Lessons Learned From a Pioneer ACO

On July 16, 2013, CMS announced the results¹ of its accountable-care organization (ACO) program, the Pioneer ACO Model. The program was designed to test the impact of higher levels of shared savings and risk on ACO success, and it attracted 32 participants from around the country. After the first year of participation, seven Pioneer ACOs that did not produce shared savings announced their intention to transition to the lower-risk (and lower-reward) Medicare Shared Savings Program, while two dropped out of the ACO model entirely. Among the participants staying in the Pioneer program is Bellin-ThedaCare Healthcare Partners (Appleton, Wisconsin). As David Krueger, MD, MBA, executive and medical director of the ACO, explains, “Bellin-ThedaCare was organized to create and deliver higher value before ACOs were really the rage. We have been continuously improving—driving toward better outcomes, lower readmission rates, and better value for consumers. In a fee-for-service world, we knew we were losing revenue because of that. There comes a point when you have to reengineer your financial structure to support your goals.” The Pioneer ACO Model was a good fit for the health system, which was five years into its initiative to improve quality and lower costs when it enrolled. “We entered the program because it is a system of reimbursement that recognizes the creation of better value, and I think a lot of the success we’ve seen in the first year is owed to the work we had done before that. I look at these kinds of programs as accelerants: They create environments that encourage a drive to produce value over volume. Once the infrastructure is in place, then the clinical entrepreneurship can take off,” Krueger says. Bellin-ThedaCare takes advantage of its electronic medical record extensively in tracking measurements related to quality and outcomes, establishing the benchmarks for improvement necessary to create savings. Claims data on its patients allow the system to take the next step, linking those data to outcomes. “With the Pioneer program, we receive information on all patients attributed to us—where they’ve been and what they’ve had done, for all of their care,” Krueger explains. “We’re taking on accountability for their care being coordinated, no matter where they go. Now, our challenge is to figure out how to take these claims data and embed them in our clinical-improvement work: We want our physicians concentrating on the patients in front of them, not the screens next to them.” Critical to this process will be finding a way to plug the existing gaps in patient data, Krueger says. “From a clinical-data perspective, we’re able to track and follow metrics, report scorecards, and drive improvements using data,” he says. “The drawback is that we can only see the care we deliver. Any care outside our network, we’re blind to, and that means we’re missing the total care experience of the patient. Patients with chronic conditions are vulnerable to needing additional, unnecessary services because of those gaps.” Clinical Collaboration As a component of care, imaging often falls in the unnecessary-services category because of inappropriate utilization or duplication of studies owing to incomplete records. “One of the gaps we know we have, in health care today, is the appropriateness of imaging,” Krueger says. “On the clinical side, the questions we are asking are when a test should be done—and in what way. If it’s the right test, it shouldn’t matter what it costs. What I don’t want are primary-care physicians who aren’t sure what to do (and don’t have the support they need) ordering the wrong test.” Krueger stresses that he believes that the answer to this conundrum lies in deeper clinical collaboration, in which radiologists assume a leadership role in gauging appropriateness. “Who better to identify and create guidelines than the radiologists on the receiving end of the orders?” he asks. “That’s one of many areas where we’d like to see more collaboration and consultation between the various points in the care spectrum. We want to see efficiencies that don’t rely on rationing or cutting fee schedules, and I see more and more pulling of our radiologist colleagues to the table to help us work on patients’ total care.” Krueger adds that providing incentives for collaboration will be critical to making it a permanent part of health-care culture. “Today, physicians are penalized for taking the time to collaborate,” he says. “They want to do things of value for patients, but they’re frustrated by a payment structure that tells them there should be more care, without regard for quality. It’s an incomplete incentive structure.” Programs like the Pioneer ACO Model might not be the wave of the future, Krueger says, but he views them as an invaluable step forward. “Programs like this recognize that there is so much more to medicine than fee-for-service care,” he says. In terms of outcomes, he adds, “A large part of why we don’t stack up against other countries is that our incentives don’t support that direction. We have a lot of smart folks in health care, however, and if the incentives are right, look out: We’ll go a long way.”