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Better Integration to Improve Care Outcomes Highlighted at AJMC’s

ACO Coalition

Finding the right way to address a patient’s condi-tion before it worsens will ultimately lower the cost of healthcare—and it seems like the health-

care industry is now getting on board with that notion. “You do the right thing, at the right time, at the right dose with the right patient … and the total cost of care goes down, not up,” said Leonard M. Fromer, MD, FAAFP, from Group Practice Fo-rum. “Even if the cost of the treatment might be a lot of money.” Over the course of 2 days, attendees at the spring live meeting of the ACO & Emerging Healthcare Delivery Coalition, presented by The American Journal of Managed Care, not only heard case studies, panel discussions, and presentations that highlighted how better integra-tion and more coordinated care can improve quality of care while lowering costs, but also shared their own best practices.

Integrating Behavioral HealthWith ACOs accountable for both the health and the cost of the population they serve, integrating the behav-ioral and medical components of health is a necessity. “Unless you address both the medical and behavioral, you’ll have poor outcomes,” said Roger G. Kathol, MD, CPE, of Cartesian Solutions, Inc, and the University of Minnesota. Only 25% of people with behavioral health problems are seen in the behavioral health sector, which means that 75% never have access to evidence-based care. The vast majority of patients seen in the prima-ry care setting receive either no treatment or ineffective treatment, he explained, which provides a tremendous opportunity to better

address the needs of those with behavioral health issues seen in the medical setting.

For ACOs, there are a few options for how to handle behavioral health: do nothing and eat the cost when patients have poor out-comes, buy traditional services that people are proven to not use, or build behavioral health services inside the ACO. In his workshop, John Santopietro, MD, outlined the virtual care model being used by Carolinas HealthCare System. Instead of co-locating 1 social work-er in each practice, the system adapted the model by deconstruct-ing what the provider does and recreating that as a virtual team of providers that includes the call center clinician, a care manager, a behavioral health coach, a pharmacist, a therapist, and a psychiatrist. “If you do it that way, you can deploy [the team] much more effec-tively,” Dr Santopietro said.

The early results from the program have found a decrease in de-pression and anxiety scores, and a decrease in glycated hemoglobin, total cholesterol, and low-density lipoprotein cholesterol. The big-gest hurdle to getting the program off the ground was not hesitation on the part of the patient, but that from psychiatrists.

“But we’re getting out of the world where psychiatrists were con-cerned and didn’t want to do it,” Dr Santopietro said. “More and more, they are getting trained in telepsychiatry.”

Precision Medicine and ACOsDuring his keynote presentation, Dr Fromer explained that preci-sion medicine is a fundamental piece of the accountable care move-ment. The benefit of precision medicine is that caring for patients

LAURA JOSZT, MA

Coverage from the 2016 Spring Live Meeting of the ACO & Emerging Healthcare Delivery Coalition™ held April 28-29, 2016, in Scottsdale, Arizona.

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becomes less expensive when healthcare zooms into classes of pa-tients, he said. Medications may be more expensive, but “the big pic-ture cost” plummets only by improving the health of the individual and keeping them well.

Oncology is the biggest and earliest adapter, and stakeholders in that space have begun to create nomograms that use an alpha-nu-meric code to describe something unique about the patient: genetic makeup, tumor makeup, comorbidities, social environment, etc. “To know which drug will work best first, and not hunt and peck, that’s where you save money—a lot of money,” Dr Fromer said.

Where this all ties into ACOs is through the idea of being pro-active with the population being cared for. Dr Fromer added that he expects to begin seeing quality measures move precision medi-cine forward. “Precision medicine quality measures—they’re com-ing,” he said. “It will follow, not lead. It will be there because it will be a natural output from aligning the payment model in general.” The Future of HealthcareClifford Goodman, PhD, of The Lewin Group, moderated a panel discussion between Michael E. Chernew, PhD, of Harvard Medi-cal School; Patricia Salber, MD, MBA, of The Doctor Weighs In; and Bruce Sherman, MD, FCCP, FACOEM, of Buck Consultants, A Xerox Company. They discussed the future of healthcare in the United States, including the sustainability of the Affordable Care

Act (ACA), the impact of the presidential election on healthcare delivery, employer coverage, and maintaining cost of care in the era of innovation.

