Rebecca Pifer
Aug. 8, 2018
Dive
Brief:
- Medicare
ACOs with a higher proportion of primary care physicians with
patient-centered medical home experience were more likely to generate
savings and demonstrate higher quality scores, according to the
Patient-Centered Primary Care Collaborative's (PCPCC) 2018 Evidence
Report.
- Researchers
grouped 333 ACOs into quartiles from no PCMH experience (Q1) to 43%
PCMH primary care physicians (Q4). After adjusting for organizational and
beneficiary characteristics, the relationship between PCMH PCP and higher
cost outcomes was positive, with ACOs in the 2nd, 3rd and 4th quartiles
averaging savings of 1.9%, 1.3% and 1.2%, respectively — notable,
given that the overall savings benchmark was 0.6%.
- Regarding quality, ACOs in the
highest quartile of PCMH PCP share performed better in clinical quality
scores related to preventative screenings, chronic management, health
promotion and health status.
Dive
Insight:
With 10% of the U.S. population in ACOs and
almost 1,000 available around the country, these findings are widely applicable
for healthcare players in both the public and private sectors as they work out
new payment models amid the turbulent rise of value-based care.
This
report, co-created by the PCPCC and the Robert Graham Center, coalesces two
promising approaches in the space, as PCMHs and ACOs (although created
separately) both exist in the same ecosystem focused on outcomes-driven care.
PCMH
is a care delivery model where a patient's care is coordinated through their
PCP, and the system aims to produce coordinated, team-based holistic
treatment. They have become more widespread over the past decade, with nearly
500 public and private sector PCMH initiatives being tracked across the U.S.,
according to the report.
Introduced
in 2006, ACOs are similar but more broad.
They hold groups of providers across different care settings accountable for
both the cost and the quality of a cohort of patients. The providers therefore
share the risks and rewards of patients' health, prioritizing value.
"ACOs
and patient-centered medical homes are cut out of the same
cloth," said Robert Mechanic, executive director of the Institute for
Accountable Care in a panel convened by PCPCC on Wednesday.
He
also pointed out that, although both PCMH and ACO performance have varied in
U.S. studies, a wealth of evidence supports the role of robust primary care
delivery in bolstering population health, reiterating the importance of
continued studies such as this report.
The
study also stressed that the characteristics that lead to the success of ACOs
were also pivotal to the success of advanced primary care models such as the
PCMH.
The
study, which is the first of its kind to examine the interaction between these
two models, also identified six domains that contributed to successful ACOs,
with success defined as ACOs with shared savings, improved quality or adroit
use of healthcare services. The six categories were leadership and culture,
prior experience, health IT, care management strategies, organization and
environmental factors and incentive and payer alignment.
Regarding
leadership and culture, one important factor referenced throughout the
literature was physicians acting as "clinical champions," acting
in leadership roles and lobbying on their patient's behalf. Diverse,
collaborative governance structures were also noted as important to foster
coordinated communication across the ACO, along with establishing a culture of
shared commitment and accountability.
"Providing
care is a service, not a building," said Ann Hwang, director of the
Center for Consumer Engagement in Health Innovation. The focus should always be
on the patient as a whole being, not a set of symptoms, she said.
From
a provider perspective, two things are inserted into this equation, according
to Farzad Mostashari, chief executive officer of Aledade: total cost of care
accountability and voluntary alignment of practices. Successful ACOs must be a
coalition of the willing, as the "whole dynamic of the network is
incredibly powerful."
Another
subject brought up in Wednesday’s panel was the mounting role of technology in
health. Along with using technology to coordinate care, identify high-risk
patients and track patient care beyond the ACO, the report highlighted the
critical role of health IT in performance data feedback for quality
improvement.
William
Kassler, deputy chief health officer and lead population health officer at IBM
Watson Health, said he sees such technology as an "enabling
tool" for providers, stressing that "data is key for quality
improvement."
When
asked to identify obstacles to ACO and value-based progress, the panel was
quick to provide a flurry of answers, including sluggish public policy,
increasing consolidation threatening competition (a notable quote was from
Mostashari, “if you’re big, you don’t have to be good") and binary
or reductive analytic results.
According
to Anthem vice president of provider alignment solutions Mai Pham, larger
structural issues such as a fee-for-service cornerstone of American healthcare
are the elephant in the room. Anthem, she said, plans to pivot to a place where
it is "ready to leave some providers behind" if they fail to
modernize their business models.
A 2017 evaluation of the Medicare MSSP
program showed that one-third of ACOs in the program achieved savings, although
they outperformed their FFS counterparts on most quality measures. These new findings,
taken in tandem with past research, suggest that a foundation of advanced
primary care is crucial to successful care delivery reform focused on lowering
costs and keeping people healthy and out of the hospital.
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