Home Feature Building ACOs from the ground up

Building ACOs from the ground up

March 2014

Published in the March 2014 issue of Today’s Hospitalist

AS AMERICAN MEDICINE dives headfirst into launching accountable care organizations (ACOs), hospitals are learning some hard lessons about what it takes to succeed with population-based care and shared risk. And hospitalists, perhaps more so than other specialists, are being thrust into the role of helping to pioneer these new organizations.

Working as a hospitalist for a fledgling ACO can mean many things. For some, it’s still figuring out the basics: How do you identify patients at high risk for readmissions, and who should you partner with outside the hospital? For others, working within an ACO means adjusting to new staffing patterns.

But the good news, according to hospitalists building an ACO, is this: “A lot of what ACOs are asking are extensions of things hospitalists have been doing for many years “utilization, length of stay, the continuum of care and better communication,” says hospitalist Adrienne Green MD, the physician lead on the ACO work being done at the University of California, San Francisco. “This is infrastructure that hospitalists have been talking about, but now, there are much more structured ways to get to it.”

Here’s a look at how four ACOs are changing the way hospitalists work in their institutions “and the lessons that hospitalists are learning about working in new systems of population-based care.

Seton Health Alliance
Seton Health Alliance, a network designed to accept ACO contracts, was one of the country’s first Medicare ACOs. But it is still in the early stages of creating nearly every aspect of the infrastructure needed to manage care. That’s in part because the group’s home base of Austin, Texas, has had virtually no track record of managed care since the 1990s.

The ACO is a partnership between the multispecialty Austin Regional Clinic, which has more than 320 physicians, and Seton Healthcare, with more than a dozen hospitals and around 500 doctors. Norman Chenven, MD, a family physician who is the founder and CEO of Austin Regional Clinic, says the first big step in integrating large organizations like these into an ACO is building connectivity to track patients.

“You need to know where the patients are, how to reach them, how to follow them,” Dr. Chenven says. For a system and a medical community that have deep roots in fee-for-service medicine, he adds, that’s been a big challenge.

To start, the hospital system is “spending an enormous amount of time and energy trying to interface information systems,” he says. “We need to match patients so that we know when an ACO patient hits the front door of the hospital to get a case manager working immediately.”

At the same time, the ACO is working hard to figure out which patients are at highest risk for readmission. But identifying the local conditions and factors contributing to readmissions is proving difficult.

“We used to have our own ways of identifying who is a high-risk patient for readmission,” says Mauricio A. Sardan, MD, one of Seton Medical Center Austin’s 23 hospitalists and the group’s associate medical director. “Now, we’re working to standardize that identification by implementing interdisciplinary rounds.”

The hospitalists are also piloting the use of different scoring systems and checklists to try to identify patients at high risk for readmission. And Seton Medical Center Austin is also collecting data on nearly 1,000 patients to parse out the reasons why patients bounce back.

Finally, ACO leaders are taking a very hard look at post-acute care. Dr. Sardan now leads a new hospital medicine and transitions subcommittee, which includes post-acute and home health care providers, to develop quality measures for sharing information. The subcommittee is focusing on three post-acute areas: LOS, ED utilization and readmissions.

“We need to get patients to the right SNF or nursing home where we have relationships “and where the facility can feed clinical information back into the centralized system,” Dr. Chenven says. “Between 20% and 30% of the cost of care is in that post-acute phase. If you are more efficient inside the hospital, you’re getting people out earlier, but then they need more follow-up on the outpatient side.”

“We are just now starting to try to get our heads around that,” Dr. Chenven admits. “We don’t have it all figured out yet.”

While the University of California, San Francisco (UCSF) is not currently participating in the Medicare ACO program, it has entered into two small commercial ACOs. Its big challenge right now is to tap into the capabilities of its various ACO partners.

That partner list includes Blue Shield of California for an ACO that covers a small population of the city and county of San Francisco employees, and HealthNet for an ACO covering some employees of the University of California. For both ACOs, provider partners include UCSF Medical Center, Hill Physicians Medical Group (a giant multispecialty group with 3,800 providers) and two Dignity Health facilities.