The panel kicked off with a discussion on Medicaid expansion. Dr Salber noted that it is difficult to separate the decision to expand the program from the politics and she added that since the imple-mentation of the ACA, resistance to expanding the program has begun to deteriorate. She also expects to see more and more states agree to expand Medicaid. Dr Chernew echoed this sentiment, ex-plaining that the ACA was designed to have very strong incentives for states to agree to expand.

“I think that if the election moves in a direction that it looks like the ACA will not be repealed at the federal level, you will see a lot of states move to [expand Medicaid],” he said. “If it looks like it’s really here to stay, you’ll see more states expanding.”

According to Dr Sherman, from an employer standpoint, expand-ing Medicaid has been a good thing. After all, if people have the mon-ey to pay for healthcare, the employer stands to benefit. Expanding Medicaid potentially helps to mitigate some of the disproportionate share of costs that employers cover because of charity care, he added. One of the biggest challenges to the ACA may not even be the politics and the threat of a Republican president repealing the law. Healthcare spending continues to grow, and if the United States can-not get the healthcare delivery system working in a more sustainable

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way, then the ACA may collapse under its own weight when the country can no longer afford the level of subsidies included in the law, explained Dr Chernew.

Dr Salber then shifted the conversation over to drug pricing. Al-though there has been development of life-saving, life-altering ther-apies, they come with huge price tags that the health system hasn’t figured out how to deal with just yet. She expects to continue to see innovative drugs and the pharmaceutical industry continuing to increase the cost of those treatments. Nevertheless, how those drugs are handled in the insurance benefit design could have huge ramifi-cations, she added.

“If all of those things end up fourth tier with huge coinsurance or huge deductibles, there will be a situation where if you have money you can survive, but if you don’t, you will get chemotherapy instead of targeted therapy,” Dr Salber said. “In that part of healthcare we could see a widening disparity.”

Dr Chernew pointed out that regardless of the public senti-ment around drug pricing, it has been well established that there is a relationship between profitability and innovation. And while it can be debated whether that relationship should be there, it is. “I think that the fundamental challenge that healthcare faces is that innovation is universally considered good, but it’s something we continue to struggle to finance,” Dr Chernew said.

Telementoring in OregonIn Oregon, there are some unique innovations taking place regard-ing healthcare delivery. The state is home to coordinated care orga-nizations (CCOs), which are essentially ACOs, but specifically for Medicaid. These CCOs are charged with the responsibility of en-suring that healthcare delivery change is driven by providers and to improve quality of care. In order to do so, Health Share of Oregon has invested in Project ECHO, a telementoring program that con-nects specialists with primary care providers.

The basic idea of Project ECHO is to “demonopolize the spe-cialist’s knowledge,” explained Mark Lovgren, director of telehealth services at Oregon Health & Science University. The program runs for 40 weeks and includes 15- to 20-minute didactic presentations delivered by specialists and real-time case-based presentations from primary care providers who are struggling with specific situations. The expert team of specialists are able to provide recommendations to the primary care provider who is struggling with how to care for a specific patient.

“The idea is that through repeated exposure to these difficult cas-es, everyone participating will feel more comfortable with them,” Lovgren explained.

It does take a few weeks for providers to feel comfortable when participating in the program to open up and share a case, he added. After all, when a provider shares a case, he or she is asking for help, which isn’t always easy for them to do.

“The secret sauce is your facilitator and team,” explained Chris-tine Bernsten, senior manager of delivery system transformation for Health Share of Oregon. “You can get the cookbook to implement [Project ECHO], but you need the facilitators who are good teachers and they are kind and supportive of the providers participating in [the program].”

Voluntary ACO AccreditationAlthough ACOs are by no means new, few so far have sought ac-creditation in the way that patient-centered medical homes have. Michael Massey, MD, chief medical officer at BSWHA, related why Baylor Scott & White Quality Alliance (BSWHA) decided to become one of just a handful of ACOs that are accredited.

