AJMC's ACO and Emerging Healthcare Delivery Coalition: First Live Meeting Coverage

The American Journal of Managed Care hosted its very first ACO and Emerging Healthcare Delivery Coalition meeting in Baltimore, Maryland, on April 17-18, 2014. The 2-day event engaged coalition members as they discussed important issues surrounding accountable and patient-centered care delivery models.

Marketplace Overview and Real-World Perspectives

The opening session was presented by Ira Klein, MD, MBA, FACP, chief of staff, office of the chief medical officer, national accounts clinical sales & strategy, Aetna, Inc, and Anthony D. Slonim, MD, DrPH, CPE, FACPE, executive vice president and chief medical officer, Barnabas Health, and executive director, Barnabas Health ACO North and Central Jersey ACO.

Dr Klein opened with a discussion that analyzed the findings of a survey performed by The American Journal of Managed Care and Health Research & Analytics (HRA), both part of Intellisphere, LLC. The brief survey was sent to 41 ACO Coalition members, including Johnson & Johnson, Aetna, Walgreens, and the National Pharmaceutical Council. Findings centered on everything from the challenges they faced with collaboration to some of the innovative solutions they have implemented within their ACOs.

Dr Klein suggested to audience members that the survey was used as a “map” by which speakers could guide the conversation on topics that audience members had the most interest in. The poll asked Coalition members to rank, on a scale of 1 through 5, the most important topics in 4 categories:

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Patient Experience—Patient engagement was ranked as the most important aspect to “progress collaboration in activating patient interest to engaging them long term” (2.6/5). Patient satisfaction was ranked least important in this category by survey takers (0/5).

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Quality—Survey takers ranked “quality metrics” (2.7/5), followed by “enhancing care management” (2.2/5) as the top 2 important under quality topic discussions.

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Cost/Financial—Contracting was deemed to be the most important for members (5/5), but cost-effectiveness (2.6/5) and value-based reimbursement (2.9/5) were not far behind.

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Data Technology—The most significant results here were what was found to be not important by survey takers. This included “tracking measures” (4.2/5). Dr Klein noted that most survey takers seemed not to care about sharing data as much as they did about sharing information.

Overall, Dr Klein determined that one of the most crucial and beneficial aspects of the Coalition and of the meeting was that every life cycle of the ACO presents a variety of opportunities and challenges. With such a diverse group of members from organizations such as ACOs, pharmacies, and insurers, members are able to share their unique experiences and learn from one another.

ACOs and the Evolving Healthcare Marketplace

Anthony D. Slonim, MD, DrPH, CPE, FACPE, Barnabas Health, provided a very thorough analysis of ACOs and how they function. With an estimated one-third of care offering little to no value, Dr Slonim said that many want to know what the value proposition of an ACO is, and what it will mean for patients. The value proposition says that value is subject to quality as it relates to total costs of care. To increase value, one must improve quality or lower costs. Value decreases when quality is reduced or costs increase.

Dr Slonim explained that current care models can be chaotic in non-hospital settings. To improve managed care settings, beyond controlling costs, organizational processes must be reengineered and health- system employee roles must be clearly defined. ACO models have been perceived as a potential solution to ensuring that doctors practice better, specifically when dealing with a panel of patients.

ACOs also offer a variety of payment/reimbursement models, including shared savings (both 1-sided and 2-sided risk models), bundled payments, partial capitation, and global payments. An ACO’s structured network can allow physicians to take risks with payment models where they might not otherwise be able to do so in other care delivery settings.

As an ACO matures, its priorities will change, as will the opportunities within the industry. Dr Slonim suggested that many within ACOs simply are “learning as they go.” Additionally, he recommended that the doctor-patient relationship remain front and center in all that ACOs do. As the healthcare landscape evolves, conversations amongst health professionals such as those at the ACO Coalition meeting will be needed to determine the best path to successful ACO management.

Healthcare Delivery Implementation Strategies

Ed Cohen, PharmD, FAPhA, Walgreens, presented a session that focused on WellTransitions, a Walgreens program which “bridges gaps in care by supporting patient recovery through several hospital-to-home transition steps.” These steps aim to reduce patient readmissions, increase patient satisfaction, and lower the costs of overall care.