Despite the diversity of the group’s partners, they all have one unifying principle: “We want to provide high quality care to our patients across the continuum of care at an overall reduced cost,” explains Ami Parekh, MD, JD, a hospitalist and medical director of health systems innovation at UCSF. To help accomplish that goal in the outpatient setting, “we are building and developing patient-centered medical homes, so our patients feel a connection to the health system and their primary care physician.”

Teams at UCSF also have a new inpatient ACO resource: a care transitions manager, a nurse who acts as “a combination navigator, concierge and case manager” for all ACO patients in the hospital, says Dr. Green, associate chief medical officer and UCSF’s ACO physician lead.

That manager identifies the resources patients need to be discharged safely, then follows patients for 30 days post-discharge. According to Dr. Green, the care transitions manager commonly addresses the confusion patients may have post-discharge about medications, follow-up instructions, equipment issues and pain management.

When patients need longer-term care management to stay out of the hospital, the care transitions manager refers them to Hill Physicians’ complex case management program. That program, Dr. Green points out, has been in place for some time but is an example of a resource that was “invisible to our providers prior to implementation of the ACO.”

UCSF is also “flirting” with the idea of stationing hospitalists outside inpatient wards in the emergency department or partnering with other providers to care for UCSF patients in skilled nursing facilities. “We aren’t doing this now,” Dr. Green notes, “but having that continuity and those relationships over time are going to be important.”

She sees UCSF’s current ACO work as an opportunity to learn the ropes so that, eventually, the system can become a much bigger, regional ACO.

As systems throughout the country move into an era of accountable care, says Dr. Parekh, “hospitalists will have to embrace the mindset that, ‘I am one part of the extended care team for my patient.’ We have our inpatient expertise, but it will be even more critical to work with outpatient providers before and after we are involved with a patient.” That will likely entail not only closer post-acute care partnerships, she adds, but pre-acute and sub-acute ones as well.

Montefiore Health System
Bronx, N.Y.-based Montefiore Medical Center has a long history of accepting financial risk for patients, having for years managed the care of 150,000 patients. So it came as little surprise when Montefiore was one of the first Medicare Pioneer ACOs in the country “and that it was one of the few in that category to actually earn back some savings in its first year. But that doesn’t mean that its ACO isn’t learning a thing or two about how to improve its use of case managers.

The health system has long had case managers who talk to Montefiore’s hospitalists about everything from utilization to discharge planning for its shared-risk beneficiaries, explains William Southern, MD, Montefiore’s chief of the division of hospital medicine. But hospitalists have long complained that their interactions with those case managers were too frequent, repetitive and distracting.

In part, that’s because case managers used to each cover several floors. Doctors were frustrated by having to talk to several different case managers every day.

But case managers complained that “the physicians were never around,” Dr. Southern says “and they had a point. Each hospitalist saw 13 or 14 patients scattered all over the hospital, and they worked with PAs who each had a slate of 11 patients.

“Communication was ridiculous,” Dr. Southern notes. “Each PA had to talk to six or seven doctors, and each doctor had to talk to eight or nine different PAs.” Dr. Southern says he also began to wonder why the hospital couldn’t make case management useful for all patients, not just those in shared-risk programs. That way, the medical center would be prepared when most or all patients move to a risk-sharing model of care.

Dr. Southern and his colleagues figured out what they needed: an integrated, interdisciplinary team on the floor consisting of a nurse, physician, social worker and care manager. Once that vision was in place, the solution was obvious: geographic rounding, which the center implemented in July 2012.

The transition to unit-based care, Dr. Southern says, was “extraordinarily painful, but now that we have crossed to the other side, no one can conceive of a time when we did it any other way.” Each hospitalist-PA team is responsible for 15 patients on one floor, and case managers are now assigned to only one floor. Each interdisciplinary team meets every day.

The big payoff for hospitalists, says Dr. Southern, is the ability to work more efficiently. “We didn’t see a change in efficiency, as shown in something like LOS.” Instead, the efficiency the hospitalists gained is related to the fact that “doctors have a completely predictable day” now. There is, for instance, a direct correlation between the number of patients discharged and the number of new admissions.

