Some of the nation's most prestigious systems have developed successful population health strategies without forming a Medicare accountable care organization.
With focus on achieving healthcare's triple aim hospitals and health systems are looking to increase the quality of care they provide and improve patient satisfaction while lowering healthcare costs. To help meet those goals, healthcare organizations are concentrating on improving population health, or the health outcomes of individuals within a particular group.
Population health and the formation of ACOs
ACOs were created under the Patient Protection and Affordable Care Act to improve quality and efficiency by linking provider reimbursement to quality metrics and healthcare costs for an assigned population.
The Medicare Shared Savings Program has become a popular option for hospitals interested in participating in a value-based care model, while limiting the risk involved. MSSP participants receive bonuses based on improving quality and cutting costs and are only responsible for their organization's losses if they participate in Track 2 of the MSSP. However, all of the 19 organizations participating in the Pioneer program, another Medicare ACO program, share in both savings and losses.
When the systems participating in the Pioneer program were announced, it revealed some of the prestigious systems had chosen to forgo forming an ACO. Although Rochester, Minn.-based Mayo Clinic, Cleveland Clinic, Danville, Penn.-based Geisinger Health System and Salt Lake City-based Intermountain Healthcare could have all served as models for the Pioneer program and likely received bonuses for their participation, all four declined to apply for the Pioneer program, which caused a stir in the healthcare industry and raised concerns about the Medicare ACO model.
Even with some of the major systems choosing not to participate in the Medicare pilot programs, Leavitt Partners analysis from June 2014 shows there were 626 ACOs as of May of last year. Of those, 329 had government contracts, 210 had commercial contracts and 74 had both types. The remaining organizations hadn't released the specifics of their contracts at the time of the report.
Intermountain Healthcare's choice to focus on population health without an ACO
Salt Lake City-based nonprofit Intermountain Healthcare is widely known for the quality of care it provides and its efficiency.However, the 22-hospital system has chosen not participate in the Medicare pilot programs and instead to pursue its own broad population health strategy.
Although Intermountain is aligned with the goals of a Medicare ACO, such as following evidence-based standards, integration and coordination, the system has chosen not to form a Medicare ACO or to participate in any of the pilot programs because Intermountain was concerned the guidelines for participation were "too prescriptive," says Joe Mott, vice president of healthcare transformation at Intermountain.
In spring 2011, Intermountain's management committee announced the system's strategic direction, a shared accountability strategy. Since then, the system has been aggressively moving forward with its initiative, which today involves more than 20 teams focused on creating new competencies to enable Intermountain to manage population health.
According to Mr. Mott, the system's population health strategy has three legs: following evidenced-based standards, engaging patients and aligning financial incentives.
There are critical technology elements to Intermountain's strategy, and the system is "on the early-end for many technology decisions," says Mr. Mott. One of those pieces of technology is the EHR. Intermountain is in the process of implementing a Cerner EHR, and the population health group is working closely with Cerner to ensure the system is fully utilizing its EHR for population health.
Intermountain is also using technology to improve patient engagement. "We are testing a patient activation tool to allow patients to engage and better understand how the decisions they make impact their health," says Mr. Mott.
Although technology plays a key role in Intermountain's population health strategy, Mr. Mott says perhaps the biggest shift has been in integrating the care management function across the system. "While we have coordinated our efforts in the past, we were really operating separate Care Management functions within different divisions of the system," he says. But care management really needs to be patient-centered." To deliver such, Intermountain is looking to implement a common patient risk scoring tool and is also examining how the system assigns case managers across the system.
Like Medicare ACOs, Intermountain is beginning to look at physician payment models, and the system is in the beta test with a payment model designed to align incentives for physicians, reducing the focus on fee-for-service payment.
Even without a formal ACO, Intermountain has and will continue to focus on how to deliver high-quality care at sustainable costs. "For us, it's a mission issue," says Mr. Mott. "We are working to transform ourselves because our mission requires us to provide the highest value care we can, and we believe this model best enables us to meet that obligation.”
Cleveland Clinic's population health strategy
Cleveland Clinic is another prestigious health system that initially made the decision not to participate in the Medicare ACO programs.
However, the system has been tracking its performance on ACO quality metrics, and it has done very well. "We have been simulating being an ACO for the last year and a half," says David Longworth, MD, chairman of the Cleveland Clinic Medicine Institute.
Based on its simulation results, Cleveland Clinic applied to CMS to form a Medicare ACO. In January, the system will be notified if it will be participating in the MSSP.
With a focus on population health, Cleveland Clinic has transformed the way it delivers care during its ACO simulation process. "We have begun to identify our high-risk patients and to provide proactive care coordination to try and keep them out of the ER and prevent hospital readmissions," says Dr. Longworth.
The system also has 35 care coordinators who work with its high-risk population. In addition, "We have medical assistants who are helping us do pre-visit planning to identify gaps in care," says Dr. Longworth.
Although Cleveland Clinic has made strides, there is still work to be done. The system wants to begin identifying rising risk patients, instead of just high-risk patients, and Cleveland Clinic is also trying to figure out how to activate patients to get them engaged in their care. We want to make patients "partners in their care," says Dr. Longworth, because the system believes that is going to be vital going forward.
Conclusion
Although population health is often times a term used when discussing ACOs, prestigious systems across the country have shown successful population health management doesn't require an ACO.
Using their own strategies, both Cleveland Clinic and Intermountain have made great strides in the population health arena. Although Cleveland Clinic may become an MSSP participant, both organizations are planning to continue aggressively pursuing their population health strategies in the future.