With the Affordable Care Act causing a shift in healthcare to look at not only quality in care, but ways to be more efficient in delivering healthcare, a Centers for Medicare and Medicaid initiative is making strides toward cutting down waste in the Medicare program and reducing healthcare costs for Medicare patients. Six West Tennessee primary care clinics have joined forces to participate in a three-year Shared Savings Program with hopes of reaping benefits for themselves, their practices and their patients.
The Centers for Medicare and Medicaid Services (CMS) developed the Shared Savings Program under the Affordable Care Act. It is designed to facilitate coordination and cooperation among providers to improve the quality of care for Medicare Fee-For-Service (FFS) beneficiaries and reduce unnecessary costs. Eligible providers, hospitals, and suppliers participate in the Shared Savings Program by creating or participating in an Accountable Care Organization (ACO). The program creates financial incentives for ACOs that lower their growth in healthcare costs while meeting performance standards on quality of care and putting patients first.
Under the program, CMS specifies a Minimum Savings Rate (MSR) to account for the normal variation in expenditures based upon the number of Medicare fee-for-service beneficiaries assigned to the ACO. To form an ACO, there must be a minimum of 5000 beneficiaries covered. The MSR helps ensure that savings are a result of the ACO’s performance instead of normal variation in Medicare expenditures. Before an ACO can share in any savings generated, it must demonstrate that it met the quality performance standards for that year. In the first year of the three-year agreement period, ACOs satisfy the quality standard based on their complete and accurate reporting of data. Quality performance benchmarks are phased-in during the second and third performance years of the ACOs’ agreements. The ACO’s patients’ claims over the prior three-year period are utilized to set the baseline for the group. For 2015 there are 33 quality measures scored as 31 individual measures and 1 composite measure (which includes 2 individual component measures). These measures span four quality domains: Patient/Caregiver Experience, Care Coordination/Patient Safety, Preventive Health, and At-Risk Population.
In 2012, the program’s first year, there were 89 ACOs participating in the program across 49 states plus Washington, D.C. and Puerto Rico. In 2015, the number had grown to 404 with more than half comprised of networks of individual practices. Only nine percent of the total ACOs in the program this year are rural health clinics, one of which is West Tennessee Clinical Partners, which was formed in 2015 and is comprised of six clinics from the independent physician’s association, West Tennessee Primary Care (WTPC).
When forming the ACO, WTPC Executive Director Dustin Summers says he saw a natural match in the Primary Care Physicians group. The 20 physicians are from East Wood Clinic, Griffey Clinic, Paris/Henry County Medical Clinic located in Paris, Martin Medical Clinic, Milan Medical Clinic, and Northside Medical Clinic in Jackson. Imperium Health Management, LLC was utilized to set up the ACO and is consulting with the group on its participation in the Shared Savings Program.
“This was an opportunity to strengthen the presence of our independent doctors across West Tennessee. We approached the clinics in the independent physician’s association about forming an ACO to participate in the program. Six joined initially but we hope to add the other practices in the future,” he said. “While Accountable Care Organizations are often an organization of multi-state, multi-specialty practices, that is not the case with ours. This group is unique in that they are all independent practices that already knew one another and had an ongoing relationship. The goal is to manage our more than 8200 Medicare patients in a more cost-effective manner in hopes of saving Medicare money with the incentive that Medicare will in turn share half of the savings with the doctor group.”
The clinic administrators recognized the benefit this program could have for their clinics. While some were initially apprehensive about it, all were receptive to the idea that it could work in the development of sound fiscal policies. While participation in the program meant some modifications in the type and manner data is reported, participation has not caused an undue burden or increased paperwork.
“I had read a lot about the ACOs and Shared Saving Programs and knew that there was not a lot of opportunity in the West Tennessee area for independent clinics so when Dustin and Imperium Healthcare came to us with their proposal, it was hard to pass up the chance to participate, especially when there was really no risk on our part,” said Tammy Hazelwood, administrator for Martin Medical Center. “This day and time you have to be willing to try new things to stay competitive and profitable. Now, we are working to see if we can make a difference. It has put another factor into the equation of clinical decision making for the provider. As a part of this program, they want to make the best decision for the patient both medically and financially.”