There also seems to be a big upside to geographic rounds in terms of patient satisfaction. According to Dr. Southern, “You don’t want patients to ask, ‘Don’t you guys talk to each other?’ ”

Sharp HealthCare
Integrating case management has also been a major project for Sharp HealthCare, the San Diego-based system with seven hospitals, two medical groups, several thousand physicians and a health plan.

It too has long experience with managed care, and when Sharp joined Medicare’s ACO program, it added 29,000 Medicare beneficiaries to an existing roster of 300,000 managed care patients, which included 35,000 Medicare Advantage patients. But Jeffrey Hay, MD, chief medical officer of Sharp’s Pioneer ACO, explains that the ACO forced the system to up its game. “An ACO brings a lot more volume under a coordinated care model, with financial risk,” Dr. Hay says. While volume is important when sharing risk, it also means more opportunities for patients to fall through the cracks.

As a result, Sharp created seven case management programs specifically for ACO patients. The different programs focus on hospital case management, SNF case management, complex care, end-of-life care, disease management, out-of-network care and care transitions.

And since Sharp formed its ACO, those seven new programs are now being offered to Medicare patients, not just to Medicare Advantage beneficiaries. “As a result,” says Dr. Hay, “we’re able to deliver better outcomes like lower readmission rates at lower cost and with a better patient experience.”

For Sharp hospitalists discharging patients, the ACO case management programs mean that doctors no longer treat their Medicare patients differently than patients covered by a Medicare Advantage plan, explains Brent Drouin, MD, chief of Sharp Rees-Stealy Medical Group’s hospitalist division at Sharp Memorial Hospital. If a Medicare and a Medicare Advantage patient both need complex case management referrals, they now both get the same service.

“It’s much easier for us not to have to worry about which patient is eligible for post-discharge case management,” Dr. Drouin says.

But how to manage the different case management referral options? The fix, put in place more than a year ago, has two parts. One, when the night hospitalist signs out to a day doctor at 8 a.m., one case manager is there. “That person’s job is to capture any discharge planning needs that the night doctor anticipates, then distribute those tasks to the case management team,” Dr. Drouin explains.

Then at 11 a.m. or 1 p.m. (depending on the floor), a few hospitalists attend a daily care team meeting with the entire team of case managers to run through the whole roster of patients. The emphasis is on patients’ discharge plans.

“This is where the rubber meets the road,” says Dr. Drouin. “We actually identify which services individual patients need.”

The biggest benefit for hospitalists? Thinking about how a patient could benefit from case management is no longer “payer-specific,” he says.

“Most of our patients are now eligible for these programs,” Dr. Drouin explains, “and because the programs are on everybody’s mind, they’ve become hardwired.” As for readmissions, “my gut is that patients are getting everything that I think they need to stay out of the hospital. If they do come back, it’s not for lack of effort.”

Deborah Gesensway is a freelance writer who covers U.S. health care from Toronto.

ACO snapshot

AS OF LAST COUNT, there were nearly 500 ACOs, both commercial entities and those working with the Centers for Medicare and Medicaid Services (CMS), covering about 20 million lives nationally. An ACO is an organization “typically, a combination of hospitals, physician organizations, insurers or employers “that agrees to accept the risk of caring for a patient population for a set cost while also improving the quality of care. ACOs are similar to managed care HMOs and PPOs, but without the closed networks.

The CMS’ first batch of 32 “Pioneer ACOs” are the most advanced, where shared savings are potentially highest but so is risk. Last summer, the CMS reported that per-beneficiary costs among the pioneers grew by less than those in traditional, fee-for-service Medicare. Pioneer ACOs also reported better scores than non-ACO providers on a host of quality measures. Among the pioneers, 13 did well enough to share in Medicare savings, while two reported significant losses and two dropped out of the Medicare ACO program altogether.

While the rest are continuing for a second year, seven opted out of the shared-risk program and have moved to another Medicare ACO tier instead: the Medicare Shared Savings Program (MSSP). These ACOs take less risk while they learn to operate under a new way of doing business. Many analysts think the MSSP may be a more attractive option for organizations in the early years of accountable care because it offers an upside-only track.

According to the CMS, 123 new MSSPs this January joined the 220 already operating. All ACOs “whether MSSP, pioneer or commercial “have reported making significant expenditures to operate under a shared savings, coordinated care model.