Tag Archives: Accountable Care Organization

ACOs and Value Based Care: The Best of Times Or The Worst of Times? It Depends!

By Fred Goldstein, MS and Gregg Masters, MPH

This past year has seen major changes to the Medicare Shared Savings Program (MSSP) that launched the huge growth in Accountable Care Organizations (ACOs) a principal workhorse in the transformational copy of the Affordable Care Act (ACA).  It seems that the Center for Medicare and Medicaid Services (CMS) and the industry had a difference of opinion as to how successful ACO’s were under the original model, and of course CMS won.

The argument had to do with just how well the ACOs involved in the Medicare Shared Savings Program Track one participants were doing.  For those new to this, the Track 1 model were the least risky model, with most ACOs choosing this upside risk or shared savings only track which had a term of six years before they had to begin taking on two sided risk.

CMS looked at the 2016 data and was seeing limited savings particularly with the overwhelming majority of participating ACOs enrolled in this track. In May of 2018 Seema Verma (CMS Administrator) hinted at a new approach pointing to a study by Avalere that ACOs not only did not save money, but they have increased federal spending by $384 million, versus a projected $1.7 billion in net savings from 2013 to 2016. Couple this concern with the ongoing debate on whether Medicare Advantage Plans (MAs) are still costing the Treasury (via over funding or “up-coding”) vs. advancing the needle on the Triple Aim (better experience of care, better outcomes at lower per capita costs).

Of course, the industry, led by the National Association of ACOs (NAACOs), were completely against this decision and stated that the ACOs had indeed saved money when they reviewed the 2017 results, which indeed showed net savings of $314 million dollars. NAACOS also stated that if these changes were made many ACOs would quit , pointing to a survey they had conducted showing that 71% of the ACOs in track 1 would quit if they had to take on 2 sided risk.

But by then it was too late and in last December CMS announced their new Pathways to Success models with the following by Seema Verma:

…the presence of an “upside-only” track may be encouraging consolidation in the marketplace, reducing competition and choice for Medicare FFS beneficiaries. While we understand that systems need time to adjust, Medicare cannot afford to continue with models that are not producing desired results.

The key changes were as follows:

  • Only 2 years before ACO must accept down-side risk
  • Beneficiaries notification of ACO participation at 1st primary care visit
  • Payment for tele-health services
  • Incorporates regional spending into ACO targets
  • Authorizes termination of ACOs with multiple years of poor financial performance
  • Could potentially save $2.2 billion in Medicare costs during the next 10 years

The new tracks and their “glide path” are as follows:

So what does this mean for ACOs?

What better place to figure this out than the Florida Association of ACOs annual meeting. Florida has been leading the way in ACO participation and performance and while this conference is in beautiful Orlando Florida in the fall, the attendees and speakers are national so one can get a full view of the impact and what’s working.

For an update on market conditions including an overview of the annual conference from FLAACOS CEO Nicole Bradberry, listen here.

Florida Association of ACOs

Attending the 2019 FLAACOs annual conference you’ll hear from Aneesh Chopra, President, Care Journey and former CTO of the United States opening the conference, followed by, you guessed it, a panel on MSSP ACO and Pathways to Success with Sheila Fusé, Vice President, Policy and Payment Models Navvis Healthcare, Kelly Conroy, Executive Director Holy Cross Physician Partners ACO, Travis Broome, Vice President for Policy and ACO Administration, Aledade a technology enable physician practice management company who recently reported some rather impressive results for 2018 from their network of clients ACOs.

The conference will then dig deeper exploring such topics as the new CMS primary care contracting models, Social Determinants of Health (SDoH), Direct employer contracting 2.0 and mental/behavioral health from a rather packed agenda.

So, join us November 7th – 8th in Orlando Florida to network and learn from those getting it done in the ACO world.

For registration details, click here.

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Is Text Messaging being Overlooked as an Engagement Tool in Healthcare?

 

the-holy-grailImproving the consumer’s engagement in their health has become the holy grail; we’re all searching for it. It seems every week some company is coming out with a new app, system or program claiming they’ve developed an incredible engagement tool that will finally get people involved in their health. Most have stumbled.

Could it be that we are overlooking something because it’s just not cool and there are potential HIPAA concerns? That something is SMS text messaging. Think about it, everyone has a cell phone and text is typically unlimited and has become the new way to communicate.

