Big bet No. 2: The risk in doing nothing
Indeed, when asked about the challenge of accepting risk on patient outcomes in any accountable care model, whatever its particulars, those interviewed for this story almost always turned the question around in a similar way that Prince framed his answer. The biggest risk is in doing nothing.
Rick Lopez, MD, chief medical officer of another physician-run ACO, Atrius Health in Newton, Mass., sings the same tune, although he points out that Atrius started its journey well ahead of other physician-led ACO concepts. "The risk of remaining on the sidelines is that the train will pass you by and you'll be even further behind in two to three years," he says.
Atrius has a long history of managing under global payment and accepting risk. Ten years ago, about 40% of Atrius's revenues were global payment. Now that number is about 65%, he says, so Atrius has built, over time, infrastructure to support that system.
"It's not going from 0 to 60," he says. "We were already going 45 mph."
He says if there was a time when Atrius was bold strategically, it was in retaining that infrastructure in the early part of the last decade, when "we were driving toward a totally fee-for-service environment. In that model, a lot of groups took down their infrastructure to manage care because things were moving in the other direction, and this infrastructure is expensive. If you're just in fee-for-service and it's about churning out services, then clinical pharmacists and care managers and IT systems are just overhead. A lot of places reduced or eliminated those and it took courage and mission to say, 10 years ago, ‘No, this is part of who we are, and we'll hold on to this.' "
Lopez says creating an accountable care strategy is a difficult calculus no matter which group leads the effort or when it starts, because of the many moving parts. Atrius has to work with skilled nursing facilities, for example, to develop a network for its patients with clear-cut standards and accountability. Information technology is another big component, he says, because interoperability helps ensure that transitions in care sites and protocols occur and that no duplication of services occurs. The IT infrastructure required significant investment in a proprietary data warehouse and in analytics.
"This investment is necessary so we can understand high-risk patients, their status, who needs outreach, and in tracking our performance overall." The benefit of that investment has been to provide Atrius with the actionable data it needs for population management, says Lopez.
"We provide information that cascades down to the physician level that supports our quality and care management programs," he adds. "Information included is for all patients from our EMR and administrative claims data for our risk patients." Examples include identification of high-risk patients, high-utilization patients, patients with "defects" in their quality metrics who need outreach, and rosters of patients with certain disease characteristics that require ongoing monitoring, maintenance, and outreach.
On the cost side, the data warehouse and analytics tools reveal data such as case costs of various types and utilization rates, as well as support in contracting with hospitals and payers. The tools can also model the pros and cons of new business arrangements. Finally, the tools can provide analysis of data for practice variation patterns that are amenable to quality and efficiency improvements, Lopez says, carefully noting that those are only some of the applied uses for the data warehouse.
Atrius is also very open to partnerships and affiliations with hospitals, citing the need to develop collaborative relationships with "a multitude" of hospitals and closer collaborations with a smaller set of preferred hospitals to deliver value for patients.
"We've done a lot of work meeting with hospitals regularly, and in publishing a scorecard, which measures them on a series of qualities," he says. "We'll be able to share with them data that they may not have seen before because we have exchange data about how they compare with the other 19 hospitals on the list."
The overriding goal is continuous improvement. Atrius has invested heavily in Lean process improvement over the past four years, which gives leaders the ability to adapt and implement changes as they figure out better ways to manage both patients' costs and their care. He says organizations that have fully embraced Lean seem to have been able to remove waste from the system in a dramatic fashion.
"Because we have incorporated Lean methods into everything we do, it's difficult to separate out the savings from Lean specifically," Lopez says, adding that Atrius has seen a decrease in the growth of its total medical expenses in the past two years from double-digit growth down to low single digits.
"Who knows what it will evolve to in the next five years," he says. "But if you're doing it on less cost and patients are happy, regardless of your payment mix, you're going to be well positioned."
He concedes the task of creating accountable care structures in Massachusetts—which has large integrated systems, five of the 32 CMS Pioneer ACOs (including Atrius), and a long history of managed care and prepaid delivery that has persisted beyond the 1980s and '90s—may be considerably less difficult than elsewhere, especially for physician-controlled ACOs. But he says the biggest issue with the transformation is not procedural, regulatory, or dependent on market-moving organizations such as health plans or the government leading the process. It's culture change.
"You can hire a dozen care managers and spend a few million dollars to put in an EMR or data warehouse, but if people and physician leadership aren't compelled that this is an important mission, it's really going to be hard to move the organization forward," he says.