Crystal Run Healthcare is a multi-specialty group medical practice headquartered in Middletown, N.Y., which provides services primarily in Orange and Sullivan Counties of New York. The group was formed in 1996 and has been working to provide high quality, coordinated care ever since. Its strong foundation and commitment to value-based care helped the multi-specialty practice of about 250 physicians become one of the first 27 Medicare Shared Savings accountable care organizations in April 2012.
Almost a year later, Crystal Run was part of another "first" in accountable care: It became one of the first ACOs to be accredited by the National Committee for Quality Assurance. Crystal Run reached Level 2 ACO accreditation, the highest level possible in the first year of accreditation.
Here, the Crystal Run ACO team — Hal Teitelbaum, MD, JD, MBA, managing partner and CEO; Michelle Koury, MD, COO; Gregory Spencer, MD, CMO; Scott Hines, MD, co-chief clinical transformation officer; and Betty Jessup, RN, BSN, director of quality and patient safety — discusses the accreditation, gives tips for the new members of the Medicare Shared Savings Program and talks about what the future has in store for Crystal Run as an ACO.
Question: Crystal Run was one of the first Medicare Shared Savings ACOs and one of the first ACOs accredited by the NCQA. What do you think gives Crystal Run an edge over other organizations?
Gregory Spencer: We're a pretty young practice, and we've been using EMR since 1999. The majority of our growth has been from hiring physicians individually. That makes it easier to achieve unity of vision than when you have two medium-sized groups that merge together. From a culture standpoint, we've had an easier time of it, I think, than some groups that have been forming as an aggregate model.
Additionally, I think we've been moving in this direction for a long time. We didn't suddenly think it was a good idea; we've been moving to value-based model for quite awhile. Coupled with our Joint Commission accreditation and NCQA-accredited medical home, it serves to lay a foundation from a technological and organizational standpoint.
Hal Teitelbaum: I agree with that. If you had to say what is it that gave us an edge, first and foremost, we feel passionately about value and care transformation. We believe that accountable, value-based care is essential if we're going to have a high-quality, sustainable healthcare system in the future. That is why we chose to, and frankly had to, take a lead in accountable care.
Scott Hines: We didn't wake up one morning and decide we wanted to be an ACO. A lot of the central themes — high quality care, patient experience, maintaining costs — we've been doing for a long time now.
We've been investing in care managers since 2004 and have had them in the practice for 10 years now — well before we were financially rewarded for it — because it was the best thing to do for high-quality care. It's been interesting to find that other physician groups want to turn the switch on but haven't invested in care managers or changing their culture. We've done a good job doing that even before there were financial rewards.
Q: Why did you decide to apply for NCQA ACO accreditation?
Michelle Koury: I think, culturally, Crystal Run has tried to be ahead of the curve and we have respect for the NCQA and their process. We looked at it as an opportunity to scrutinize the ACO and make sure we were structured in a way to meet rigorous standards.
Internally, you can think you're doing the right things, but [in our case] an outside organization came in and said the same thing. That's why we've gotten our patient-centered medical home accreditation from NCQA and Joint Commission accreditation, which is one of the first [accreditations] we earned in 2006.
HT: We believe in accountability. We believe you can't be accountable only to yourself; you have to be accountable to someone. External validation is a framework for improvement and make sure what we're doing measures up to standards others have set. NCQA ACO Accreditation informs patients, other providers, payors and perspective partners that we are the right physicians to be working with.
SH: Another reason for going through the NCQA — in our region, and in much of New York, payors have not been leading the charge when it comes to accountable care. It's not like payors are beating down our doors to work with us and incentivize value. External validation including NCQA accreditation and [participation in the] Medicare Shared Savings Program shows the payors we know what we're doing; we're dedicated to value; and we, and others, believe we can be successful. When we speak with payors, it's powerful to show we have been accredited as ACO — they understand we're the group they should work with to bring the model of accountable healthcare delivery to the region.
