There have not been enough positive headlines this year. The Centers for Medicare & Medicaid Services (CMS) was responsible for one of the very few positive actions when, in September, it announced the results of its Shared Savings Program for 2019.
Collectively, the 541 accountable care organizations (ACOs) participating in the program generated $1.19 billion in total savings by shifting their payment models from volume to value.
The grand experiment that promised to bend the curve in healthcare costs once-and-for-all by aligning payment incentives with outcomes was proving the theory of value-based care in the real-world.
But that was before COVID-19 disrupted life and healthcare as we knew it.
The urge to celebrate the results was quickly tempered by reports of massive financial losses, widespread macroeconomic uncertainty and even several hospital closures, raising the important question: Can the pattern of success ACOs achieved in 2019 continue in the age of COVID-19?
The fact that many hospitals, health systems and provider groups around the country struggled just to stay open and many Americans still deferred routine care, begged the question that was yet to be answered. Can ACOs still afford to focus on annual well visits, community outreach and chronic disease management as a path to improve patient outcomes and strengthen financial performance?
We recently posed this question to the ACOs we advise—a diverse group that includes large hospitals, small, rural critical access hospitals and mid-sized provider groups. Together, this group generated $154 million in savings to CMS and earned more than $50 million in shared savings payments while maintaining an average quality score of 94.1% in 2019.
Their responses were encouraging. They reported that their ability to adapt to the changing landscape and implement new structures have been key to their successful navigation of the COVID-19 pandemic in three critical ways: streamlined transition to telehealth, better analytics and improved patient engagement.
Unintended preparation for telehealth pivot
The core principle driving the value-based care movement is that by focusing on a defined set of key variables and continually benchmarking performance against those criteria, organizations will start to see outcomes will start to improve—even in areas that aren’t necessarily a focal point of the program. In the case of Tampa General Hospital, a 1,000-bed teaching hospital in Tampa, FL with satellite facilities throughout the state of Florida and beyond, one of those tagalong benefits came in the form of telehealth readiness.
Dale Aggen, director of managed care at Tampa General, explained that the work his team put in focusing on chronic care management as part of their ACO transformation became the lynchpin to the system’s pivot to telehealth during the pandemic.
“We didn’t know it at the time, but all of this work got us in great shape for dealing with COVID-19. We were 100% laser-focused for the last year on chronic care management—building systems and processes that let us reach out to patients with chronic conditions and actively work with them to manage their care,” Aggen explained. “The most important tool in that quest was the phone. We got really good at using the phone—and telehealth—in our chronic care management work and that skillset translated seamlessly when it came time to deal with COVID-19.”
Aggen added that the health system’s aggressive focus on annual well visits and proactive patient outreach during its first year as an ACO have been central to its management of the pandemic, helping providers maintain important preventive care relationships even during the thick of regional lock-downs and spikes in COVID-19 cases.
Centralized analytics, better outcomes
Another area where ACO homework has paid dividends during the COVID-19 pandemic is improved patient analytics. At the root of any performance-based incentive system is the ability to objectively and accurately understand patient populations and track the cost and quality of care they receive. For the Mankato Clinic—a small, provider-owned practice in Minnesota—a focus on patient data has become a key to proactive patient outreach efforts.
Nicole Krenik, care manager, RN at Mankato explained the practice’s approach to analyzing hierarchal condition categories (HCC) to spot gaps in care and target patients for intervention more efficiently.
“Data played a key role in this whole process. We were able to assemble a lot of data on hierarchal condition categories and build a dashboard that could automatically search for a patient’s last visit, last labs and other data and send alerts to our care management team triggering outreach. This allowed us to prioritize and be highly personalized in our outreach,” she said.
“We were very grateful to have these systems in place when COVID-19 came into play. All of our nurses were put into COVID triage, so our PharmDs and chronic care managers needed to be able to follow the data and track the dashboard to make sure we were touching these intense need patients. We couldn’t have taken that team approach without a centralized approach to patient data and analytics,” Krenik concluded.
Patient engagement amplified
Patient engagement is yet another core focus of ACO transformation efforts, providing the critical link between administrative and clinical policy and real-world patient behaviors. In the case of Sullivan County Community Hospital, a rural, 25-bed critical access hospital in southwestern Indiana, establishing that link meant bringing the hospital to the community—literally.
To address the unique needs of its patient population—a demographic that is geographically dispersed and includes a significant number of patients who live well below the poverty line—Sullivan County Community Hospital care managers started making house calls.
Specifically, the ACO put a systematic patient outreach program in place that identifies those most in need and schedules them for regular home health visits. The effort has led to a 33% increase in diabetes eye exams, 33% increase in preventive care, a sharp drop in ED volume and hundreds of thousands in cost savings. These endeavors became a key to the hospital’s successful management of the COVID-19 pandemic.
“Going out to peoples’ homes was the game-changer,” said Ashley Kilpatrick, RN, leader of Sullivan County’s Care Coordination Program. “We were focused on chronic care management outreach, but there are things you just can’t see over the phone. By building trust and getting to know the members of our community who were most in need, we started to see significant improvement. These relationships were key during COVID because we could reach out and conduct education, make sure they were getting the care and PPE they needed and keep tabs on chronic conditions to make sure they weren’t being neglected.”
2020 and beyond
There is no sugar-coating the fact that 2020 has been a tough year for everyone. Decades from now, researchers analyzing trends in healthcare costs and charting the transition to value-based care will need to put an asterisk on 2020, explaining it as an outlier year in which a pandemic disrupted everything.
Even with this disruption, there are some bright spots in value-based payment care delivery. Between the first quarter of 2019 and mid-2020, we saw the number of chronic care management visits increase by nearly 70%, from 27,128 to 45,880. The rate of CCM visits increased a similar amount over the same period, from 40 to 72 per thousand patients. Our practices are learning some important lessons about the value of population health.
But the challenges faced during these last several months—and the various approaches hospitals, health systems and provider groups have taken to address them—have provided an invaluable perspective on what works and what perhaps more importantly, what needs to change in the future of healthcare. Throughout, successful ACOs have been a beacon of hope for what is possible when healthcare leaders coordinate their efforts and commit themselves to deliver the best possible care. These strategies are working during the thick of a historic pandemic, and they will work in the better times ahead. We just need to stay focused on the big picture.
Tim Gronniger is the president and CEO of Caravan Health, a leader in accountable care for community health systems