Better Integration to Improve Care Outcomes Highlighted at AJMC's ACO Coalition

Finding the right way to address a patient’s condition before it worsens will ultimately lower the cost of healthcare—and it seems like the healthcare industry is now getting on board with that notion. “You do the right thing, at the right time, at the right dose with the right patient … and the total cost of care goes down, not up,” said Leonard M. Fromer, MD, FAAFP, from Group Practice Forum. “Even if the cost of the treatment might be a lot of money.” Over the course of 2 days, attendees at the spring live meeting of the ACO & Emerging Healthcare Delivery Coalition, presented by The American Journal of Managed Care, not only heard case studies, panel discussions, and presentations that highlighted how better integration and more coordinated care can improve quality of care while lowering costs, but also shared their own best practices.

Integrating Behavioral Health

With ACOs accountable for both the health and the cost of the population they serve, integrating the behavioral and medical components of health is a necessity. “Unless you address both the medical and behavioral, you’ll have poor outcomes,” said Roger G. Kathol, MD, CPE, of Cartesian Solutions, Inc, and the University of Minnesota. Only 25% of people with behavioral health problems are seen in the behavioral health sector, which means that 75% never have access to evidence-based care. The vast majority of patients seen in the primary care setting receive either no treatment or ineffective treatment, he explained, which provides a tremendous opportunity to better address the needs of those with behavioral health issues seen in the medical setting.

For ACOs, there are a few options for how to handle behavioral health: do nothing and eat the cost when patients have poor outcomes, buy traditional services that people are proven to not use, or build behavioral health services inside the ACO. In his workshop, John Santopietro, MD, outlined the virtual care model being used by Carolinas HealthCare System. Instead of co-locating 1 social worker in each practice, the system adapted the model by deconstructing what the provider does and recreating that as a virtual team of providers that includes the call center clinician, a care manager, a behavioral health coach, a pharmacist, a therapist, and a psychiatrist. “If you do it that way, you can deploy [the team] much more effectively,” Dr Santopietro said.

The early results from the program have found a decrease in depression and anxiety scores, and a decrease in glycated hemoglobin, total cholesterol, and low-density lipoprotein cholesterol. The biggest hurdle to getting the program off the ground was not hesitation on the part of the patient, but that from psychiatrists.

“But we’re getting out of the world where psychiatrists were concerned and didn’t want to do it,” Dr Santopietro said. “More and more, they are getting trained in telepsychiatry.”

Precision Medicine and ACOs

During his keynote presentation, Dr Fromer explained that precision medicine is a fundamental piece of the accountable care movement. The benefit of precision medicine is that caring for patients LAURA JOSZT, MA Coverage from the 2016 Spring Live Meeting of the ACO & Emerging Healthcare Delivery Coalition™ held April 28-29, 2016, in Scottsdale, Arizona. ajmc.com 6.16 / 63 becomes less expensive when healthcare zooms into classes of patients, he said. Medications may be more expensive, but “the big picture cost” plummets only by improving the health of the individual and keeping them well.

Oncology is the biggest and earliest adapter, and stakeholders in that space have begun to create nomograms that use an alpha-numeric code to describe something unique about the patient: genetic makeup, tumor makeup, comorbidities, social environment, etc. “To know which drug will work best first, and not hunt and peck, that’s where you save money—a lot of money,” Dr Fromer said.

Where this all ties into ACOs is through the idea of being proactive with the population being cared for. Dr Fromer added that he expects to begin seeing quality measures move precision medicine forward. “Precision medicine quality measures—they’re coming,” he said. “It will follow, not lead. It will be there because it will be a natural output from aligning the payment model in general.”

The Future of Healthcare

Clifford Goodman, PhD, of The Lewin Group, moderated a panel discussion between Michael E. Chernew, PhD, of Harvard Medical School; Patricia Salber, MD, MBA, of The Doctor Weighs In; and Bruce Sherman, MD, FCCP, FACOEM, of Buck Consultants, A Xerox Company. They discussed the future of healthcare in the United States, including the sustainability of the Affordable Care Act (ACA), the impact of the presidential election on healthcare delivery, employer coverage, and maintaining cost of care in the era of innovation.

The panel kicked off with a discussion on Medicaid expansion. Dr Salber noted that it is difficult to separate the decision to expand the program from the politics and she added that since the implementation of the ACA, resistance to expanding the program has begun to deteriorate. She also expects to see more and more states agree to expand Medicaid. Dr Chernew echoed this sentiment, explaining that the ACA was designed to have very strong incentives for states to agree to expand.

“I think that if the election moves in a direction that it looks like the ACA will not be repealed at the federal level, you will see a lot of states move to [expand Medicaid],” he said. “If it looks like it’s really here to stay, you’ll see more states expanding.”

According to Dr Sherman, from an employer standpoint, expanding Medicaid has been a good thing. After all, if people have the money to pay for healthcare, the employer stands to benefit. Expanding Medicaid potentially helps to mitigate some of the disproportionate share of costs that employers cover because of charity care, he added. One of the biggest challenges to the ACA may not even be the politics and the threat of a Republican president repealing the law. Healthcare spending continues to grow, and if the United States cannot get the healthcare delivery system working in a more sustainable way, then the ACA may collapse under its own weight when the country can no longer afford the level of subsidies included in the law, explained Dr Chernew.

