Strengthening primary care has been a core goal of health care payment reform over the past several years. Primary care physicians are the cornerstone of the health care delivery, directing billions of dollars of follow-on care. With better support, the models presume, primary care doctors could guide their patients toward a better health, direct them to the right care when needed, and in so doing, bring down unnecessary medical costs. Moreover, especially if coupled with payment reforms that can support better coordination with specialist practices, these reforms can provide an alternative to health system employment and health care consolidation, thus buoying competition in local markets.
The most recent effort toward this goal lies at the heart of the recently announced Comprehensive Primary Care Plus (CPC+) program. This program doubles down on the kinds of “medical home” payment and delivery reforms that were the hallmarks of previous Medicare initiatives, most notably the Comprehensive Primary Care Initiative, which in its first two years showed significant improvements in some dimensions of quality – but so far has generally failed to show reductions in overall costs significant enough to offset the per-member per-month (PMPM) payments to primary care practices to support their reforms. While some medical home payment reforms have shown both savings and outcome improvements, overall results have been mixed particularly in Medicare, with the result that the CMS actuaries have not yet “certified” any such medical home model as leading to overall spending reductions.
This would mean that in less than three years, around a quarter of a trillion dollars of health care spending would be made to providers who are being compensated not for ordering more tests and more procedures, but for delivering better outcomes – keeping patients healthier, keeping them out of the hospital, and keeping their chronic conditions in check.
This shift will address a central problem of the US health care system, one that lawmakers and policy experts on all sides of the issue agree is a key contributor to runaway medical inflation.
The logic is straightforward: by simply paying for the volume of services delivered, every provider has a strong incentive to do more — more tests, more procedures, more surgeries. And under this system, there is no financial incentive to maintain a comprehensive overview of patient care – to succeed by keeping the patient healthy, and health care costs down.
We launched Aledade on June 18th, and by the end of July we had recruited 80 primary care physicians in 4 states to join us in creating the very first Aledade ACOs. We have been work together ever since- but haven’t been able to talk about our wonderful practices until the official notification from CMS that came today.
We are thrilled to announce that beginning January 1, our two newAledade ACOs will be taking accountability for the care of over 20,000 attributed Medicare patients, and stewardship of nearly a quarter of a billion dollars of health care expenditures each year. We’re building a new delivery system on the foundation of trust between patients and the physicians who have been caring for them in their communities for decades, and enabled and accelerated with cutting-edge technology and analytics.
One ACO will operate in the state of Delaware, in close collaboration with our physician partners and our field team, Quality Insights of Delaware. Our second ACO, the Primary Care ACO, will take the same model spanning three states — New York, Maryland, and Arkansas, where we are also working with local partners like the Arkansas Foundation for Medical Care. Our hand-picked ACOs physician partners are some of the most capable and inspiring primary care physicians in the country. They are leaders in their local, state and national physician associations; they are pioneers of Meaningful Use and Patient Centered Medical Homes; they are much-decorated top doctors in quality; but most of all, they are the pillars of their communities.Continue reading…
On June 18, we launched Aledade – a company built on our belief that independent primary care physicians are best positioned to lead the next revolution in health care delivery – boosting quality of care and bringing down costs. Over the past six weeks, we traveled across the country meeting doctors, discussing the future of independent primary care practice, and recruiting physician partners for our first wave of Accountable Care Organizations.
Meeting these doctors, from areas and backgrounds as diverse as the populations they serve has been a constant reminder of the reasons we founded this company. One physician, having spent decades serving the same community from the same office, lamented that in the past, he felt more involved – and more informed – about all aspects of his patients’ care. Today, he told us, fragmentation in care delivery had given him less insight into his patients’ health, and less influence in coordinating their treatment.
When we started Aledade, these were the type of doctors we wanted to empower.
Today, I am elated to announce that we have formally submitted applications to the Center for Medicare & Medicaid Services to form ACOs serving physicians in Delaware, Maryland, New York, and Arkansas for 2015. We expect this first wave of Aledade ACOs to serve tens of thousands of Medicare patients beginning January 2015.
