Vipul Mankad, MD, helped launch Austin, Texas-based Integrated ACO, one of the most successful Advance Payment ACOs in the country.
Midland, Texas is an oil boom town, perhaps best known as the childhood home of former President George W. Bush. It was there, in 2012, local urologist Nick Shroff, MD, had a new idea for a healthcare system.
After the PPACA passed, physicians around the country began to reorganize practices and hospitals into accountable care organizations, which aim to deliver higher quality healthcare at a lower cost. Dr. Shroff was the considering ACO adoption in the Permian Basin region, an area of 86,000 very flat square miles surrounding Midland in western Texas.
However, it was not easy to get other physicians in the area on board. Some were unfamiliar with ACOs, others skeptical. Some were still expecting the Supreme Court to overturn the PPACA.
Dr. Shroff teamed up with Vipul Mankad, MD, to pitch the idea to more than 50 physicians from surrounding towns. Dr. Mankad, a board certified pediatrician specializing in hematology oncology, had extensive experience in academic medicine, physician leadership, clinical care and healthcare policy. Among other achievements, Dr. Mankad served as CMO of Children’s Hospital & Research Center Oakland (Calif.), senior medical advisor for CMS and Robert Wood Johnson Health Policy Fellow for the U.S. Senate. He now leads healthcare consulting firm Qualitas Healthcare Solutions as president and CEO.
When Dr. Shroff asked him to help pitch the Texas ACO idea, Dr. Mankad already successfully helped create several ACOs. Their presentation encouraged more than 22 regional physician practices to participate.
In January 2013, Integrated ACO was approved by CMS to be one of four Advance Payment Model ACOs in Texas. Dr. Shroff now serves as chairman of the board and Dr. Mankad is the senior medical advisor to the board of Integrated ACO.
Advance Payment Model ACOs are typically physician-led and formed in smaller, more rural communities where providers have less access to capital. They receive fixed and variable funds in advance from CMS to increase participation, generate savings and improve care more quickly. Integrated ACO's startup funds totaled $1.54 million.
The organization is obligated to repay CMS for the advanced payments in order to share in savings. If it cannot generate enough savings in the first year, CMS will offset shared savings in the following years, absorbing the downside risk.
Integrated ACO was successful in its first year — it reported saving Medicare $3,567,881 and was able to share in savings. It was one of six Advance Payment Model ACOs in the country to achieve this, out of 36 total Advance Payment Model ACOs. Now, Integrated ACO serves a much larger geographic area including Austin, San Antonio and further south.
"The impact on the patient and the patient's quality of life is the number one reason why we are so proud," said Dr. Mankad.
The organization's success boils down to a few basic strategies, according to Dr. Mankad.
Like most ACOs, the organization uses descriptive analytics and common sense approaches, or what Dr. Mankad calls "basic elbow grease," though he hastens to say this strategy is not enough on its own to ensure success. For example, Integrated ACO collects data from insurance companies, CMS and EMRs. Using this data, it can develop a list of common ailments and high-cost patients.
"In descriptive statistics, you would know which patients were admitted in the last year for various problems; you know 5 or 10 percent generate 50 percent of the cost," he said. "But if you simply generate a list of high-cost patients from last year, it might not be the same group next year. That's because you've already worked on their problems and a problem in the past doesn't necessarily repeat in the next year."
Take a patient with coronary heart disease. If this patient received a $100,000 bypass surgery this year, he or she won't need another next year. Since past lists of high-cost patients can't accurately predict future costs, Dr. Mankad employed another strategy.
"Our secret sauce is predictive modeling and psychographic overlay," he said.
Instead of looking at patients who already had major surgeries, Dr. Mankad and his team identified patients who might need high-cost care in the next six months to avoid preventable hospital admissions. If patient symptoms or behaviors put up red flags, physicians and their staff followed those patients more frequently.
As for the psychographic overlay, the work is just beginning, according to Dr. Mankad. "In the Information Age, we're using it in a lot of other sectors, from retail marketing to political campaigns. In medicine, we've been doing it gut level." The idea is physicians will be able to use systematically collected information about a patient's personality and emotional needs to determine what sort of care the patient may need, especially outside the office or hospital, like individual telephone reminders, group educational health classes or self-help tools. Developing a systematic way to use psychographic information could help continue to cut costs in the future, which is a challenge Integrated ACO will face going forward.
"ACOs that have succeeded, including ours, have done so by plucking the low-hanging fruits. Now, there are still a lot of low-hanging fruits. As we go forward, the challenge I see is it will be tougher and tougher to cut costs. I think we will have to be smarter about how we use our resources. That's why I'm excited about our analytic tools, because it will allow us to focus our resources and be smarter in the way we allocate them," said Dr. Mankad.
"All of us dedicate ourselves to compassionate care of individuals," he continued. "There is no substitute for a trusting physician-patient relationship. I'm truly excited about big data and analytics for population health, but I hope we don't lose sight that in the end it is for the health of individuals and the quality of their lives."
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