MSSP Lessons Learned: What Worked, What Didn't & Why 

Accountable care organizations participating in the Medicare Shared Savings Program (MSSP) made a multitude of investments into their networks, health information technology and care management systems.

But what really worked...and what didn't? Now that CMS has released results from the first operating period, four ACOs previously profiled by ABN, one of which will receive shared savings from CMS, offered their thoughts on what works and what doesn't in the MSSP program.

Houston-based Memorial Hermann ACO started with its physicians, says Chris Lloyd, CEO of MHMD (formerly known as Memorial Hermann Physician Network) and Memorial Hermann ACO (ABN 1/14, p. 8). The organization chose its initial group of doctors carefully, with a 15-item checklist that required they already have an electronic medical record, accept some risk and have efforts underway to implement other aspects of the ACO triple aim, Lloyd tells ABN.

The approach worked: Memorial Hermann saved Medicare about $33 million and will receive shared savings of about $16 million.

The key to the organization's success, Lloyd says, was choosing a subset of physicians who already were invested in population health management, instead of enlisting its entire network and then trying to get buy-in.

"Using the ACO as the call to action for your physicians and hospital network is not the right strategy," he says. "There has to be physician leadership. Our physicians are leaders of this effort."

In its first year, Memorial Hermann had about 22,000 lives attributed to its MSSP program. That number has grown to about 40,000 beneficiaries, Lloyd says. He credits the ACO's success to having the right doctors, a strong care management structure, a set of robust population health and risk stratification tools "that gets it down to the physician and individual level," and full data transparency down to the individual doctor level.

"We made a commitment to really developing this primary care network to which MSSP lives are attributed, and wrapping a pretty significant outpatient care management strategy around the network," Lloyd says.

Memorial Hermann hasn't had a perfectly smooth ride to its first shared savings payment. "One of the things that surprised us was the sheer mechanics of getting off the ground - the fact we had to process and accept the first file of claims data, and contact all the beneficiaries," he says. "The strategy and mechanics need to be well understood before you undertake to participate in a product like this."

It's also been a challenge to find the right people for the ACO to hire, Lloyd says. For example, "care managers are extremely hard to find - that's one of those things we wish we had continued to move faster on." In addition, Memorial Hermann needs more experts in population and risk stratification health information technology, he says.

Although the $16 million Memorial Hermann earned "doesn't cover our investment in our strategy, our strategy has been a multi-year strategy," Lloyd says. "This just recognizes that we're moving down the right path." The ACO will divide the savings according to "a formula we decided on even before we submitted our [MSSP] application," he adds.

At Catholic Health System, a Buffalo, N.Y.-based non-profit provider that includes four different hospital locations and an affiliated 900-physician independent practice association (IPA), Michael Edbauer, D.O., chief medical officer, says he sees two tactics as integral to the ACO's progress so far: extensive use of electronic health record (EHR)-based registries and data, plus care management "across the continuum" with a focus on emergency room and inpatient opportunities.

Catholic Health, with its multiple independent physicians, must contend with a variety of different EHRs - 13 to 15 in total, Edbauer estimates. The ACO did not earn a shared savings payment in the first reporting period.

"Being able to pull clinical data from the practice EHRs and combining with claims data allows us to get a fairly accurate picture of care being provided as well as opportunities for improvement," Edbauer tells ABN. "We have then taken this information and provided timely and actionable reports back to practices."

Catholic Health also monitors these reports and turns over feedback from practices to its in-house process improvement team, Edbauer says. In addition, the ACO supports practices with EHR implementation, meaningful use requirements and patient-centered medical home accreditation, he says.

For care management, "we have increased our care management resources at the ER level to assist in appropriate diversions to lower levels of care as well as coordinating for and with the primary care community," he says. "This has had the greatest impact on our cost reduction as this is a population that is immediately actionable and without intervention will incur unnecessary costs."

Meanwhile, Catholic Health realized its outpatient care management wasn't working as intended, and now is modifying it to focus on higher-risk patients based on CMS-HCC scores, which identifies individuals by their demographic, health history, enrollment status (e.g., Medicaid eligibility) and other factors.