Patients who participated in the program were:

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46% less likely to have an unplanned readmission

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26% less likely to be readmitted with non-CMS—targeted con- ditions, while those with CMS–targeted conditions were 55% less likely to be readmitted

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44% less likely to be readmitted under age 65 years, while those age 65 years or older were 48% less likely to be readmitted.

Dr Cohen provided a study which took place at DeKalb Medical Group, which partnered with Walgreen pharmacists to increase patient education about their medication following a hospital admission. The collaborative pharmacist-hospital relationship enabled DeKalb to improve its Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) score, which monitors patient satisfaction, just 90 days after it was initiated. In fact, they reported a 26% relative increase in HCAHPS domain score. Dr Cohen stressed that Walgreens functions not as a vendor at DeKalb, but as a department of hospital system operations.

“We don’t want to be looked at as an outside vendor, we want to be looked at as another department in the hospital, so we work really hard to integrate, we have our staff go through all of the orientation as though they were an employee at the hospital, so we are really proud about that,” said Dr Cohen.

With nearly 1 in 3 patients nonadherent to the medications that manage their disease, health systems require treatment programs supported by a collaborative team to ensure patient wellness and healthy outcomes.

ACOs: Key Functions & PCMH Support

Paige Cooke, National Committee for Quality Assurance, defined an ACO as a provider-based governing body responsible for the provision of resources to meet the triple aim. It is supported by stakeholders that include payers, purchasers, pharmacy, and ambulatory care sites. The foundation of building any strong ACO model, she said, is the patient-centered medical home (PCMH).

She provided 2 testimonials that described the ACO experience. The first group was Bon Secours Virginia Medical Group. Bon Secours achieved savings in the first year of participation in the CMS Medicare Shared Savings Program, with enterprise-wide electronic medical record use, early adoption of the medical home model, and other patient engagement initiatives.

She also shared the example of the Montefiore Medical Center in New York, a group which also integrated patient engagement as well as implementing “innovative nurse-driven interventions that supported patient outcomes and experience.”

Ms Cooke noted that the PCMH model is the fastest growing delivery system innovation in the United States. As of March 2014, there were 7118 PCMH sites throughout the country. The National Committee for Quality Assurance (NCQA) ranks several PCMH quality standards on a score-based scale. PCMHs can help:

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Enhance access and continuity

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Encourage team-based care

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Identify and manage patient populations

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Plan and manage care

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Track and coordinate care

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Highlight performance measurement and quality improvement.

In 2014, there were various quality-standard updates to team-based care, behavioral health, and measuring costs. Ms Cooke noted that ACOs can provide valuable resources to support the delivery of patient-centered primary care including access and coordination of patient management.

“One of the most important concepts that ACOs need to embrace is that the patient-centered medical home model is an evolutionary one, it’s one that is designed to align with the growth and evolution of what is happening in health reform,” said Ms Cooke. She praised NCQA’s PCMH Recognition Program, which provides accolades to those ACOs and PCMHs which demonstrate success with implementing evidence-based practices within their health systems.

Real-World Best Practices: Financial Structures, Quality Measurement, Medication Management

Kelly Conroy, Palm Beach Accountable Care Organization (PBA- CO), LLC, provided insight into experience with managing patients at the PBACO. CMS accepted the group on July 1, 2012. As with other accountable care models, PBACO focuses on a triple aim of care, which includes improving the patient experience, improving population health, and decreasing per capita healthcare costs. Additionally, as a member of CMS’s Medicare Shared Savings Program, they are able to be rewarded for achieving specific quality and cost-saving benchmarks.

Ms Conroy noted that initial implementation was difficult. They had to put pressure on the community stakeholders, like hospitals,to buy into the accountable care model. It was difficult to convince providers and doctors that transitioning from the fee-for-service model to and ACO was not only possible, but the financially responsible and logical choice. It was important to reach out to physicians and let them know that their contributions were making a difference once they agreed to join PBACO’s efforts.