Dr Salber then shifted the conversation over to drug pricing. Although there has been development of life-saving, life-altering therapies, they come with huge price tags that the health system hasn’t figured out how to deal with just yet. She expects to continue to see innovative drugs and the pharmaceutical industry continuing to increase the cost of those treatments. Nevertheless, how those drugs are handled in the insurance benefit design could have huge ramifications, she added.

“If all of those things end up fourth tier with huge coinsurance or huge deductibles, there will be a situation where if you have money you can survive, but if you don’t, you will get chemotherapy instead of targeted therapy,” Dr Salber said. “In that part of healthcare we could see a widening disparity.”

Dr Chernew pointed out that regardless of the public sentiment around drug pricing, it has been well established that there is a relationship between profitability and innovation. And while it can be debated whether that relationship should be there, it is. “I think that the fundamental challenge that healthcare faces is that innovation is universally considered good, but it’s something we continue to struggle to finance,” Dr Chernew said.

Telementoring in Oregon

In Oregon, there are some unique innovations taking place regarding healthcare delivery. The state is home to coordinated care organizations (CCOs), which are essentially ACOs, but specifically for Medicaid. These CCOs are charged with the responsibility of ensuring that healthcare delivery change is driven by providers and to improve quality of care. In order to do so, Health Share of Oregon has invested in Project ECHO, a telementoring program that connects specialists with primary care providers.

The basic idea of Project ECHO is to “demonopolize the specialist’s knowledge,” explained Mark Lovgren, director of telehealth services at Oregon Health & Science University. The program runs for 40 weeks and includes 15- to 20-minute didactic presentations delivered by specialists and real-time case-based presentations from primary care providers who are struggling with specific situations. The expert team of specialists are able to provide recommendations to the primary care provider who is struggling with how to care for a specific patient.

“The idea is that through repeated exposure to these difficult cases, everyone participating will feel more comfortable with them,” Lovgren explained.

It does take a few weeks for providers to feel comfortable when participating in the program to open up and share a case, he added. After all, when a provider shares a case, he or she is asking for help, which isn’t always easy for them to do.

“The secret sauce is your facilitator and team,” explained Christine Bernsten, senior manager of delivery system transformation for Health Share of Oregon. “You can get the cookbook to implement [Project ECHO], but you need the facilitators who are good teachers and they are kind and supportive of the providers participating in [the program].”

Voluntary ACO Accreditation

Although ACOs are by no means new, few so far have sought accreditation in the way that patient-centered medical homes have. Michael Massey, MD, chief medical officer at BSWHA, related why Baylor Scott & White Quality Alliance (BSWHA) decided to become one of just a handful of ACOs that are accredited.

The main reason for seeking accreditation is to evaluate an organization’s ability to delivery coordinated, patient-centered care; improve clinical quality; enhance patient experience; and reduce costs, Dr Massey explained. In addition, accreditation, although voluntary, identifies which ACOs are likely to be good partners.

BSWHA sought its accreditation through the National Committee for Quality Assurance, which assesses organizations on 65 elements across 7 categories: ACO structure and operations, access to needed providers, patient-centered primary care, care management, care coordination and transition, patient rights and responsibilities, and performance reporting and quality reporting.

In a panel discussion following his presentation, Dr Massey said that seeking accreditation allowed BSWHA to see where it had gaps and what it had to work on to become better. The organization went through the same issue when it sought accreditation for its patient-centered medical home.

“We thought we had it all covered and then we found we had a huge problem with access,” he said.

Dennis Scanlon, PhD, professor of health policy and administration and director of the Center for Health Care and Policy at the Pennsylvania State University, explained that accreditation programs are good for the sake of providing an internal assessment. However, he was skeptical about the idea that getting accredited could be a differentiator among ACOs.

Lysette Cournoyer, a consultant, said that ACO accreditation is likely to follow the precedent set by patient-centered medical homes, which started with just a few getting accredited and grew.

“For providers, it helps them start with something,” she said. “It gives them guidance. A lot of times you go into systems that are burdened by their own data and this helps them know where to start.”

Transitional Care Management

With 18% of patients readmitted within 30 days of hospital discharge and 50% of those readmissions being preventable, transitional care management can save billions of dollars each year. Further, providers are being incentivized to follow best practices that reduce unnecessary readmissions.

Megan Hunt, MD, PGY3, and Luke Peterson, DO, PGY3, both from Banner University Medical Center, discussed how their program formalized a protocol and utilized 2 specific reimbursement codes in order to decrease hospital readmission rates, decrease emergency department visits, and increase clinic revenue.

The 2 new codes—99495 and 99496—significantly increased reimbursement compared with the older, comparable codes from $223 to $356 and from $300 to $501, respectively. Dr Peterson explained that they built the protocol for patients when they leave the hospital based on those 2 codes with the hope to exchange an expensive hospital with a reimbursed clinic visit.

The transitional care protocol requires that when a patient is discharged that an inpatient team member makes an appointment within 2 weeks. The lead medical assistant calls the patient to confirm the appointment, review discharge instructions and medication and if there are nay questions, an inpatient team member calls the patient or if it is a difficult case, then a case manager follows up. And even if the lead medical assistant calls but is unable to make contact with the patient, they need to document that 2 attempts were made in the chart.

In the small pilot study that they ran, Drs Hunt and Peterson’s group found significant reductions in readmissions and emergency department visits. In addition, they saved almost $200,000 from their inpatient service and increased revenue by $25,000 by billing with the new codes. “This additional revenue pays for the [medical assistant]’s salary that is making all the calls,” Dr Peterson explained.