Cleveland Clinic Tackles Downside Risk in Medicare ACO

The health system is confident of success based on performance in its first Medicare ACO contract as well as recent improvements in care coordination, skilled nursing partnerships, and care access.

Cleveland Clinic is taking on downside risk in the Medicare Shared Savings Program, shifting from the upside-only Track 1 of the program to Track 1+.

"The migration toward risk is something we realize is happening across northeast Ohio and the country," says James Gutierrez, MD, president and medical director of Cleveland Clinic Medicare ACO. "We know that we need to be ready to embrace greater risk and we need to be ready to do it successfully if we are going to survive as an organization."

Cleveland Clinic Medicare ACO, which manages a population of 105,000 beneficiaries, participated in MSSP Track 1 from 2015 to 2017 and posted strong financial performance. In 2016, the ACO achieved $42.2 million in savings, which was a 24.5% increase over 2015 performance. Also in 2016, the ACO received $19.9 million back from MSSP in shared savings, a 19.8% increase over 2015.

In its three-year MSSP Track 1+ contract that starts this year, Cleveland Clinic Medicare ACO faces a 30% loss-sharing rate if the ACO fails to meet its spending benchmark and as high as a 50% gain-sharing rate.

Anticipating Success

In addition to its strong performance in MSSP Track 1, Gutierrez says the health system expects to perform successfully in Track 1+ because of recent capability improvements in care coordination, post-acute care, and patient access.

He says the 11-hospital health system took a major step toward improved care coordination last fall, with the launch of Cleveland Clinic Community Health.

"Although we talk about one Cleveland Clinic and we are a unified enterprise, there are two populations that we serve," he says. "One is the regional, national and international referral base that we serve for tertiary care, the other is a large segment of the local population in northeast Ohio."

Cleveland Clinic Community Health features a newly formed leadership team designed to unify several classes of caregivers who serve the local population:

• Adult and pediatric primary care services
• Urgent care
• Social workers
• Behavioral health
• Pharmacy services
• Support services including analytics and finance

"It brings together many, if not most, of the types of individuals and services that we need to do well in the ACO," Gutierrez says.

Other care coordination investments have been made at primary care practices, where Cleveland Clinic has been focusing on managing the health system's high-risk and highest-utilizing patients. Adding registered nurse care coordinators to the staff is one example, he says. In addition, Gutierrez says the health system has improved care coordination for inpatient services with bolstered transitions of care in the hospital, specialty care, and primary care settings, but while rewards from these investments may be significant, costs may be as well, and the Clinic declined to provide that information.

Related: Medicare Shared Savings Program Swells in 2018 to More ACOs Than Ever

While Cleveland Clinic does not own skilled nursing facilities, the health system has been placing physicians and nurse practitioners at SNFs with the highest-volume of its patients, he says. Skilled nursing is one of the bigger buckets of spending for the Medicare population, he says.

Gutierrez says having the health system's clinicians work with SNF patients has generated several quality and financial benefits for the ACO and its patients, including:

• Decreased length of stay
• Improved quality and outcomes such as a 16.7% decrease in the 30-day all cause readmission rate from 2016 to 2017
• Smoothed transitions of care, both from the hospital to the SNFs and from the SNFs to the home and primary care

Patient access is a key component of meeting MSSP spending benchmarks because managing patients effectively at low-cost settings such as primary care practices can avoid expensive emergency department and inpatient care, he says.

In addition to expanding access to primary care and specialty care practices, the health system has opened several urgent care clinics, Gutierrez says. The Express Care clinics are walk-in settings that handle a range of medical issues beyond coughs, colds, and rashes.

In 2016, Express Care visits increased by 76% to 133,333, with the increase attributed mainly to the opening of six new sites, according to Cleveland Clinic's 2016 annual report. In another measure of improved patient access, same-day visits increased 10% in 2016, to 1.3 million.

Patient Attribution

Unlike MSSP Track 1, which attributes patients to ACOs retrospectively at the end of a performance year, Track 1+ features prospective patient attribution at the beginning of a performance year.

"It is in some ways akin to getting answers to the test ahead of time and being able to take it home to work on it," Gutierrez says.

In Track 1+, prospective patient attribution helps ACOs manage the care of their patients, he says. "Knowing the population that we are accountable for is going to help us make sure we manage that population effectively and don't let people slip through the cracks."

Since joining MSSP, Cleveland Clinic has developed new population health analytics capabilities, which the ACO will be able to use more effectively with prospective patient attribution, Gutierrez says.

"Knowing who our population is will allow us to use clinical and claims data, then risk-stratify the population to identify the high-risk patients who need special attention."