Medicare Shared Savings Program (MSSP): Track 1 ACO

As the name implies, an accountable care organization (ACO) is held accountable for the quality, cost, and care experience of an assigned population. Through CMS’s multi-track Medicare Shared Savings Program (MSSP) participants nationwide explored the ACO model with Medicare fee-for-service beneficiaries. In Track One, ACOs share savings but don’t incur losses.

Here are two examples.

Crystal Run: Data Accelerates Progress

Physician-owned multispecialty medical group Crystal Run Healthcare was one of the first participants in the MSSP program, joining in 2012 as one important step in its overall journey from volume to value. In AMGA’s webinar series, Chief Quality Officer Scott Hines advised AMGA members to prioritize data and be proactive about making the change from volume to value. “Don’t wait for the market to move and then catch up,” said Hines. “Be a leader in your market because there is a first mover advantage, particularly if risk-based contracts benchmark you in the market.”

By mining claims information, Crystal Run identified three major cost centers: acute and subacute rehabilitation, admissions and readmissions, and overuse of specialists and labs. With these insights sharpening its focus, Crystal Run reconciled in-home medications for the sickest patients, which reduced hospital readmissions, and educated primary providers about the unnecessary use of specialist and labs. In addition, they had patients go to physical therapy prior to surgery to increase strength and flexibility for easier post-op recovery.

With multiple quality measures to report, finite windows of time to do so, and the ever-present possibility of a CMS audit, robust information management is critical to MSSP success. Crystal Run got ahead of the situation by writing the code for data collection over nine months in advance.  The organization had the foundation to do so, as an early adopter (since 1999) of electronic health records and the first New York practice to achieve Joint Commission accreditation. Since Performance Year 1 (PY1) pays for reporting, as long as a group reports data accurately and completely, it will get full credit regardless of their performance. Hines suggests that groups use PY1 to grow their capabilities to perform well on the measures, since PY2 and beyond are pay for performance, and it takes time to build those competencies.

Involving physicians and IT specialists in the effort was key. “It was important to have providers show the business intelligence team where to look in the chart,” Hines said.

Memorial Hermann: Care Integration Delivers Powerful Results

With an estimated 323,000 lives covered by its ACO, Memorial Hermann Health System reported nearly millions in savings in per-employee, per-year claims costs over four years. Meanwhile, its rates for avoidable ER visits and readmissions fell below the averages for the Houston market where the organization operates.

D. Keith Fernandez, Memorial Hermann’s then president, physician in chief, and CMO, credited much of this success to clinical integration.

“Physicians must be integrated on a clinical basis to determine and commit to the right and best ways to practice medicine, commit to mutual accountability, and develop active performance improvement programs to enhance healthcare quality and efficiency,” Fernandez told AMGA members.

As an MSSP participant, Memorial Hermann segmented patients by risk and delivered care based on matching intensity levels: from wellness and prevention programs for healthy patients to chronic disease management, telemedicine, and home visits for the smaller number of sickest (but most costly) patients.

MSSP participation has laid the groundwork for future transformation, he said. “Clinical integration provides the foundation for risk-based contracting, population health management, and an ACO within a hospital or hospital system.” It’s a necessary journey for Texas’ largest not-for-profit health system. “Employers are bearing more risk, turning to providers as allies. They want a reliable product with predictable and stable costs.”

AMGA: Your Partner for Value-Based Care. Contact Bill Baron, 703.838.0033 ext. 336 to take the next step.