Q: What was the application process like?
HT: I want to mention that the process [of NCQA accreditation] doesn't begin with the application, but rather begins with Joint Commission accreditation, being a patient-centered medical home, achieving meaningful use, implementing electronic health records, electing to participate in the Medicare Shared Savings Program and emphasizing culture, philosophy and the commitment to value. That's the prelude.
Betty Jessup: All of the recognition in the past laid the groundwork for the application. The NCQA application was labor intensive and took four and a half months to complete. We had to lay out that we were functioning as an ACO. There were 100 possible points and, to achieve Level 2, you needed 70 points. There are five core areas they look at: program operations, access and availability of care, primary care, care management and care coordination and transitions.
Again, the application is labor intensive and you need a strong business intelligence support team to help gather the information. We began reviewing the application around March 2012 and submitted it in October.
MK: It's hard to describe the rigor of the application because the questions are important, but the ACO was only up and running for eight months by the time it was due. Some questions couldn't be answered until we ran reports and looked at data.
It's important to have key people leading the effort. It was really a push to the finish, but we are that committed to working with the process and seeking to be the best we can be. We feel it's important to demonstrate our capabilities by going through the process. It was a detailed effort.
HT: People ask me to compare the NCQA application compared to the MSSP application. The MSSP process, in my opinion, is aspirational…essentially, what makes you think you can do this. You've got the organization and you think you can do it.
[The NCQA process] is more 'show us that you put into place the types of processes you need.' It's process-oriented. They want examples of exactly what you've done with a look-back period of six to 12 months. You have to have data and processes and show how you applied these things to make it work that will give you a high probability of success in achieving the triple aim. So I think the NCQA accreditation process is rigorous — it involves moving beyond aspiration to implementing processes and achieving some level of success.
Q: What are some advancements that you expect the ACO to make now that it's in its second year?
HT: I think we're continuing to evolve. What people need to realize is that it's not about calling yourself an ACO or building the structure — in order to be effective, there must be a process of continuous improvement. There is a lot of work to be done to be successful as an ACO. You need to continuously identify and implement best practices. We work on that daily. That includes an emphasis on variation reduction, identifying standards, where possible, and making sure that we eliminate non-value-added services.
We implemented a care team, which is essentially a form of a house calls program where we send nurse practitioners and others to homes of high-risk patients to prevent complications and avoidable readmissions.
We're working aggressively on hospital and payor partnerships, including partnerships with tertiary care partners. We're working on encouraging specialists and primary care physicians to work more effectively together in terms of mutual education, and we're embedding specialists in primary care. We're also working on new physician compensation models.
There is a lot to be done and lots of room for improvement. That's one of the most exciting things about accountable care: It frees us from the constraints imposed by transaction-based payment and allows — and in fact encourages — us to innovate to improve value. The process is continuous and unending, which makes it both exciting and challenging.
SH: Last year, Jonathan Nasser [editor's note: Jonathan Nasser, MD, is co-chief clinical transformation officer at Crystal Run] and I began laying the groundwork for clinical programs to achieve value that started as pilots to see how they work. The plan in 2013 is to proceed with further implementation and dissemination of these programs throughout Crystal Run
One such foundational process is our variation reduction program. We identify best practices for a particular procedure or diagnosis, and study resource utilization for that procedure or diagnosis. For example, we have examined diabetes and have analyzed the cost per provider to provide care for the patient for a year. We look at all the care processes and costs and identify the variation [between physicians] providing diabetic care. We actively involve the physicians, meeting and asking why there is variation in approach. We build consensus around best practices. Once the physicians identify and agree on implementation of best practices, variation and cost are ultimately reduced. We plan to have quarterly variation reduction meetings with all the departments, and we'll have the physicians in those departments choose diagnoses to study. The goal is to embed the concept of value in everyone's mind so it's not something you just hear about, but something you practice.
