Using the MSSP ACO Model to Become Involved in Alternative Payments

The Medicare Shared Savings Program (MSSP) is providing a way for physicians to get involved in alternative payments as Medicare moves to replace fee-for-service, explained Hymin Zucker, MD, chief medical officer of the Triple Aim Development Group.

The move away from fee-for-service means physicians will now have to move from “providing the minimal amount of service” to more comprehensive care, Dr Zucker said during his session at the Fall Managed Care Forum presented by the NAMCP Medical Directors Institute, the American Association of Integrated Healthcare Delivery Systems, and the American Association of Managed Care Nurses and held in Las Vegas, Nevada. Dr Zucker shared lessons learned from being hired to go into accountable care organizations (ACOs) that aren’t making money to determine if they should continue and how they can make money moving forward.

Unfortunately, the transition to value-based care doesn’t work well if the physicians aren’t on board. However, the benefit of the MSSP is based on improvement over previous performance.

“There is no better way to get into an alternative payment model for a primary care doctor than to join into the MSSP, specifically in an accountable care organization,” Dr Zucker said. “However, the message is very difficult to deliver.”

When it comes to the meeting quality outcomes and measurements, physicians have to be good at making the diagnosis and reporting it, and primary care physicians (PCPs) to do this better than anyone else, he said.

The PCP is the only person able to truly impact the cost of discharge and reduce readmissions because of a simple visit to the primary care office. As a result, Dr Zucker said, the focus should be to ensure that the PCP gets to see the patient.

PCPs looking to work for or join an ACO need to understand and believe that they can make a difference in this new care environment, and ACOs need to realize that change starts at the visit between the PCP and the patient. Experience with managed care, pay for performance, and the patient-centered medical home are not really necessary for success, he said.

“The point is that: just believe it’s a good time to change now,” Dr Zucker said. “The truth really is, once you understand fee-for-service is dead, and you want to know, you have a little bit of leeway to learn this [new model of care] and a good student can learn this.”

It’s important that the healthcare organization gets physicians who want to learn and believe in the change, he added. Even looking at ACOs that could be considered failing based on their performance, almost all of them have about 20% to 30% of their physicians who are doing well if you look at the performance of physicians separately instead of as a whole.

“So one of the biggest things that I do, and that we need to do, is we need to show physicians that there are people who are doing it right,” he said. “The point is that a competition of physicians is probably the most successful thing you can do to get physicians working.”

Risk contracting in the new value-based care environment requires the ability to sort population data to define risk readiness, Dr Zucker said, which includes:

1. Beneficiary retention
2. Patient access
3. Workflow/office operations
4. Quality/outcomes
5. Cost and utilization management
6. Patient experience/engagement

However, there is plenty that can be done proactively without waiting for the data.

“We don’t need metrics to know things would be going wrong if doctors weren’t answering the phone at night and that things would be going wrong if every office was closed on Friday,” Dr Zucker explained.

Looking at emergency room (ER) data afterwards, the physicians who weren’t open on Friday and didn’t answer the phone at night had much higher ER visits, he added. All it takes is making a change, but physicians continuously do the same thing even though it’s not working.

As part of his proactive approach when going into struggling ACOs, Dr Zucker surveys for risk readiness, introduces population health dynamics—ie beneficiary retention, appropriate access, ER reduction program, readmission reduction, and transition of care—and sets expectations for expense reduction.

As part of the survey, he gauges existing ACO practice patterns and has found that 40% of PCPs didn’t know what an ACO was and the same proportion had answering machines directing patients to the ER if there was an emergency. Furthermore, 60% of PCPs only worked 4 days a week. Afterwards, 40% of PCPs had increased their same-day appointments and worked 5 days a week, and 45% had improved their current on-call process so that a PCP answered the phone during non-office hours. The result was decreased ER visits, increased patient retention, and increased quality metrics.

“The big data analysis, all that data is really nice to give after [physicians] know why they want it,” Dr Zucker said. “Giving it to them first is basically useless.”