After releasing the first-year results from its Medicare Pioneer Accountable Care Organization Model, CMS confirmed Tuesday that nine Pioneer ACOs would exit the program, with seven planning to join the Medicare Shared Savings Program and two exiting the Medicare ACO program completely.
Here, healthcare experts give their take on why the organizations are leaving the Pioneer program and what that means for accountable care efforts as a whole. Note: Responses were lightly edited for style and clarity.
Blair Childs, senior vice president of public affairs for Premier healthcare alliance. All organizations that participated in the Pioneer program deserve praise for stepping up to the plate and making investments in care delivery and risk-based payment. As early adopters, they blazed a trail that can be used to help other providers and CMS in making future modifications to the program.
Innovation in care delivery is a two-way street that requires not just assumption of risk on the part of providers, but also flexibility from CMS and other payers to create an environment that fosters creativity and rapid adaptation. As this program matures, we are learning important lessons that should be factored into future decision making.
From the provider point of view, the Pioneer program is extremely ambitious, even for the most advanced health systems. Participating providers ramped up at impressive speeds to meet the challenge of the Pioneer program, making necessary investments in ACO infrastructure, HIT, governance and care delivery models, all of which involves a high degree of risk. From the CMS perspective, the Innovation Center is learning what is realistic given their challenges in providing timely access to data, reasonable quality benchmarks and flexibility in terms of structure and design.
Dropping from the Pioneer program does not mean providers are abandoning their investments or wavering on the concept of ACOs. Instead, many are moving from Pioneer to the less risky options in the Medicare Shared Savings Program. Others are not changing to MSSP, in some cases because of the existence of unnecessary regulatory barriers, and are instead applying their ACO investments to private contracts with insurers.
We are hopeful that the Innovation Center is listening carefully and applying all these learnings to enhance current and future programs designed to help providers move away from today’s broken fee-for-service system.
Jim Hansen, vice president of the Accountable Delivery System Institute for Lumeris. Despite the fact that some CMS-designated Pioneer ACOs are leaving the program or switching to lower-risk models such as the Medicare Shared Savings Program, which offer an upside-only option, Lumeris maintains its strong belief in the benefits of value-based care to achieve the Triple Aim Plus One…our Plus One [is] enhancing physician satisfaction.
The journey to value-based care is complex. It requires both business model and care delivery model transformation. It is dependent on changing physician behaviors and workflows and having the right engagement methods, information and tools in place to deliver better care at lower cost. [Electronic medical records] are a part of the solution, but not the solution. To accomplish population health management, providers need a platform that can aggregate both in-network and out-of-network clinical data, as well as cost-of-care data from claim.
Based on Lumeris' decade of experience as practitioners and enablers of value-based care, we're not surprised that a number of Pioneer ACOs lack the readiness and new capabilities to coordinate their patients' care and manage and report quality metrics for their populations. The Pioneer ACO program has an aggressive timeline, and there have been many challenges and learnings along the way related to data availability and the program’s quality metrics.
CMS Pioneer-designated ACOs leaving the program does not spell the end of value-based care. In addition to government-led models, there are an increasing number of commercial ACO arrangements. According to Leavitt Partners, research indicates that the private sector is driving many value-based initiatives with private payer ACOs nearly equal to public program ACOs. In our experience, national and regional payers are innovating and collaborating with health systems and physician groups on both inpatient and outpatient value-driven contracts.
Value-based care is not a "one size fits all" proposition, but we do believe it is fundamental in reforming the way health care is delivered and paid for and our best hope for reforming a broken healthcare system.
Ken Perez, senior vice president of marketing and director of healthcare policy for MedeAnalytics. Of the 32 Pioneers, 13 succeeded in the first year, generating some shared savings; seven have opted to step down to the less-risky Medicare Shared Savings Program; and two have decided to no longer be a Medicare ACO, Pioneer or MSSP. That leaves 10 Pioneers that are still in the Pioneer program, but did not have a successful first year. I'm sure that the providers in those ACOs are adopting a "wait and see" attitude regarding the viability of the model and whether it rewards them sufficiently for their efforts.
These results are somewhat similar to what happened with the Physician Group Practice Demonstration Project, a precursor to the current Medicare ACO programs, in which only two of 10 participating ACOs succeeded in the first year. Encouragingly, the participants in the PGP Demonstration Project in general improved their performance in the following years, so one would expect the 23 Pioneers still in the program to show better results in the years ahead.
That being said, the fact that only a minority of the Pioneers succeeded in year one will probably deter some organizations from applying to the Pioneer program in the future. For the 10 Pioneers that did not succeed in the first year but are still in the program, this coming year will be the make-or-break year for them, since shared savings provide the economic engine to reward providers and sustain the ACO model.
Do you have a response to the Pioneer ACO News? Email Becker's Hospital Review assistant editor Heather Punke at hpunke@beckershealthcare.com.