Q: A new class of MSSP ACOs was recently announced. Can you share any tips for the newcomers?
SH: The most important thing is you have to have the providers on board from day one. You need to educate the providers before you decide to embark on a shared savings contract. What Dr. Nasser and I did when we first started, we made it a priority to meet with every provider in groups of four to explain what value-based care is and why we think it's important and then discuss what concerns they have. That was a powerful message to people, that the organization saw it was a priority to meet and plant the seed to what is coming in the future.
At every quarterly provider meeting and partner meeting, we spend a good portion talking about value-based care. Initially, we focused on why, and now we're focusing on how.
I can't underscore how important it is to educate the front-line physicians. If they're not on board, no amount of committees or infrastructure will make it successful.
GS: Expect to be surprised by the data. There's leakage you don't know about of patients that see other providers. It's just surprising the amount of certain areas and distribution of things. Prior to this, we only had data in our practice, and we had been working with that information to try to give that best we could to providers of what their practice patterns were. The all-in data you get from Medicare is pretty interesting.
SH: Also, don't leave patients out of the discussion. You need patient education as part of it. If you're an ACO even before being part of the MSSP, it's important that you have a standard, easy to follow or read educational material of what an ACO is — Crystal Run Healthcare is an ACO; what does that mean for you as a patient? Some the connotations of healthcare reform can be misinterpreted as rationing or withholding care. You need to get across that it's about increasing the quality of care and eliminating waste, not eliminating necessary services.
HT: ACOs are not simply about committees and meetings, you actually have to have processes in place to improve care and adopt best practices. I've heard organizations say, 'We're all set to move forward, we have committees and managers, but have yet to get physicians involved.' That's a dangerous mistake, and I think it's key that physicians and providers become early participants in the process.
There should be no schizophrenia — those who become ACOs must be all in. You don't want to operate with one foot in each of two canoes any longer than necessary, by promoting volume based care for some patients and value based care for others. If you do, you will send an inconsistent message to your team regarding what you think is important and valuable. Be all in, move forward and understand that value-based care is the right thing to do for patients and the healthcare system. If done well, value based care is not only the right thing for patients, but will lead to organizational success in accountable care.
Almost a year later, Crystal Run was part of another "first" in accountable care: It became one of the first ACOs to be accredited by the National Committee for Quality Assurance. Crystal Run reached Level 2 ACO accreditation, the highest level possible in the first year of accreditation.
Here, the Crystal Run ACO team — Hal Teitelbaum, MD, JD, MBA, managing partner and CEO; Michelle Koury, MD, COO; Gregory Spencer, MD, CMO; Scott Hines, MD, co-chief clinical transformation officer; and Betty Jessup, RN, BSN, director of quality and patient safety — discusses the accreditation, gives tips for the new members of the Medicare Shared Savings Program and talks about what the future has in store for Crystal Run as an ACO.
Question: Crystal Run was one of the first Medicare Shared Savings ACOs and one of the first ACOs accredited by the NCQA. What do you think gives Crystal Run an edge over other organizations?
Gregory Spencer: We're a pretty young practice, and we've been using EMR since 1999. The majority of our growth has been from hiring physicians individually. That makes it easier to achieve unity of vision than when you have two medium-sized groups that merge together. From a culture standpoint, we've had an easier time of it, I think, than some groups that have been forming as an aggregate model.
Additionally, I think we've been moving in this direction for a long time. We didn't suddenly think it was a good idea; we've been moving to value-based model for quite awhile. Coupled with our Joint Commission accreditation and NCQA-accredited medical home, it serves to lay a foundation from a technological and organizational standpoint.
Hal Teitelbaum: I agree with that. If you had to say what is it that gave us an edge, first and foremost, we feel passionately about value and care transformation. We believe that accountable, value-based care is essential if we're going to have a high-quality, sustainable healthcare system in the future. That is why we chose to, and frankly had to, take a lead in accountable care.
