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A Medicare Shared Savings Program Success Story

September 02, 2015

About a quarter of the ACOs in the MSSP program earned a total of $341 million in payouts. Among them is Delaware Valley Accountable Care Organization, whose CEO shares tips for success.

Quality and financial performance data are in for the accountable care organizations in the Centers for Medicare & Medicaid Services' Pioneer and Medicare Shared Savings Programs, and the results are mixed.

But the spotlight is on the payouts: Eleven of the 20 Pioneer ACOs qualified for performance payments totaling $82 million, and 92 of the 333 MSSP ACOs earned payouts of $341 million.

Established as part of the Patient Protection and Affordable Care Act, the MSSP rewards ACOs that meet certain performance standards on quality and patient satisfaction. It's part of CMS's ongoing efforts to incent healthcare organizations to provide better care coordination for individuals and populations, improve patient outcomes, reduce unnecessary costs, and slow the rate of growth for expenditures.

ACO Model is 'Framework for Collaboration'
While the majority of ACOs in the MSSP did not achieve the thresholds required to receive a shared savings payment, roughly one quarter of them did. Among those is the Delaware Valley Accountable Care Organization, which is based in Villanova, PA, and jointly owned by Main Line Health, Jefferson University and Hospitals, Holy Redeemer Health System, Doylestown Health, and Magee Rehabilitation Hospital.


MSSP ACO Final Rule Released


DVACO president and chief executive officer Katherine Schneider, MD, says the organization provides an important framework for collaboration among the owners that is necessary for success in a value-based reimbursement environment.


Katherine Schneider, MD

It gives providers, physicians, and everyone across the continuum a system and an opportunity to collaborate in a legal fashion that doesn't require everyone to merge or be employed by a health system," Schneider says.

"We are a new breed of Super ACO that gives [the owners] an economy of scale and a regional market presence. It's a good structure to be able to do that, particularly for Medicare fee-for-service where there has not been any way to approach that market. And for most markets, Medicare beneficiaries are a substantial portion of the market share."

A Good First Year
DVACO has been focused on enhancing care coordination, care transformation, and data informatics for its joint partners. And while Schneider says it's difficult to know exactly why its five equity owners were successful in driving down costs last year, she cites decreased admissions as the most likely cause.

"Most of the savings come from reducing acute-care hospitalizations and then other things that tend to be associated with those. If you aren't hospitalized, there is less likelihood for the need for skilled nursing care, ambulance transports, and durable medical equipment, for example," she says. "We don't have 100% certainty, but the signs point to that being the underlying reason for our success in the first year."

In 2014—DVACO's first year in the MSSP—the organization earned a shared savings payment of $6.5 million, placing it "in the top 10 in the country in terms of absolute dollars earned," Schneider says.

"For year one, you get full credit just for reporting on 33 measures, so it's a pay-for-reporting scenario… It's no small accomplishment to go around to five counties, plus some outlying areas and 100 physician offices, and chase down charts, so we are actually thrilled that we could get 100% on the reporting metrics as we were required to."

For year two of the MSSP, DVACO will become accountable for its performance on quality metrics, Schneider says, adding that she is "reluctant for the ACO infrastructure to take too much credit or to rest on its laurels to say we are sitting pretty now."

Looking to the Future

Instead of feeling satisfied with its performance so far, DVACO is pushing hard toward developing more programs to improve outcomes, patient satisfaction, and costs.

For instance, DVACO is using the data it collected in 2014 as a foundation for increasing the effectiveness of primary care office visits.

"One of our learnings from the quality data collection is that there is a lot of opportunity for hard wiring some of the preventive services. For example, we really want to encourage primary care physicians to maximize that annual wellness visit, which is a benefit for Medicare beneficiaries. It's an opportunity for the care team in the primary care office to do some care planning … and address screenings and preventive measures that should be done."

Another key piece of DVACO's plans to transform care delivery, Schneider says, is its regional event notification program, which will provide primary care physicians with much-needed information on their patients.

"We are now on behalf of primary care physicians starting to have real-time notification so the physicians know where their patients are, not just within our hospitals but in all regional hospitals and the black holes of skilled nursing and home care," she says.

"A primary care physician can't coordinate care if they don't know where their patients are. And this is real-time data, not information they are getting three months later from claims data… It's a perfect example of how small data can be hugely valuable because now we start to piece together all these parts of where a lot of the expensive care takes place. But, you can't coordinate it after the fact."
 
The next challenge, Schneider says, is to increase interoperability among DVACO's owners and their employed and independent physicians because they do not all use the same electronic medical record.

"Anyone who has worked in healthcare knows how fragmented the system is, and that is a fundamentally tough nut to crack… DVACO has recently signed a contract with an outside vendor for a population health platform that all teams will [use] to support care coordination," she says.

"Over the next 12 months, we will pull in clinical data in real-time from the EMRs … to close care gaps, track performance, and see where those patients are going but in a much more clinically relevant fashion."

Words of Advice
For those MSSP ACOs that failed to qualify for performance-based payouts, Schneider offers some advice.

"First, I would say to stick with it and don't be discouraged. This is not a light switch that can just be switched on in an instant. This is a long journey that we are all on, and you can't win it if you aren't in it," she says.

"My other advice would be to look at your care models and asked how you have changed care. That is a great litmus test. Go to your frontline doctors, not the physicians on your board, and ask how their participation in your ACO has changed the way they care for patients. If the answer is a blank look, then no wonder you were not successful."

The answer, Schneider says, should include changes such as physicians now having more information about their patients, having the opportunity to work with care coordinators to help patients overcome social barriers to good health, and changing their practice to provide more access to care.

"There should be something that feels different. Success in population health will not be achieved by just continuing with an episode-based care model, but it isn't easy and it isn't going to happen overnight."

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