Panelists Provide Insight on What It Will Take to Truly Move to Accountable Care

So far, most providers and other healthcare stakeholders are reinventing the wheel when it comes to successfully managing a population rather than sharing best practices and learning from others, said David Muhlestein, PhD, JD, of Leavitt Partners, at the beginning of a panel on using new payment models to advance accountable care during The American Journal of Managed Care^®’s Accountable Care Delivery Congress.

Michael Funk, FACHE, CMPE, of Humana, explained that his company’s strategy has been to meet providers where they are and how comfortable they are with taking on risk. Humana is currently managing more than 1000 accountable care relationships, but those relationships are at various stages.

“Not everybody is ready for risk and we’re not going to push anyone there before their time,” he said. “And there may be some provider organizations, and probably will be, that might never make it to the transition to risk. But that path to value space can be just as impactful.”

However, it’s interesting to note that CMS seems determined to close down the track of the Medicare Shared Savings Program (MSSP) where accountable care organizations (ACOs) don’t bear any risk, added Tim Gronniger, MPP, MHSA, of Caravan Health, which helps interested organizations get into MSSP.

The level of knowledge and readiness to take on an ACO varies by organization when Caravan first starts working with a new client, but often there are 1 or 2 people in the organization that are interested in making the change, and they are trying to educate the rest of the leadership team, he explained.

Meanwhile, Oregon has made its own transition to accountable care. The state moved to coordinated care organizations (CCOs), a type of ACO, back in 2012, and during the first 5 years, spending came down compared with Washington State, while access and quality measures were mixed, said John McConnell, PhD, of Oregon Health & Science University.

The state is currently pausing after the first 5 years to analyze what worked and what did not, and then it will begin contracting for CCO 2.0.

“I think [CCOs] are here to stay [in Oregon], at least for the next 5 years, which I guess is a long time,” McConnell said.

While describing the state of payment reform and attempts to make the move to value-based care, Muhlestein tweaked a common analogy describing the healthcare industry as having a foot in 2 canoes, with 1 canoe representing fee-for-service and the other canoe representing value-based care. As he explained it, the better analogy is that healthcare lives in the fee-for-service canoe, but it would like to get over to the value-based care canoe, “if we can figure out a way to get in there.”

Just starting with accountable care contracts isn’t enough, he added. Organizations can’t just have 10% of patients in full risk; they need to have the majority of patients in some risk with enough revenue tied to risk in order to force them to make changes to how they deliver care.

Gronniger added that he didn’t think the market is currently set up to move to something with greater risk. He echoed Muhlestein’s point that business and revenue is currently holding organizations back from making the transition, and former HHS Secretary Sylvia Mathews Burwell was aware of that. As a result, HHS had come up with the timeline of moving 30% of Medicare payments to value-based payment contracts by 2016 and 50% by 2018 in order to present a better business case.

“If you’re better off in fee-for-service, if you will be paid better in fee-for-service or there are higher margins, why would any rational actor move” to value-based payments, he asked.

The panelists also discussed the uncertainty when the new administration changed, with former HHS Secretary Tom Price, MD, backing off of mandatory bundled payments. That decision made people think the administration was “closing the door” on a large-scale expansion, Gronniger said.

However, the current HHS secretary, Alex Azar, is shifting direction again. Muhlestein pointed out that Azar has been more in line with continuing what was started under Burwell—and her belief that Medicare and Medicaid are not just programs to be managed, but that they can be policy levers—than following in Price’s footsteps.

Azar has said that there has to be major federal involvement in order to move the country to value-based care and to improve costs and outcomes, Muhlestein said. “And this is coming from somebody in the Trump administration. He said there will be an ‘uncomfortable level’ of federal involvement for many actors to make them move, because the status quo is just not sustainable.”

Overall, Funk is encouraged by what he has seen, although it is still early in the shift to value-based care. Ultimately, he doesn’t think the models and payment structures that are in place today will still be around at the end of this transformation.

McConnell added that he believes more evaluation for a better understanding of what is working is needed, as well as better rewards for risk-taking. Stalling the move or just doing what has been for the last 10 years “isn’t helpful,” he said.

Muhlestein closed the panel with the suggestion to “change our governance, where we pay our healthcare leaders and reward them for doing more with less instead of rewarding them for doing more, period.”