The choice of four dissimilar states was intentional. We intend to establish a model that can be replicated across the country, and the diversity in our practices matches the diversity of our country. Each state has strengths to build on. Delaware- ‘the First State’ has been a leader in electronic health record implementation. Maryland and New York’s health reforms set the stage for alignment and collaboration with acute-care facilities. Arkansas’ tradition of independent primary care practice is strong. We’ll also be serving very different patient populations in each state – from practices that serve urban neighborhoods to those that treat folks in small towns and rural communities.
Like many participants in the Medicare Shared Savings ACO Program (MSSP), Family Health ACO is sailing in uncharted waters.
All ACOs are facing significant challenges in better understanding patient utilization patterns, identifying high-risk patients, and implementing care coordination strategies.
Even more unique is that Family Health ACO (“Family Health”) is composed entirely of federally qualified health centers (FQHCs). FQHCs are community based organizations that provide critical primary and preventive care for millions of underserved and uninsured Americans, regardless of their ability to pay.
Nationwide, there are over 1200 FQHCs serving the health care needs of the working poor, the unemployed, the undocumented, and anyone else in need of primary medical care. Family Health provides care to over 200,000 patients and spans nine counties in New York State; from the bustling streets of New York City to the rural landscapes of the Hudson Valley.
Collectively the ACO includes 120 physicians, 60 advanced practice nurses and physician assistants, and nearly 100 dental providers.
These organizations have a strong history of collaboration, including their first venture in 2008 to form the Hudson Information Technology for Community Health (HITCH). HITCH enabled the organizations to pool resources and work collaboratively on cancer screening and diabetes management outreach programs.
The ACO partnership is helping to further strengthen the ties between these three community-based health care organizations and their communities.
Several of the provisions included within the Affordable Care Act in 2011 designate Accountable Care Organizations (ACOs) as formal, contractual entities.
However, in the real world ACOs come in a variety of shapes and sizes.
When compared to larger, hospital-sponsored ACOs, rural and small physician-led ACOs face a tough challenge, because despite limited resources they need to come up with substantial upfront capital and infrastructure investment to establish a strong ACO foundation.
To help ease this burden, 35 ACOs were selected to participate in the Advanced Payment Model ACO demonstration through a grant program from the Center for Medicare and Medicaid Innovation (CMMI). The grants provided a portion of upfront capital to determine whether or not this financial assistance would help ease the startup burden for smaller ACOs, and increase their success rate.
One of those 35 organizations includes the central Florida-based Physicians Collaborative Trust ACO, LLC (PCT-ACO). They are participants in the January 2013 Medicare Shared Savings Program (MSSP) ACO cohort, along with 106 other ACOs.
Larry Jones, PCT-ACO’s CEO, describes his personal mission as an effort to “preserve and protect the independent practice of medicine.” For over 25 years he has been advocating for physicians through their efforts to organize, negotiate with health plans, and other challenges.
As noted in a previous post, shifting to an accountable care model is a long-term, multi-year transition that requires major overhauls to care delivery processes, technology systems, operations, and governance, as well as coordinating efforts with new partners and payers.
Participants in the MSSP program are also taking much more responsibility and risk when it comes to the effectiveness and quality of care delivered.
Given these complexities, it is no surprise that MSSP’s first year results (released January 30, 2014) were mixed. The good news? Of the 114 ACOs in the program, 54 of the ACOs saved money and 29 saved enough money to receive bonus payments.
The 54 ACOs that saved money produced shared net savings of $126 million, while Medicare will see $128 million in total trust fund savings.
At the time, CMS did not provide additional information about the ACOs with savings versus those without.
While a more complete understanding of their characteristics and actions will be necessary to understand what drives ACO success, the recent disclosure of the 29 ACOs that received bonus payments allows us to offer some preliminary interpretations.
Over the next few months, Jacob Reider will serve as the interim National Coordinator for Healthcare IT while the search continues for Farzad Mostashari’s permanent replacement.
What advice would I give to the next national coordinator?
David Blumenthal led ONC during a period of remarkable regulatory change and expanding budgets. He was the right person for the “regulatory era.”
Farzad Mostashari led ONC during a period of implementation when resources peaked, grants were spent, and the industry ran marathons every day to keep up with the pace of change. He was the right person for the “implementation era”
The next coordinator will preside over the “consolidate our gains” era. Grants largely run out in January 2014. Budgets are likely to shrink because of sequestration and the impact of fiscal pressures (when the Federal government starts operating again). Many regulatory deadlines converge in the next coordinator’s term.