The ACO has a four-year-old care management system in place, with 240 care managers - a mix of licensed nurse practitioners and registered nurses - who are financially supported by the health system but who are embedded in physicians' practices. In addition, the care management program employs both pharmacists and dietitians, who work mainly within adult primary care practices.

"Previously we focused our efforts based upon disease states, which was much broader and did not differentiate the individual complexity of the patients very well and sometimes resulted in use of resources with very limited impact," Edbauer says, adding that Catholic Health is "just ramping up this modified approach and anticipating having preliminary results of its effect in Q4 of this year."

Summit Health Solutions Executive Director Kimberly Kauffman says embedded care coordination represents her ACO's biggest success story. "Without a doubt, embedded care coordination has had the biggest impact on providing better care [and] lower cost for our Medicare patients," she says. "This model allows us to proactively engage patients and act as the point of first contact for patients."

Knoxville, Tenn.-based Summit, which has approximately 36,000 attributed Medicare patients and uses a single EHR from Allscripts, did not earn a shared savings payment in the first reporting period.

However, the ACO has been able to reduce inpatient admissions by 11% and readmissions by 2% - "and those are off of starting points already consider- ably lower than the national average," Kauffman tells ABN.

Summit uses a daily data feed from its Allscripts-provided EHR, and utilizes Optum Care Suite from OptumInsight to help it identify at-risk patients. The ACO shares information with its physicians in a primary care dashboard.

However, the ACO hasn't seen the reduction in emergency room visits it was anticipating based on its interventions, Kauffman says. "We have reviewed utilization patterns and expanded access to our PCPs [primary care physicians] and urgent care centers accordingly, but changing patient behavior takes time," she says. "We have just now gotten to the point where we can objectively analyze post-acute providers and plan to work with those facilities to reduce non-emergent visits to the ER."

In addition, Kauffman admits that Summit leaders "could have done a better job preparing our physicians to direct team-based care, [and] to include appropriate use of the care coordinators." She says that success stories and specific examples from other ACOs of what to do - and, perhaps as importantly, what not to do - have been helpful in seeking to address these issues.

"We have invested far more time and resources than we anticipated to develop actionable and reliable reports to engage our providers," she says. "Using the analytics capability of a Medicare managed care organization as the yardstick, we worked for nine months before delivering reports to our providers."

The data limitations inherent in downloading and processing CMS claims data and quarterly trend reports have been problematic, he says.

Jordan Hospital, a not-for-profit, 155-bed community hospital based in Plymouth, Mass., was prepared to see its hospital admissions suffer as a side effect of the MSSP program (ABN 10/13, p. 4). But after nearly two years in the program, the ACO is still focusing its efforts on reducing the facility costs, says James Fanale, M.D., senior vice president of system development for the hospital. The ACO did not earn a shared savings payout in the first reporting period.

Jordan Bring In Geriatric Experts

Part of the puzzle involves more efficient, effective evaluation in the emergency room, he says. "We have a plan to have a geriatric nurse practitioner work alongside the ER doctors when an ACO patient arrives in the emergency department," Fanale tells ABN. This process potentially could lead to a quicker, more geriatric-focused evaluation, possibly with less cost, he says. It also could prevent some admissions: "We will only admit those who need to, and most importantly, provide close follow-up if they go home," he says.

Another part of the puzzle is patient education: "We can encourage folks not to come to the emergency department whenever they feel the need to," he says. "Our emergency department visits are way too high, and we need to focus on the education of patients."

In addition, Jordan's skilled nursing facility days are high, to the point where the organization considered opening its own hospital-based transitional care unit, Fanale says.

Hospital officials met with area nursing home officials and asked them to work on reducing days, or the hospital would proceed with its own unit, he says. This led to a closer working relationship with the local nursing homes, and the hospital shelved its plans, he says.

Physician engagement is key to the success of the ACO, but "sometimes you have to work with and around [the physicians] to demonstrate that different processes work," Fanale says, adding, "pilots are key. Finally, more analytical support - especially focusing on chronically ill patients, who need to be managed very closely - would have helped as the ACO started up, he says.

This week's Friday Fast Facts was provided by: 

ACO Business News 

March 2014 - Volume 5 - Issue 3