Scott Hines: We didn't wake up one morning and decide we wanted to be an ACO. A lot of the central themes — high quality care, patient experience, maintaining costs — we've been doing for a long time now.
We've been investing in care managers since 2004 and have had them in the practice for 10 years now — well before we were financially rewarded for it — because it was the best thing to do for high-quality care. It's been interesting to find that other physician groups want to turn the switch on but haven't invested in care managers or changing their culture. We've done a good job doing that even before there were financial rewards.
Q: Why did you decide to apply for NCQA ACO accreditation?
Michelle Koury: I think, culturally, Crystal Run has tried to be ahead of the curve and we have respect for the NCQA and their process. We looked at it as an opportunity to scrutinize the ACO and make sure we were structured in a way to meet rigorous standards.
Internally, you can think you're doing the right things, but [in our case] an outside organization came in and said the same thing. That's why we've gotten our patient-centered medical home accreditation from NCQA and Joint Commission accreditation, which is one of the first [accreditations] we earned in 2006.
HT: We believe in accountability. We believe you can't be accountable only to yourself; you have to be accountable to someone. External validation is a framework for improvement and make sure what we're doing measures up to standards others have set. NCQA ACO Accreditation informs patients, other providers, payors and perspective partners that we are the right physicians to be working with.
SH: Another reason for going through the NCQA — in our region, and in much of New York, payors have not been leading the charge when it comes to accountable care. It's not like payors are beating down our doors to work with us and incentivize value. External validation including NCQA accreditation and [participation in the] Medicare Shared Savings Program shows the payors we know what we're doing; we're dedicated to value; and we, and others, believe we can be successful. When we speak with payors, it's powerful to show we have been accredited as ACO — they understand we're the group they should work with to bring the model of accountable healthcare delivery to the region.
Q: What was the application process like?
HT: I want to mention that the process [of NCQA accreditation] doesn't begin with the application, but rather begins with Joint Commission accreditation, being a patient-centered medical home, achieving meaningful use, implementing electronic health records, electing to participate in the Medicare Shared Savings Program and emphasizing culture, philosophy and the commitment to value. That's the prelude.
Betty Jessup: All of the recognition in the past laid the groundwork for the application. The NCQA application was labor intensive and took four and a half months to complete. We had to lay out that we were functioning as an ACO. There were 100 possible points and, to achieve Level 2, you needed 70 points. There are five core areas they look at: program operations, access and availability of care, primary care, care management and care coordination and transitions.
Again, the application is labor intensive and you need a strong business intelligence support team to help gather the information. We began reviewing the application around March 2012 and submitted it in October.
MK: It's hard to describe the rigor of the application because the questions are important, but the ACO was only up and running for eight months by the time it was due. Some questions couldn't be answered until we ran reports and looked at data.
It's important to have key people leading the effort. It was really a push to the finish, but we are that committed to working with the process and seeking to be the best we can be. We feel it's important to demonstrate our capabilities by going through the process. It was a detailed effort.
HT: People ask me to compare the NCQA application compared to the MSSP application. The MSSP process, in my opinion, is aspirational…essentially, what makes you think you can do this. You've got the organization and you think you can do it.
[The NCQA process] is more 'show us that you put into place the types of processes you need.' It's process-oriented. They want examples of exactly what you've done with a look-back period of six to 12 months. You have to have data and processes and show how you applied these things to make it work that will give you a high probability of success in achieving the triple aim. So I think the NCQA accreditation process is rigorous — it involves moving beyond aspiration to implementing processes and achieving some level of success.
Q: What are some advancements that you expect the ACO to make now that it's in its second year?
HT: I think we're continuing to evolve. What people need to realize is that it's not about calling yourself an ACO or building the structure — in order to be effective, there must be a process of continuous improvement. There is a lot of work to be done to be successful as an ACO. You need to continuously identify and implement best practices. We work on that daily. That includes an emphasis on variation reduction, identifying standards, where possible, and making sure that we eliminate non-value-added services.