“Joining the group helps me coordinate care that benefits my patients. We hope to get better prices for them along with higher standards of care” said Susan Lowry, MD, Martin Medical Clinic. “I had no reservations in joining. It is a chance to work with several outstanding colleagues to practice cost-effective medicine. I can work with several colleagues to pick service providers – nursing homes, home health agencies, hospice groups, hospitals, and dome companies to help control the costs to our Medicare patients and ultimately Medicare program itself.”
Beneficiaries seeing healthcare providers in ACOs always have the freedom to choose doctors inside or outside of the ACO. Participating clinics in the ACO are required to post a notice in their waiting room that they are participating in the Shared Savings Program. CMS also sends a standard letter to their Medicare patients informing them of their doctor’s participation and that they have the right to opt out of having their data included in the program. For West Tennessee Clinical Partners, less than 10 percent of Medicare patients opted out.
Quarterly reports give participating physicians and clinics information, based on claims data, they may not otherwise have that helps evaluate practice and referral patterns. “It is a great picture of the quality and cost of services we are utilizing. We can see what services or facilities cost Medicare more, which, in the end, may cost the patient more. We can then work with our patients to make sure they are getting the same level of care at the most efficient price,” said Summers. “It is an educational tool for our providers that lets us look at their practice patterns as well as those of who we refer patients to. From this we can make adjustments designed to improve quality of care, efficiencies and thereby reduce costs.”
Now in the third quarter in the program, Summers says the group is learning a lot. “In the first quarter report, we really looked at our providers’ numbers to get a perspective on where we stood and where we could see some improvement in practice patterns. We saw about what we expected for most things but in some services, it was an eye opening experience as to the vast disparity in terms of cost and quality of providers. The data will give us more information and will serve to illustrate the effectiveness of our physicians,” he said. “”With our second quarter numbers, we will be able to see if there have been any changes in provider behaviors that increase cost savings. We can see if changes are being made or if we need to further evaluate a service or an area.”
Nationally the program seems to be working because last year many ACOs had higher quality and better patient experiences than published benchmarks and qualified for shared savings payments of $460 million. About half of ACOs earned bonuses for saving the government money during their first year of participation. While Summers anticipates the ACO will receive some financial benefit in its first year, how much, if any, will not be known until after the first quarter of 2016.
“This first year is really a process of fact finding. We are looking internally and externally at how we can make improvements that benefit our Medicare population as well as all patients,” said Summers. “With this increased level of information for evaluating our practice patterns we can make more informed decisions in the care of Medicare beneficiaries. We hope to see trends in ancillary services that aid in our overall evaluation of how best to provide the highest quality of care in the more efficient and cost-effective manner. I think the program is ideal for every independent primary care doctor in West Tenn. as it increases the cost effectiveness of the practice and improves quality of care delivered.”
‘The information we have access to, as a participants, will definitely give us leeway to strengthen our clinical processes. We have always advised our providers to care for the patient and let the administrative staff worry with the financial side of healthcare. Now the providers are gaining access to information that can help them make better decisions for their patients based on quality of care as well as expense,” said Hazelwood. “The information that we are able to access as a part of this program allows us to better serve our patients. We can develop better clinical practices and help identify areas where we can help our patients stay healthier, while cutting expenses. Plus the ability to network and learn from other groups within West Tennessee Clinical Partners will allow us to be a better primary care provider. If we provide excellent care to our patients, while helping cut their healthcare expenses, we can both win.”
Sources/Links:
HHS Announces 88 New Accountable Care Organizations http://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2012-Press-releases-items/2012-07-09.html
Quality Measures and Performance Standards http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Quality_Measures_Standards.html
Fact sheets: Medicare ACOs continue to succeed in improving care, lowering cost growth http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2014-Fact-sheets-items/2014-09-16.html
Accountable Care Organization (ACO) Investment Model
https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-06-25.html