“We created this outside component of competition with our community stakeholders pushing on the doctors, and eventually, the doctors started answering the phones, and then eventually, the doctors started to appoint a point of contact in their office to get it,” said Ms Conroy. “And then, after they made $22 million or saved $22 million, then they got really interested in doing things.”

They quickly discovered that patient satisfaction was key to improving outcomes. Even something as a simple as a follow-up call was found to improve the patient experience. As a “low-tech” ACO, PBACO still found ways to engage patients in their care plans. She provided the example of their In-Form‐A‐Doc document which allows the patient to document health concerns and questions in between visits. She noted that it is important to keep track of patients and to treat the same patients prospectively assigned in the beginning of year as at the end of a tracking period. Still, patient engagement and outcomes can be improved, even solutions are low-tech.

“Patient engagement: I see a lot of ACOs went really high-end; patient portals, all kinds of patient engagements. We went very, very low end,” said Ms Conroy. “We used the Medicare opt-out letter that you have to send to patients as a good way to start talking to the patients, and it turns out once the physician had that conversation with the patient, the patient wants to save Medicare, wants to work closer with the doctor, and it made them feel good.”

Achieving Quality in ACOs: Are They Ready to Maximize the Value of Pharmaceuticals in Patient Care?

Kimberly Westrich, MA, director for health services research, National Pharmaceutical Council (NPC), said ACOs intertwine quality and cost-effectiveness like yin-yang.

“We’re moving to an ACO world, a value-based world,” she said, and changing to a different reimbursement model provides the opportunity to develop a strategic framework “where lowering costs and raising quality can really be merged.”

There is also a large opportunity for pharmaceuticals, and the collaboration between the American Medical Group Association, Premier Health Alliance, and NPC has been focusing on just that. These partners seek to develop and implement a framework that will define the role of pharma in ACOs, and how that will aid in the success of meeting financial targets and quality benchmarks. They have considered several recommendations which include a reduction of the “one-size-fits-all” mind-set in medication therapy management.

“We heard about silos this morning, that’s the way the system is currently built,” said Ms Westrich. “One part of really optimizing medication value is getting out of that silo world, thinking about the resources as being a pooled thing that we can access, not silos; medications are something that in many conditions can help cost offsets.”

Aside from de-siloing care systems, Ms Westirch recommended moving away from the one-size-fits-all approach by using composite risk to identify the patients who may require an intervention, and putting into place a system of checks and balances to ensure that patients—especially those with chronic diseases—are receiving optimal care. These quality checks will also certify that there are not incentives that inappropriately lower costs.

Health providers should also assess how “ready” pharmaceutical companies are to enter an ACO arrangement. After identifying existing gaps in care, they can develop a partnership with pharma companies that improve patient outcomes. Pharmacists will ultimately play an important role in many ACOs’ success if the infrastructure can be built.

How to Decrease Cost While Improving Quality and Safety: Medication Therapy Disease Management Program

As a pharmacist, Michael A. Evans, BS, RPh, said that his organization—Geisigner Health System—has taken a risk by imple- menting pharmacist-run disease management clinics. Mr Evans suggested that clinical pharmacists are the “drug experts” who can teach pharmacology to everyone in a system, including physicians, physician assistants, and nurse practitioners. They also work with physicians and utilize electronic health records (EHRs) to coordinate patient care. He said that while there remains a challenge with coordinating care with retail pharmacies, Geisigner has already begun to explore ways to close that gap.

The organization’s medication therapy disease management program (not to be confused with CMS’s definition of medication therapy management, or MTM) includes 51 pharmacists in 47 locations. It focuses on anemia management, pain therapy, heart failure, geriatrics, and several other conditions.

“In our process—prior to the patients being referred into the program—their adherence to medications was about 50% of the time; the normal population that we see across the country,” said Mr Evans. “But once we start managing the patient, we’re touching them, we get the patient on a therapy that they accept, we get the patient on a therapy that’s not causing them side effects, [and] we get them on a therapy that the patient is willing to accept the burden of the cost. Patients now will become adherent to the therapy 81% of the time.”

Pharmacists can improve adherence rates and increase medication cost savings by having a role in a patient’s continuum of care. For instance, he said, a patient may be prescribed a medication, but there is no way to ensure they are taking it as prescribed. Patient questionnaires and EHR documentation are just some of the ways that pharmacists and providers can monitor patient activity and prevent adverse drug reactions.

