their positive MLR corridor and 12% higher than those that fell below their negative MLR. The OIG report reached the same conclusion. During the first three years of the program, ACOs that received shared savings had a $11,748 per beneficiary benchmark compared to a $10,284 per beneficiary for ACOs that did not receive shared savings, a 12% difference. As noted last year, because of this successful ACOs only had to comparatively spend a trivial amount less than their financial benchmark to be successful.

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Reducing Opioid Abuse, A Quick Guide to Internet Resources

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By DAVID HARLOW, MD

The opioid crisis has been upon us for years now, and we are now seeing the problem become more pervasive, with more than 90 deaths per day in the U.S. due to this scourge. The president recently said he would be declaring a public health emergency (which would free up some funds) but has not done so as of this writing. The public health threat is so persistent that it calls for responses on many levels, and those responses are coming. Some have been in place for a while, some are more recent. These responses may be broken down into a number of different categories:

The overarching goal is to eliminate the use of opiates for all but the most critical short-term needs (limiting prescriptions to a seven-day supply) and medically-appropriate chronic and palliative pain management. There are alternative pain relief drugs — and a wide variety of other treatments for pain, ranging from TENS to meditation to VR.  Taken together, the initiatives highlighted and linked to above represent a good start. Of course, we need more than a good start, as the US consumes a wildly disproportionate share of opiates compared to other countries — follow link for some facts and figures — for predictable reasons of economics, politics and culture, and we are paying a staggering price in excess morbidity and mortality and in secondary effects (the effects on family and community).

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Why the Potential CVS Acquisition of Aetna is Brilliant, The Law of Unintended Consequences

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By FRED GOLDSTEIN

Many people have been surprised by the announcement that CVS is interested in purchasing Aetna.  Why would a PBM want to own a health plan?  There has been speculation that the move by Amazon to get into the pharmacy space may be a reason.  But there is another more rationale reason and its based upon a flaw in the Affordable Care Act.

The flaw is known as the Medical Loss Ratio requirement and it reads like this from the CMS website

The Affordable Care Act requires insurance companies to spend at least 80% or 85% of premium dollars on medical care, with the rate review provisions imposing tighter limits on health insurance rate increases. If an issuer fails to meet the applicable MLR standard in any given year, as of 2012, the issuer is required to provide a rebate to its customers.

This requirement was put in place as a way to ensure that health plans did not make money by underutilizing medical care.  But it had the unintended consequence of insuring that costs never went down and here’s why.

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“Mouths Full of Gold.” Private Practice in Britain’s National Health System

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By SAURABH JHA, MD

When Aneurin Bevan was asked how he convinced doctors to come on board the National Health Service (NHS) he allegedly replied, “I stuffed their mouths full of gold.” Bevan recognized that to conscript doctors to the largest socialist experiment in healthcare in the world he had to appeal not so much to their morals, but pockets.

There is much piety about the NHS. It is the envy of the world, though oddly Saudi oil barons still favor Cleveland Clinic and Texas Heart Institute over quaint little hospitals in rural Scotland. The NHS featured in Britain’s 2012 Olympic parade along with Mr. Bean and the human right activist, Shami Chakrabarti – only one of them was there for parody. Brits aren’t ones to posture self-righteously, except when it is about the NHS, when the violins come out full mast, and we’re treated to a spectacular display of sanctimony and disingenuity. The NHS is a religion which keeps its prophets happy.

Bevan, an arch socialist, Labour to the bones, and founder of the NHS, was no social justice warrior. He recognized that berating doctors into doing the right thing wasn’t going to work. Nor was selling them a utopian paradise. Remember, this was post Second World War Britain, when socialism was in fashion, and sympathies towards communist Soviet Union was an intellectual fad. Selling the concept of the NHS should have been a cake walk, most of all to doctors. But Bevan was a pragmatist, not sentimentalist. He knew that he needed more than ethos, logos and pathos.

So, in a stroke of everlasting genius Bevan allowed doctors to see private patients in NHS hospitals, a small quirk with considerable consequences. In essence, Bevan legitimized a two-tier system, in which the rich could jump queues, and doctors could serve the rich and the poor, though the rich a little faster, and with more personal touch. The NHS is living embodiment of George Orwell’s famous quip: everybody is equal, but some are more equal than others.

If the NHS isn’t the envy of the world it should be the intrigue of the world. Its survival wasn’t probabilistic. There are two reasons why the NHS hasn’t imploded – foreign-trained doctors and private medicine. The contribution of the private sector to the longevity of the NHS isn’t immediately apparent. Both tiers support each other. The parallel private track allows doctors in Britain to earn more than their NHS salaries, with only a little extra effort. Private insurance in Britain compensates handsomely.