It also turns out, there are some very good studies to support text messaging to be effective and much more likely to be read and responded to than an app, phone call or email. As for HIPAA, there are ways to use a “text first” approach and stay HIPAA compliant.  ken-saitow

Listen to this episode of PopHealth Week  with Ken Saitow of CareWire as he provides insights into text messaging, HIPAA compliance and use cases. He even touches upon seniors and Medicaid, both of whom respond well to text messaging.

 

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Interview with Brenda Schmidt CEO of Solera Health: Creating a Broader Network of Community Providers

At the recent HiMSS 2016 conference in Las Vegas I had the pleasure of interviewing Brenda Schmidt of Solera Health, an Integrated Health Network. Solera connects a nationwide network of community organizations and digital solutions for chronic  disease prevention programs (including the CDC National Diabetes Prevention Program) with technology that manages service referrals, reimbursement and payment, aggregates data and reporting simplifying enrollment and supporting increased consumer engagement and choice.

 

 

 

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Will we get to 50% Value Based Payments by 2018

Here was my response to the question from Xerox Healthcare at the recent HiMSS conference “Will we get to 50% value based payment by 2018 as stated by CMS?”

 

Thanks to Xerox Healthcare for the opportunity to provide my thoughts.

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PopHealth Week Month End Wrap-up: Healthways, Fitbit, Oschner, Aledade & Anthem

by Fred Goldstein, Gregg Masters and Douglas Goldstein

Listen to the episode here:

 

In our second month end ‘news/e/um‘ style PopHealth Week Review this Wednesday June 24 at 9 AM PT/12 PM ET we’ll feature hot topics in the news. Our regular panel of Fred Goldstein @fsgoldstein, Gregg Masters @2healthguru and Doug Goldstein @efuturist will identify newsworthy stories and offer commentary along the way. The initial slate of stories in the news includes:

  • Healthways revised guidance
  • Fitbit’s IPO and Garmin’s lawsuit
  • Ochsner Health System
    • What they are getting, news about Apple Watch – Chronic Care Management
    • News B4 the Release – what they are working on the “New Mission Control”
  • The physician led ACO management company Aledade’s VC raise
  • Insights from the Personalized Medicine Coalition Study
  • Anthem’s sparring bids for CIGNA (and Aetna’s pursuit of Humana) Could the ‘Big Five’ be reduced to the ‘Big Three’?

Here’s some background:

Healthways: A Perenial Disappointment?

 

This company just reported revised downward guidance and their stock was hammered.  Last month, on May 18th their longtime CEO Ben Leedle stepped down and last year a group of dissident sharedholders filed to take over the Board, though they ultimately came to an agreement with a few of them joining the Healthways Board.  As one of the largest population health companies, with unique programs like Silver Sneakers, the Gallup-Healthways Well-Being Index, and relationships with Blue Zones and Dean Ornish, how can they miss?  Well the irreverent 3 have some thoughts you don’t want to miss this.

We’re sourcing our discussion from recent news: ‘Healthways Revises Financial Guidance for 2015‘ and Healthways (HWAY) Stock Sinks on Lower Full Year Revenue Guidance

Fitbit: The Wallstreet Darling of the Wearables Industry?

Fitbit went public, Woohoo! Lets take a walk as we discuss: 

  • the opportunities for wearables
  • Fitbit’s first day pop (can you say JUMP) you know, we can get them to exercise, but hey its only the first month, is it sustainable?; and
  • the recently announced Garmin lawsuit (what? So they hired employees from a competitor….. but maybe… they took more than their minds with them)

The company narrative is here, and recent discussions found via CNBC ‘Fitbit soars 20% on second trading day

The good here, and some questions, here and here. And then there’s the ‘always-in America’ litigation angle via ‘Fitbit Sued by Jawbone for ‘Plundering’ Employees, Secrets‘ with all the gory details of the complaint here.

Ochsner Health System: The New Normal?

Doug Goldstein recently visited Ochsner Health and has some interesting insights to bring us. Perhaps more interesting is this announcement:

 

Ochsner Health System First in Nation to Manage Chronic Disease with AppleWatch

We all know how much buzz the product (better yet, platform) has produced in the digital health and exploding apps market, we’ll lean into the real world implications for its deployment to population health via Ochsner’s first mover vision inside their EHR.

