Medicare Shared Savings ACOs: Crystal Run Shares Lessons Learned

Change isn’t easy, especially when it affects how much you are paid for services rendered. But the writing on the wall is clear: the fee-for-service model, especially for Medicare patients, is slowly but surely disappearing into the Affordable Care Act sunset. What’s a physician to do: work more and get paid less?

Instead of adopting a wait-and-see attitude, a group of primary care physicians and specialists dove in headfirst, tackling the steep learning curve to become a National Committee for Quality Assurance (NCQA)-recognized accountable care organization (ACO). Just 18 months after being named a Medicare Shared Savings Program (MSSP) ACO, Crystal Run Healthcare, located in Middletown, New York, about an hour northwest of Manhattan, has become a model, functioning ACO that provides value-based care for patients.

In a session entitled “Medicare Shared Savings ACOs: One Organization's Initial Lessons Learned,” delivered May 4 at the meeting of the Healthcare Information and Management Systems Society (HIMSS) in New Orleans, Louisiana, Gregory A. Spencer, MD, FACP, describes how Crystal Run Healthcare became one of the nation's first Medicare Shared Savings Program ACOs and the lessons learned in the process, as well as challenges, infrastructure requirements, and necessary competencies.

Why did the multi-specialty practice elect to take this path? Physicians have a choice, Spencer says.


Gregory A. Spencer“You can keep getting paid fee for service, and it will be like a death spiral, doing more and more and making less and less: You don’t want to be like a vendor on an assembly line, getting paid to do a thing. You don’t want to be a colonoscopy salesman.”

— Gregory A. Spencer, MD, FACP


 

Laying the Groundwork

A seven-member physician group when it started in 1996, Crystal Run Healthcare is now made up of 300 providers in 15 locations including an ambulatory surgery center, urgent care, diagnostic imaging, a sleep center, and a high complexity laboratory.

More than half of the patients in the area—designated as a high expenditure area in the Dartmouth Atlas—used to go to New York City for their care, enabling the organization to grow rapidly. “This lack of out-migration has allowed us to grow large,” Spencer explains.

It became a Joint Commission-accredited practice in 2006, and an NCQA-designated Level III patient-centered medical home (PCMH) in 2009, a key component of ACO success. In April 2012, Crystal Run Healthcare became a single-entity ACO participant in the Medicare Shared Savings Program, with 9,762 attributed beneficiaries receiving 82% of their primary care services within the ACO.

Clearly, Crystal Run had quite a bit of the necessary infrastructure in place before it became an ACO. You can’t turn a switch and become an ACO, Spencer says. “You have to do things for quite a while and get people on board to know what to do in order for it to work well,” he adds. “We’ve been preparing this ground for a long time.”

Getting Started

Crystal Run elected to take the NCQA-accredited path to becoming an ACO, quite a bit more rigorous than what is required by the MSSP. Core competencies include:

• infrastructure to coordinate care, improve quality, and patient experience,
• sufficient numbers and types of providers,
• access to a PCMH,
• the ability to collect, integrate, and use data for care management and reporting,
• timely sharing of information, and
• a performance improvement program that measures and reports

At the outset, everyone in the health care group—including patients—needs to know the goal of the ACO, which is to provide value-based care. Patients especially need to know why it’s being done and that it’s good for them. “Value-based care is not about money. It’s about improving quality and eliminating waste. If you frame it in those terms, it is much more palatable for everybody,” he says.

Leadership Is Key

For an ACO to succeed, there must be buy-in and commitment at the top, Spencer says. It takes finances and time. “If there is not a concerted effort, you are going to shoot yourself in the foot, because you will be doing things that don’t align with your payors or your contracts,” he says. “Just putting ACO on your stationery is not the same as an all-in effort.”

Reporting directly to the COO at Crystal Run are two co-chief clinical transformation officers, two well-respected partner physicians who are implementers. They have dedicated time blocked that is devoted to developing value-based care. They are empowered to make decisions to get things done, Spencer says.

Some of the ACO initiatives implemented by the co-chiefs include:

  • Education on value-based care and the medical home emphasizing a team mentality. “You can’t do it by yourself,” Spencer says. “Involve everyone along the way.”
  • A non-revenue-based reward system to increase the percentage of compliance with clinical quality metrics, meeting attendance, and timely completion of charts. All of these actions affect the quality of care, Spencer says.
  • Development and coordination of a best practice council. The co-chairs assemble best practice council representatives from involved specialties where they review current literature accepted by the council. Decisions on what practices will work for Crystal Run are made and posted on an internal intranet to make them accessible to all providers.
  • Oversight of the FLOG (a play on the word blog) internal website, which is a venue for communication where providers can post a question to a specific specialty. Once a question is posted, the specialist designated to maintain the FLOG for his/her specialty will enter a response in a timely fashion. All providers who signed up for the service receive an email notification that a new post has been created. Urgent issues are discussed by phone in the usual manner.

