Providers in a Medicare Shared Savings Program have a leg-up on the value-based delivery structure needed to meet quality payments under MACRA.
Hospitals can achieve savings and physicians in these accountable care organizations can earn bonuses for participating in MACRA's merit-based incentive payment system.
"We believe ACO-affiliated doctors do better on MIPS because they're in an ACO," said Caravan Health Senior Vice President of Development and Strategy Tim Gronniger.
But there is more than one road to success and debate is growing about whether ACOs should turn to technologies including EHRs and HIE software or start by focusing on physicians.
How Shared Savings work
The Medicare Shared Savings Program encourages ACOs to better coordinate patient care and reduces healthcare cost.
The Centers for Medicare and Medicaid Services is giving ACOs more of a financial incentive to bear downside risk as an advanced alternative payment model.
As an advanced alternative payment model, ACOs qualify to earn a lump-sum bonus payment equal to 5 percent of their Part B expenditures.
This includes ACOs participating in MSSP Tracks 2 and 3, though those that do not meet qualifying APM participant thresholds are also subject to MIPS.
The ACOs in Track 1 of MSSP do not qualify as advanced APMs, but under MACRA, physicians get the benefit of Medicare employing an APM scoring standard on some performance measures and getting out many of MIPS' reporting requirements.
To add to the some of the confusion over MACRA, this summer CMS gave mixed messages over how seriously it was moving forward with value-based initiatives when it raised the low volume threshold for MIPS, taking some doctors out of the program.
But most clinicians are participating in MIPS. Performance in 2017 affects payment in 2019. If physicians are not participating in MIPS, their compensation is frozen over the next few years, said Gronniger, who formerly worked as deputy chief of staff for CMS.
MSSP is working to save money for about 30 percent of the ACOs in the program.
In 2016, the latest year for program results, 134 out of 432 ACOs in the Medicare Shared Savings Program earned savings of more than a collective $700 million. Another 294 broke even, neither losing nor earning savings.
Persistence pays off
To do well, stay in the program, experts say, for the likelihood of getting shared savings increases with experience. A high benchmark is also a good predictor of achieved savings.
Also, both physician-led and smaller ACOs tend to have higher savings than hospital-led or integrated ACOs, according to a Health Affairs blog.
While some experts said doing well requires going all-in on integration, including having a connected electronic health record, a Scottsdale, Arizona ACO is an example of a large, but physician-focused organization that showed great results without a linked EHR.
Innovation Care Partners in Arizona and its ACO, Scottsdale Health Partners, in 2016 had one of the highest savings rate in the country, achieving more than 9 percent, according to COO Faron Thompson.
The first year of MSSP, in which systems were paid just for reporting, the ACO had a score of 60 percent. The second year it was 92 percent, and in the third year, 97 percent.
More physicians in the health system of about 500 practices are independent rather than employed, Thompson said.
The system is not vertically integrated. And he said, they are proudly not on the same EHR.
What the ACO is, however, is very physician-centric.
To make the lives of physicians easier, the organization built web-based software that has a dashboard and progress charts to replace Excel spreadsheets that weren't always being completed.
"We basically took all of the quality metrics and built it into this front-end, UI (user interface) experience," Thompson said. "It caters to them and their time constraints."
Physicians earn points and gain-sharing distribution for participating in the company's performance objectives.
The provider also has a complex care coordination program that includes medics who are military veterans. The 35-40 care coordinators and about 3,000 patients enrolled in the program form a long-term trusting relationship, Thompson said.
The care coordinators work with patients while they're still in the waiting area of an emergency room, often redirecting them to their PCP for a same-day appointment.
In Arizona, the average readmission rate is 17 percent, Thompson said. Innovation Care Partners has readmission rates of 5 and 6 percent.
The ACO has also made a big investment in health information exchange technology. About 60,000 messages per month are sent to patients.
The ACO is considering becoming an advanced APM.
"It gives an automatic bump on reimbursement," Thompson said. "We're proving we can do this without vertical integration."
The integrated approach
Caravan Health in Kansas City, Missouri, has a reason to believe in integration. The organization saved more than $26 million in 2016 across its 23 ACOs and more than 14,000 clinicians in 47 states.
The average ACO saved nearly $1.1 million.
Every clinician billing under the Caravan Health ACO is projected to have MIPS performance scores above 90 percent in 2017, Gronniger said.
Caravan received a perfect 100 percent quality reporting score in its first year of program participation, and an average year two quality score of 96 percent.
"We help mostly health systems to create clinically-integrated networks," Gronniger said.
The mistake some systems make is focusing on the shared savings rather than the bigger picture, he said.
"They have to figure out how to make this entire model sustainable for them in generating non-fee-for-service revenues," he said.
When they started running an ACO, health system costs went up by 6 percent in the first year.
They hired care managers and set up quarterly care meetings and hired a population health nurse.
The population health nurse set up annual wellness visits.
Annual wellness visits are a missed opportunity for most health systems, Gronniger said. Less than 10 percent take advantage of them, while at Caravan, more than 50 percent of patients are coming in for such preventative care as flu and pneumonia vaccinations.
"That drives up quality score improvements and patient results," Gronniger said. "Annual wellness visits create opportunities for health systems to create a sustainable business model."
The wellness visits create enough revenue to pay for the position of a population health nurse.
Along with the technology and integrated model, Caravan believes that getting physicians involved is key.
Medicare's new chronic care management codes have helped, in paying physicians for work they've been doing without previously earning reimbursements, such as checkups over the phone.
The changes have required significant workflow alterations, Gronniger said.
"It really requires a comprehensive system-wide change effort. It's easy to be middle of the pack," Gronniger said.
ACOs and pop health turning cost curve down
Advocate Health Care in Illinois is also an integrated health system with an ACO, Advocate Physician Partners Accountable Care.
Advocate was ranked second in savings of 432 ACOs participating in the Medicare Shared Savings Program in 2016. It has the experience, having spent four years in the program.
"Our quality scores have improved every year," said chief medical officer Lee Sacks, MD.
Advocate Health Care, the largest participating ACO in the program, saved $60.6 million in 2016 by applying key population health strategies and launching initiatives to better manage chronic conditions, Sacks said.
The total cost of care for Advocate's Medicare population was less in 2016 than it was in 2013.
"We're not just bending the cost curve, we've turned it downward," Sacks said. "It reflects the fact that we're a clinically-integrated network. We're not just focused on Medicare. We have an infrastructure that's been in place for 20 years."
Clinical integration requires the ability to get data and having a critical mass of the business in population health, he said.
"We decreased our inpatient discharges and also had a multi-year focus on better managing post-acute care," Sacks said. "It has reduced the average length of stay by about seven days. At $500 a day."
The system pays for a team of advanced practice clinicians to make the rounds each day to address patient concerns. It reduces readmissions and moves their treatment plan forward, he said.
"For ACOs, it's a journey," Sacks said. "You need to understand the data and where the excess Medicare spend is. It gets hard to say we're going to improve everything."