Select Highlights:

…it’s not about the wearable – it’s about the “new mission control” being built into the EPIC workflow that will change how doctors support patients in life, fitness, health and healthcare.’ Douglas Goldstein

Aledade: The Physician Led ACO Management Company “ACOcor” Revisited?

Aledade just completed a $30 million series B raise, see; ‘Bethesda health tech company raises $30 million‘. What implications if any can we draw from this continuing investor confidence in the approach and ‘secret sauce’ enabling the transformation of the U.S. healthcare ecosystem from volume to value? What does this say about the ACO market writ larger and the continued embedding of the ACA’s moving parts as the new normal for American healthcare? For discussion of this milestone event, see: Leading the Transformation: Aledade’s Growth authored by Aledade CEO Farzad Mostahari, MD.

Themes: ACOs continue their market penetration, and the need for physician led ACOs can only be expected to continue to grow as well. Someone need fill that void. Aledade intends to be a front runner.

ACA repeal types are increasingly irrelevant and the King V Burwell trial decision –  which could hit this week – is likely to only affirm the continued availability of Federal subsidies language issues notwithstanding.

Physician led ACOs are another shot at the bow of traditional hospital system led innovations including any ACOs the sponsor.

Personalized Medicine Coalition Study 

Most of us have heard about the 17 year time-line for innovation to transfer from ‘bench to bedside’ into mainstream medicine. Clearly in days past, we could tolerate such a delayed ‘on-ramp’. Yet in the Internet age, with M0ore’s Law and the explosion medical information and informatics, plus opportunities for crowd sourcing and the connected global village are within the means of anyone carrying a smartphone, laptop of PC, such a delay is unacceptable.

Yet, there’s more in the way of innovation uptake. A recent study by the Precision Medicine Coalition outlines some of these concerns, particularly as it relates to ‘alternate payment models’ (APMs):

‘..as APMs continue to develop and these, and other alternate models are proposed, it will be important to consider what effect changing incentives and payment systems will have on the decision by interested stakeholders to invest in personalized medicine. The Report concludes that “if new incentives begin to hamper access to personalized medicines in a meaningful way, the ability to invest in research and development of highly personalized therapies and diagnostics will likely shift to align with the inflexible payment systems.”

“Understanding the dynamics and challenges facing the industry as payors move toward APMs is the first step to ensuring that these therapies can continue to be developed and made available to patients. This Report is an important first step to raising the awareness of these issues as payment models continue to evolve.’

Practical Impact or ‘Reading the Tea Leaves’

As the challenge of integrating the promise of precision medicine (utility of biomarkers and better understanding of disease pathology and associated risk management opportunities) informing and guiding to day to day lifestyle (including health) choices, another potential uptake inhibitor are the hoops payors or risk bearing organizations may require before deeming the application of such technology to better patient outcomes. So in a way, it’s not just about tech innovation adding value to medicine and healthcare, but also the bureaucracies we create to protect the public while stimulating innovation.

PM remains an on the come potential to current medical practice. The theory is compelling, but the 17 year bench to bedside standard is not likely to step aside any time soon. Perhaps incentives [and compelling outcomes studies] can accelerate an otherwise glacial pace of [tech transfer] adoption.

Anthem’s Determined Dance to Acquire CIGNA

Are we revisiting the Big 6, then Big 4, and ultimately fill in the ____ of the too big to fail accounting firms [RIP Arthur Anderson’ but now squarely laid at the feet of America’s Health Insurance Industry market leaders….

This is a story on a number of levels! See: Anthem continues $47B Cigna takeover battle and Anthem offers $47 billion to buy Cigna.

Themes: Is health plan consolidation the antidote to counter the recent and persistent wave of hospital, health system and medical group mergers? One CEO’s post merger standing in way of merger. Will investors stand by and watch a premium bid sit idle?

Bottomline? Might market consolidation for price leverage (and oh yeah, scale and operating efficiencies) enable the construction of a virtual single payor (or Ellwood vision of “SuperMeds”) via acquisitions or arrangements? Is this scale required by ACA as some opine? Or just more opportunity to generate fees and exit packages for senior executives? When has scale reduced costs?

So pull up a chair, get out on a walk, put on your headset, and tune in to PopHealth Week!

 

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