Infrastructure Requirements

Managing patient data is both a challenge and a key competency for an ACO. In fact, getting access to claims data was one of the reasons Crystal Run chose to participate in the MSSP. Their information technology infrastructure incorporates homegrown dashboards and surprisingly low-tech Excel spreadsheets.

“There is something to be said for getting it done and getting it out, even if it may not be as pretty and the UI is not as cool as it could be,” Spencer says. “Most of these things identify gaps of care in patients…which is creating registries, a fancy term for a list of patients who have a condition [and] have a care gap, meaning something that needs to get done.”

The organization did, however, invest in a system to make sense of the raw claims data they receive from Medicare. “Raw claims data is non-intuitive, you do need some sort of system to put it into actionable information, and we did do that,” he says.

Other key IT pieces include a homegrown quality measurement system and a patient-facing portal. “In our next phase, there will be more of a push to get patients online,” he says.

A foundational infrastructure element is the medical home, Spencer says. Crystal Run developed a website that is broken down into four geographical groupings of primary care providers that are considered the medical home. Individual physicians within the MH coordinate care, and make sure that families are in the loop, and that specialists know what is going on, he adds.

The MH mechanism not only helps the group manage the patients the physicians see, but also the patients who haven’t made appointments in a while. It makes you aware of all of the patients under your care, Spencer says.

A key clinical infrastructure piece implemented by the co-directors of care transformation is what they call a CARETEAM—including traditional caseworkers, nurse practitioners, and others—which is embedded in the MH and in the hospital to which Crystal Run refers to ensure patients’ quality of care. Nurse practitioners get a list of patients that providers identify and often visit the patients’ homes a few days after treatment, sometimes providing continuous home monitoring through telemetry if necessary. In about a third of these visits, the patient’s care needs to be adjusted or increased.

 

Accountable Care Organizations: What Providers Need to Know

On October 20, 2011, the CMS, an agency within the HHS, finalized new rules under the Affordable Care Act to help doctors, hospitals, and other health care providers better coordinate care for Medicare patients through Accountable Care Organizations (ACOs).

ACOs create incentives for health care providers to work together to treat an individual patient across care settings, including doctor’s offices, hospitals, and long-term care facilities. The Medicare Shared Savings Program will reward ACOs that lower their growth in health care costs while meeting performance standards on quality of care and putting patients first.

An ACO refers to a group of providers and suppliers of services (for example, hospitals, physicians, and others involved in patient care) that will work together to coordinate care for the Medicare Fee-For-Service patients they serve. The goal of an ACO is to deliver seamless, high-quality care for Medicare beneficiaries, instead of the fragmented care that often results from a Fee-For-Service payment system in which different providers receive different, disconnected payments.

The ACO will be a patient-centered organization where the patient and providers are true partners in care decisions.

Source: Fact sheet from the Department of Health and Human Services, Centers for Medicare & Medicaid Services (CMS). Accessed July 14, 2013: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/ACO_Providers_Factsheet_ICN907406.pdf

Digging Into Claims

One of the first things Crystal Run received from Medicare was a breakdown of where patients live, Spencer says, as well as benchmark information on quarterly aggregate expenditure and utilization. Crystal Run sometimes had to wait for the data, but it was revelatory in demonstrating where patient leakage was happening. “I am saying this as a provider not a payor, but leakage is important,” Spencer says. “A lot of your patients, even if you see them once a month, will go places you had no idea they were going.”

Claims data also are helpful in identifying high-risk patients. “Know who the frequent visitors are and keep tabs on them,” Spencer advises. He also recommends knowing which patients have congestive heart failure, chronic obstructive pulmonary disease, and poor diabetes control, and using actuarial models available from insurers to understand costs associated with these patients.

General claims data analysis proved a game changer for Crystal Run. In response, Crystal Run re-evaluated rehab practices, a high cost center, and excess expenditures on laboratory tests. Once standardized practices were put in place and overall costs for tests were shared with group members, the issues were resolved.

Variation Reduction

Variation reduction played an important part in cost reduction by eliminating waste. Targeting one medical specialty at a time, a council within the group decides on a best practice standard, IT analyzes its use and compares the use among physicians, and then the variation is analyzed again. For example, Crystal Run did a Diabetes Variation Reduction Pilot comparing Q3-Q4 2010 versus Q3-Q4 2011, with the following results:

√ Provider cost for diabetes management reduction: 7%
√ Laboratory cost reduction: 15%
√ Radiology cost reduction: 53%
√ Total cost for diabetes management reduction: 9%

Setting up the ACO is a “fairly low risk way of learning how to do value-based care,” Spencer says. “The hope is that we will be like the payor in a few years, and we’ll have the whole pie, but we’ll know what to do with it. We’re not hoping to knock it out of the park and make twice as much money as we made before. We think we’ll do better because we have things in place that will help, but realize that there is going to be a downward trend nationally.”


Deborah Hauss is a contributing writer for Health CXO.