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To Achieve Its Goals, Population Health Needs More Specialists

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By VIKRAM REDDY, MD

I attended a Population Health conference this summer where a number of representatives from large health systems and physician organizations convened to discuss common challenges. Many of my healthcare colleagues assume that anything that carries the label “Population Health” must relate to health disparities and food deserts. While we do address these topics, the vast majority of sessions and conversations had one underlying theme: lowering the total cost of care.

In rebuttal to any charges that our group is far too corporate to be considered a fair example of Population Health advocates, even the Institute for Healthcare Improvement addresses the importance of managing costs with the third part of the Triple Aim stated as “reducing the per capita cost of health care”.

Whether it is from Medicare or commercial ACOs, the Efficiency metric in CMS’s Value-Based Purchasing program, or the continued push from commercial payors for bundled payment programs, health systems and provider groups are beset by demands regarding cost. Unfortunately, at this conference, and in most groups trying to meet the demands of Population Health, one key stakeholder group is often absent: Specialists.

If cardiologists, spine surgeons, and hospitalists cannot become engaged with Population Health principles, moving the cost needle will be very challenging, if not impossible. I believe there are ways, however, to engage specialists in providing efficient care.

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Is Obamacare Dead?

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By STEVE FINDLAY

“It’s dead. It’s gone. There’s no such thing as Obamacare anymore. It’s no longer – you shouldn’t even mention.”

— President Donald J. Trump  October 17, 2017

Not so fast, President Great-Again. First off, this is an obviously and flatly false statement. But also, don’t look now but Congress and the Trump administration itself are haltingly and chaotically moving to enact bipartisan legislation to stabilize the ACA exchange marketplaces for 2018 and 2019.

Importantly, passage of such a measure would get the ACA through the 2018 mid-term elections, although it’s unlikely that any legislation will tamp down the long-running and fierce debate about the fate and future of the law.

The primary aim of the bipartisan effort is to get funding for cost-sharing reduction (CSR) payments on the budget books. The payments, which go to health insurance companies, lower deductibles and co-pays for millions of low-income people.

They are the subject of a long-running legal dispute, which entered a new phase on Oct. 25 when a federal judge in California rejected an urgent appeal by 18 states to compel the Trump administration to continue making the payments as litigation continues. Trump announced earlier this month he would cease reimbursing insurers for the assistance, which insurers are required to deliver.

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Super Macranomics

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By KIP SULLIVAN

This is the second of a two-part series on MedPAC’s October 4 decision to recommend the repeal of the MIPS program. In Part One , I gave the MedPAC staff credit for urging the commission to support repeal of MIPS, and I criticized their irrational proposal to replace MIPS. I said MedPAC is stuck in a vicious cycle – they recommend “reforms” without evidence, and when the reforms don’t work, they recommend evidence-free tweaks that don’t work either. I referred to this vicious cycle as a “tar pit.”
In this essay I attempt to explain how MedPAC created this intellectual tar pit. I begin by describing the three most important “reforms” in MACRA – pay-for-performance, ACOs, and “patient-centered medical homes.” Then I review the decisions MedPAC made, starting in 2003, that led them to endorse those “reforms.” We will see a pattern: MedPAC adopts “reform” proposals based on opinion, not evidence, and MedPAC never works out the details of their evidence-free proposals but instead foists that responsibility on Congress or CMS.

The three pillars of MACRA

If I were asked to explain MACRA (the Medicare Access and CHIP Reauthorization Act) to someone who wasn’t familiar with it, I would start like this: “MACRA imposes a pay-for-performance (P4P) scheme on all doctors who participate in Medicare’s fee-for-service program. This program is called the MIPS program. Doctors who want to escape the MIPS program must join either an ACO or a ‘patient-centered medical home (PCMH).’”
Those of you who are familiar with MACRA will have noticed that I left out the handful of small-bore “bundled payment” programs that doctors could enroll in to escape MIPS. But those programs apply to relatively small pools of patients with specific diseases, not patient populations in the tens of thousands as ACOs and PCMHs do.

If you accept my summary description of MACRA, then you must also accept this statement: If P4P, ACOs, and “medical homes” don’t work, MACRA can’t work.