The main reason for seeking accreditation is to evaluate an orga-nization’s ability to delivery coordinated, patient-centered care; im-prove clinical quality; enhance patient experience; and reduce costs, Dr Massey explained. In addition, accreditation, although voluntary, identifies which ACOs are likely to be good partners.

BSWHA sought its accreditation through the National Commit-tee for Quality Assurance, which assesses organizations on 65 ele-ments across 7 categories: ACO structure and operations, access to needed providers, patient-centered primary care, care management, care coordination and transition, patient rights and responsibilities, and performance reporting and quality reporting.

About the ACO & Emerging Healthcare Delivery Coalition™

As ACOs and other emerging delivery and payment models evolve and move away from traditional fee-for-service system models toward cost-effective and value-based care, the need to understand how these models will evolve is critical to building long-term strategic solutions. The mission of the ACO Coa-lition is to bring together a diverse group of key stakeholders, including ACO providers and leaders, payers, integrated de-livery networks, retail and specialty pharmacy, academia, na-tional quality organizations, patient advocacy, employers, and pharmaceutical manufacturers to work collaboratively to build value and improve the quality and overall outcomes of patient care. Coalition members share ideas and best practices through live meetings, and Web-based interactive sessions. Distinguish-ing features are the Coalition’s access to leading experts and its small workshops that allow creative problem-solving. The fall

meeting of the Coalition will be held October 20-21, 2016,

in Philadelphia.

To learn more or join the Coalition, visit: www.ajmc.com/acocoalition.

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In a panel discussion following his presentation, Dr Massey said that seeking accreditation allowed BSWHA to see where it had gaps and what it had to work on to become better. The organization went through the same issue when it sought accreditation for its patient-centered medical home.

“We thought we had it all covered and then we found we had a huge problem with access,” he said.

Dennis Scanlon, PhD, professor of health policy and adminis-tration and director of the Center for Health Care and Policy at the Pennsylvania State University, explained that accreditation programs are good for the sake of providing an internal assessment. However, he was skeptical about the idea that getting accredited could be a differentiator among ACOs.

Lysette Cournoyer, a consultant, said that ACO accreditation is likely to follow the precedent set by patient-centered medical homes, which started with just a few getting accredited and grew.

“For providers, it helps them start with something,” she said. “It gives them guidance. A lot of times you go into systems that are bur-dened by their own data and this helps them know where to start.”

Transitional Care ManagementWith 18% of patients readmitted within 30 days of hospital dis-charge and 50% of those readmissions being preventable, transition-al care management can save billions of dollars each year. Further, providers are being incentivized to follow best practices that reduce unnecessary readmissions.

Megan Hunt, MD, PGY3, and Luke Peterson, DO, PGY3, both

from Banner University Medical Center, discussed how their pro-gram formalized a protocol and utilized 2 specific reimbursement codes in order to decrease hospital readmission rates, decrease emer-gency department visits, and increase clinic revenue.

The 2 new codes—99495 and 99496—significantly increased reimbursement compared with the older, comparable codes from $223 to $356 and from $300 to $501, respectively. Dr Peterson ex-plained that they built the protocol for patients when they leave the hospital based on those 2 codes with the hope to exchange an ex-pensive hospital with a reimbursed clinic visit.

The transitional care protocol requires that when a patient is dis-charged that an inpatient team member makes an appointment with-in 2 weeks. The lead medical assistant calls the patient to confirm the appointment, review discharge instructions and medication and if there are nay questions, an inpatient team member calls the patient or if it is a difficult case, then a case manager follows up. And even if the lead medical assistant calls but is unable to make contact with the patient, they need to document that 2 attempts were made in the chart.

In the small pilot study that they ran, Drs Hunt and Peterson’s group found significant reductions in readmissions and emergen-cy department visits. In addition, they saved almost $200,000 from their inpatient service and increased revenue by $25,000 by billing with the new codes.

“This additional revenue pays for the [medical assistant]’s salary that is making all the calls,” Dr Peterson explained.

• Philadelphia Westin •

October 20–21, 2016Fall 2016 Meeting