The right person for this next phase must listen to stakeholder challenges, adjust timelines, polish existing regulations, ensure the combined burden of regulations from many agencies in HHS do not break the camel’s back, and keep Congress informed every step of the way. I did not include parting the Red Sea, so maybe there is a mere human who could do this.
What tools does the coordinator have in an era of shrinking budgets?
At present, Meaningful Use Stage 2, ICD-10, the Affordable Care Act, HIPAA Omnibus Rule, and numerous CMS imperatives have overlapping timelines, making it nearly impossible for provider organizations to maintain operations while complying with all the new requirements.
In the wake of the National Coordinator’s announcement that he is departing, there has been a flurry of tweets, blog posts, impromptu online polls, and conjecture about the most likely successor. To date, none of these conversations has resulted in a thoughtful assessment of the set of characteristics that would represent the ideal candidate, nor has there been any thorough review of the most likely candidates in the context of these attributes. The need for a rapid transition to a successor is well understood by all – yet there has been no indication that the Obama administration is in a hurry. Let’s hope that we can evolve them toward a greater sense of urgency. The fragility of ONC – and the importance of its health – can’t be overlooked.
Let’s consider some history:
The first two National Coordinators, David Brailer and Rob Kolodner, were appointed before ARRA. The agency was small, focused largely on certification (through CCHIT), standards (through HITSP) and policy. When ARRA arrived, David Blumenthal, a thoughtful, deliberate, policy-savvy internal medicine physician from Boston was brought in to lead the rapid expansion of health IT that was facilitated by the HITECH Act.
ONC expanded under Blumenthal from a team of ~ 30 people to a team of >100 in the two years that he was at the helm, and the agency published the 2011 certification criteria regulations, and collaborated with CMS to publish the regulations that defined stage 1 of the Meaningful Use incentive program. The policy foundation was that the three-stage program – to be implemented over six years – would evolve the nation’s care delivery system by causing adoption of EHR technology (stage 1) and then exchange of clinical information electronically (stage 2) and finally improved clinical outcomes (stage 3).
Farzad Mostashari, who joined Blumenthal as the Deputy National Coordinator early in Dr Blumenthal’s tenure, was quickly named as Blumenthal’s successor when Blumenthal announced his resignation in the Spring of 2011. Both Mostashari and Blumenthal pushed hard for Mostashari’s appointment – so that the consistency, focus and forward momentum of the organization could be maintained.
And so it was. Under ARRA, adoption of EHRs has skyrocketed. The CMS MU Stage 2 regulations and the ONC 2014 certification regulations were published, and the size of the agency has doubled to over 150 people. Recognizing the need for experienced partners to assist him in leading a larger agency – and growing national reliance on health IT and an essential component of the care delivery ecosystem – Mostashari hired David Muntz as the “Principal Deputy” (essentially the COO of the agency), Jacob Reider as Chief Medical Officer (leading a team of clinicians focused on quality and safety) and Judy Murphy as the Deputy National Coordinator for Programs and Policy (adding internal coordination support for ONC programs).
An unfathomably complex entity such as a health system grows over time like a city. Right now, communications and data usage in the US healthcare system is a bit like a medieval town, with new streets and squares popping up in unpredictable places and no clear paths between them. Growth in health information has accelerated tremendously over the past few years with the popularity of big data generally, and we are still erecting structures wherever seems convenient, without building codes.
In some cities, as growth reaches the breaking point, commissioners step in. Neighborhoods are razed, conduits are laid in the ground for electricity and plumbing, and magnificent new palaces take the place of the old slums. But our health infomation system lacks its Baron Haussmann. The only force that could seize that role–the Office ofthe National Coordinator–has been slow to impose order, even as it funds the creation of open standards. Today, however, we celebrate growth and imagine a future of ordered data.
I came here asking two essential questions of people I met: “What data sources do you find most useful now?” and “What data is missing that you wish you had?” The answer to first can be found at a wonderful Health Data All-Stars site maintained by the Health Data Consortium,which is running the palooza.
The choices on this site include a lot of data from the Department of Health and Human Services, also available on their ground-breaking HealthData.gov site, but also a number of data sets from other places. The advantage of the All-Stars site is that it features just a few (fifty) sites that got high marks from a survey conducted among a wide range of data users, including government agencies, research facilities, and health care advocates. Continue reading…