P4P must work at the level of the individual doctor if MIPS is to work, and it must work at the group level if ACOs and “homes” are going to work as advertised. [1] And ACOs and PCMHs must work if doctors are going to have some place to run to escape MIPS, and if Medicare is going to save money on the ACOs and PCMHs that doctors are expected to run to. Not one of the three nostrums essential to MACRA’s success – P4P, ACOs, and PCMHs – has worked (they do not lower costs and have mixed effects at best on quality). Yet MedPAC enthusiastically endorsed all of them.

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My 14 Year Old Cancer Patient May Be Addicted to Opioids. What Do I Do?

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By JULIE KIM, MD

I’m a pediatric oncologist, but cancer is not always the most serious problem my young patients face. Currently one of them, a 14-year-old boy, his mother, or both may be opioid addicts. I may be enabling their addiction.

Tragically, their situation is not unique. Adolescent patients are at risk for addiction from opioid pain medications just as adult patients are. But pediatric patients are overlooked in this war against opioid addiction. No policies protect them or those caring for them.

Usually pain is short-term, and only limited opioids are needed. Most providers, including those caring for children, are trained in acute pain management. Patients and providers are also protected by policies limiting the prescribed amount of opioids for acute pain.

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ACOs: An Act of Faith, Theory, Hope, or Evidence? What Do the Data Say?

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By ROSS KOPPEL and STEVE SOUMERAI

The recent Health Affairs Blog piece by Chernew and Barbey (October 17, 2017) provides a helpful theoretical summary of the various ways ACOs might achieve savings—even if modest or still latent. But their analysis of the empirical literature, including the CMS innovations, gives us little confidence that even these small savings are real or will emerge. It is astonishing there is little or no critique of ACO studies’ limitations that generally bias the findings toward the apparent (but miniscule) savings.

Two Critical Methodological Flaws:

  1. ACOs generally volunteer to participate based on their pre-existing capacity to “manage” care. These organizations are then compared to non-volunteer organizations that are less likely to game the system and are destined to perform worse than volunteers.
  2. These studies fail to incorporate the costs of forming and maintaining ACOs. These creation and maintenance costs alone would alter the calculations and may sink them.

It is no wonder the majority of Pioneer ACOs have dropped out of the program. It seems clear they were not saving money. In fact, the arrangement put Dartmouth Hitchcock—associated with the developer of the ACO concept—at financial risk.

Other, similar studies (such as the Massachusetts’ Blue Cross/Blue Shield reports on alternative payment models), have similar methodological limitations, including volunteer bias and significant shifts in the participant population over time.

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I Refuse to Tell You What to Eat

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By MICHEL ACCAD, MD

A recent tweet from JAMA, the journal of the American Medical Association, urged me andother doctors to “include nutrition counseling into the flow of [our] daily practice.”

Along with the tweet came a link to an article that outlines “relatively small” dietary changes, based on the latest Dietary Guidelines for Americans, that can “significantly improve health.”

My response to the tweet was swift and knee-jerk.  I will not do it.  I simply will not.  I refuse to follow dietary guidelines or recommend them to my patients.

“What are you saying?!” “Are you the kind of self-interested doctor who only treats disease and cares nothing about prevention?!”  I imagine my outraged critics erupting in a chorus of disapproval.

Is my reaction unwarranted?  After all, the recommendations themselves seem sensible enough:  Eat fast food less often; drink fewer sugary sodas; consume more fruits and vegetables.  What’s not to like?

Unhealthy guidelines

I don’t know.  Perhaps it’s dietary guideline fatigue.

For more than 40 years, the nutrition experts have instructed us with guideline after guideline, food pyramid after food pyramid.  But what have they got to show for?  The obesity epidemic followed the introduction of dietary recommendations, and some doctors even blame those recommendations for causing the epidemic!

The blame may be far-fetched, but there’s something un-natural and perhaps even unhealthy about dietary guidelines.

Take the recommendations in the JAMA article.  Even though the authors claim that only “small steps” need be taken, the whole message occupies 2 pages of fine print.  What’s more, the doctor is supposed to start the process by asking patients to fill out a questionnaire.  Who has the appetite for yet another questionnaire?!

The recommendations themselves come in the usual manner of adding or subtracting “servings:” increase vegetables by one serving per day; decrease sodas by one serving per day; replace one serving of crackers with one handful of nuts, etc…

But why think about meals in terms of discrete servings of food and beverage stuff?  A meal is one thing, one experience.  To break it up into physico-chemical or caloric components makes sense for laboratory animals, and perhaps for patients with serious metabolic disorders.  But does it really work for most human beings in their natural environment?

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