“Remember, we’re touching these patients 1.44 times per month. Primary care, they’re not touching that often, or the specialist, they’re not touching the patient that often, nor do we want them to be touching them that often, right? We want the physicians practicing at the top of their license, seeing patients and diagnosing conditions, referring the patient over to the pharmacist for their care. Patients love it; you can see the satisfaction. Satisfaction surveys are greater than 95%,” said Mr Evans.

Overall, Mr Evans said that the pharmacy and the pharmacist are integral resources in accountable care models. Data integration and management, combined with effective communication, will be key as well.

Accountable Care Organization Best Practices in Specialty Pharmacy

Michael Baldzicki, CRCM, executive vice president of industry relations and advocacy for Armada Health Care, said there are a variety of innovative opportunities for collaboration with new delivery models like ACOs. Specialty pharmacy is a new segment for most participants, but it is quickly becoming an area of strategic focus. Technology has played a large role in boosting the importance of specialty pharmacies, especially as biosimilars may impact cost utilization management techniques.

“Specialty pharmacy has evolved from a more lick-and-stick game to now a service-oriented program initiative, so a lot of these specialty pharmacies are trying to prove their value stake not only to the payer, but also to the manufacturer, and really hone in on key therapeutic areas, saying, ‘I’m going to be good at these 4 things, or maybe 1 thing because I’m a local specialty pharmacy and I’m going to be really good at hep C,” said Mr Baldzicki. “And that’s where they’re sitting, kind of putting their anchor, to really put their stake in the game, not only get into the payer network, but work with local physician groups.”

There are a variety of opportunities for specialty pharmacy. One is that they have the capability to share and integrate data analytics. They also can offer and integrate disease management therapy programs. They can even enter risk-sharing agreement contracts with ACOs. By collaborating, specialty pharmacies can improve outcomes for ACOs, including in hospital readmissions, quality metrics, and overall adherence.

Mr Baldzicki noted that health reform and other shifts in care will impact the exact partnership that specialty pharmacy will have in accountable care models.

“A specialty pharmacy model really entails their relationship with the physician. Most physicians have about 2 or 3 likable specialty pharmacies that they really refer to, and then, patient care management programs and guidelines and protocols all focus around cost,” he said. “So again, there’s a lot of opportunity where specialty pharmacies can come into the game and really integrate... it’s just how, when, and where.”

Our Healthy Perspective: Healthcare Transformation Through Accountable Care

Bob Kropp, MD, MBA, CHIT, regional medical director for Aetna, put it simply: the status quo cannot be sustained. The current health system is wasteful due to disorganization, fragmentation, and incoordination. The Institute of Medicine has identified drivers of the waste inside the system, and those include unnecessary services, higher-priced services that are necessary based on site of service, duplicate care, and administrative services.

He likened the patient experience with the health system to going through a maze where no 2 pathways lead to the same outcome. Payers, Dr Kropp said, are able to provide solution that can make this system work better.

To make changes, providers must be incentivized to make decisions that will allow the system to function differently than it does today. Plan members must also be incentivized and be provided with opportunities to make different choices within the healthcare system.

“Our mission is to create an environment, a relationship with our ACOs, that addresses the drivers of waste within the system, and allow you folks to do the things that we’ve been hearing about all day today that are the right things to make the system work better,” said Dr Kropp.

Aetna’s strategy focuses on 4 main areas:

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Creating an environment where incentives are aligned

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Identifying inconsistent delivery of care and unnecessary services

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Addressing episodic and reactive care

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Technology, especially as it relates to provider-payer communication.

“So our strategy involves incentives, information, different kinds of interventions, and innovative technology that we offer in various combinations. And the combination or the solution that we offer is really based on the concept of collaboration,” said Dr Kropp. “Rather than coming in with a one-size-fits-all kind of strategy, which you usually associate with managed care, our philosophy is that we have recognized that the community is at different stages of maturation, has different needs at different times. Our overarching philosophy here is to be a partner wherever the physician organization is.”

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