We implemented a care team, which is essentially a form of a house calls program where we send nurse practitioners and others to homes of high-risk patients to prevent complications and avoidable readmissions.
We're working aggressively on hospital and payor partnerships, including partnerships with tertiary care partners. We're working on encouraging specialists and primary care physicians to work more effectively together in terms of mutual education, and we're embedding specialists in primary care. We're also working on new physician compensation models.
There is a lot to be done and lots of room for improvement. That's one of the most exciting things about accountable care: It frees us from the constraints imposed by transaction-based payment and allows — and in fact encourages — us to innovate to improve value. The process is continuous and unending, which makes it both exciting and challenging.
SH: Last year, Jonathan Nasser [editor's note: Jonathan Nasser, MD, is co-chief clinical transformation officer at Crystal Run] and I began laying the groundwork for clinical programs to achieve value that started as pilots to see how they work. The plan in 2013 is to proceed with further implementation and dissemination of these programs throughout Crystal Run
One such foundational process is our variation reduction program. We identify best practices for a particular procedure or diagnosis, and study resource utilization for that procedure or diagnosis. For example, we have examined diabetes and have analyzed the cost per provider to provide care for the patient for a year. We look at all the care processes and costs and identify the variation [between physicians] providing diabetic care. We actively involve the physicians, meeting and asking why there is variation in approach. We build consensus around best practices. Once the physicians identify and agree on implementation of best practices, variation and cost are ultimately reduced. We plan to have quarterly variation reduction meetings with all the departments, and we'll have the physicians in those departments choose diagnoses to study. The goal is to embed the concept of value in everyone's mind so it's not something you just hear about, but something you practice.
Q: A new class of MSSP ACOs was recently announced. Can you share any tips for the newcomers?
SH: The most important thing is you have to have the providers on board from day one. You need to educate the providers before you decide to embark on a shared savings contract. What Dr. Nasser and I did when we first started, we made it a priority to meet with every provider in groups of four to explain what value-based care is and why we think it's important and then discuss what concerns they have. That was a powerful message to people, that the organization saw it was a priority to meet and plant the seed to what is coming in the future.
At every quarterly provider meeting and partner meeting, we spend a good portion talking about value-based care. Initially, we focused on why, and now we're focusing on how.
I can't underscore how important it is to educate the front-line physicians. If they're not on board, no amount of committees or infrastructure will make it successful.
GS: Expect to be surprised by the data. There's leakage you don't know about of patients that see other providers. It's just surprising the amount of certain areas and distribution of things. Prior to this, we only had data in our practice, and we had been working with that information to try to give that best we could to providers of what their practice patterns were. The all-in data you get from Medicare is pretty interesting.
SH: Also, don't leave patients out of the discussion. You need patient education as part of it. If you're an ACO even before being part of the MSSP, it's important that you have a standard, easy to follow or read educational material of what an ACO is — Crystal Run Healthcare is an ACO; what does that mean for you as a patient? Some the connotations of healthcare reform can be misinterpreted as rationing or withholding care. You need to get across that it's about increasing the quality of care and eliminating waste, not eliminating necessary services.
HT: ACOs are not simply about committees and meetings, you actually have to have processes in place to improve care and adopt best practices. I've heard organizations say, 'We're all set to move forward, we have committees and managers, but have yet to get physicians involved.' That's a dangerous mistake, and I think it's key that physicians and providers become early participants in the process.
There should be no schizophrenia — those who become ACOs must be all in. You don't want to operate with one foot in each of two canoes any longer than necessary, by promoting volume based care for some patients and value based care for others. If you do, you will send an inconsistent message to your team regarding what you think is important and valuable. Be all in, move forward and understand that value-based care is the right thing to do for patients and the healthcare system. If done well, value based care is not only the right thing for patients, but will lead to organizational success in accountable care.
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