The reporting and resources needed to keep up with the demands of Medicare quality standards have only become more cumbersome both now and in the future. Toggling upside and downside risk can be difficult to keep up with and confusing at times. Many practices are constantly worried that one dropped ball could sending hard-earned revenue to the government.
Trying to manage Medicare value-based care on your own can be a vicious cycle. The strained resources to keep up with quality end up stealing from the reserves you need to provide quality. ACOs (or Accountable Care Organizations) break the spell by supporting those practices and providers with Medicare patients while easing the burden of reporting and remediating care quality.
Bill Riley (Vice President of Marketing at Medical Advantage) moderates this rich discussion centered on how ACOs not only shield your practice from downside risk, but also improve care quality across the board. This presentation was originally recorded as an on-demand webinar, but is being published as a podcast as it bears a timely message for many practices, particularly those in Michigan and Ohio.
You will hear first-hand insights and experiences of ACO strategy implementation Darline El Reda (Vice President of Population Health), Meghan Sheridan (Director of Managed Services Organization), and Shelby Courtney (Senior Consultant). These experts are actively engaged with practices who greatly benefit from ACO membership.
In this presentation we discuss:
- Why should providers care about ACOs?
- What success looks like in the ACO environment and what the “three buckets” of effective ACO strategies are.
- How ACOs are prepared to absorb the downside risk so that practices can direct more resources to care quality for patients.
- How holistic practice solutions resolve the root causes that hinder more efficient operations.
- Why improving care for Medicare patients ends up improving quality for all of the patients served.
This podcast introduces Medical Advantage’s very own ACO program for practices in Michigan and Ohio or those who represent an existing ACO. Rather than try to troubleshoot solutions when there is no time spare, our seasoned healthcare consultants provide the reporting and implement the reliable solutions needed to optimize value-based care quality for the best upside and downside risk outcome.
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Full Episode Transcript
Medical Advantage Podcast: Welcome to the Medical Advantage Podcast, where you can hear healthcare professionals, expert consultants, and industry thought leaders discuss the exciting new ideas and technologies that are changing the business of healthcare. Tune in to each episode as we hear from some of the most innovative minds in medicine about the future of healthcare and how your organization can stay profitable, efficient, and on top of industry best practices.
Bill Riley: Hello, and welcome to our session. I’m Bill Riley, the marketing leader at Medical Advantage, and on behalf of all of us, welcome to our webinar, an overview of the Medical Advantage ACO and ACO services. Now for those of you that are new to Medical Advantage, let me do a quick commercial. We’re a business unit within the TDC group or The Doctor’s Company, the largest physician owned medical malpractice insurer in the country.
Medical Advantage is the professional services arm of the group. We provide a broad range of services across practice operations, technology and financial categories. Ultimately, we help practices, groups, private equity backed organizations accelerate their performance in value-based care arrangements.
In the last five years alone, we’ve helped our ACO IPA and other clients achieve over a hundred million in value-based care reimbursements. Now, before I introduce our panelists, let me cover a couple of quick logistical items. This is an on-demand webinar, but you’re still able to submit questions as we go.
We’ll get them and I promise we’ll respond if you just use the little chat bubble in your GoToWebinar player. You can submit your questions there and we’ll get in touch with you. So, with that, let’s talk about our panel. Darline, maybe we could start with you, if you could introduce yourself and your role here at Medical Advantage.
Darline El Reda: Sure. Thank you, Bill. I’m Darline El Reda. I’m currently the Vice President of Population Health and Solutions here at Medical Advantage.
Bill Riley: Great, Meghan.
Meghan Sheridan: All right. I’m the Manage Services Organization director and I’ve worked with the company’s ACO clients over the last five years, so really excited to dig in there.
Bill Riley: Thank you. And Shelby.
Shelby Courtney: Hi, I’m Shelby Courtney and I’m a senior consultant in charge of implementation strategies to deploy out to practices for interventions for the ACO.
Bill Riley: Okay. Very good. So our session today, we really have two audiences in mind. First is if you are a physician or a practice in Michigan and Ohio, and maybe you’ve heard of ACOs and you’re considering membership within an ACO.This is an opportunity for you to learn more about our own, the Medical Advantage ACO and our approach. And we’d love to hear from you if you’re joining an ACO.
Second is the alternative would be maybe you represent an existing ACO and you know, perhaps you’re entering into the two-sided tracks of your relationship with CMS or maybe you’ve had some volatility year over year. This is an opportunity for you to learn of the services we provide to our ACO clients and how we’re helping clients just like you.
So for our session today, we’ll start it at a high level and work our way down. So from a big picture perspective, maybe Meghan, we can start with you.
For those that are new and never been in an ACO, can you give us a high-level view of what’s the ACO program all about?
Meghan Sheridan: Sure.
So at a high level, an ACO is basically a contract with Medicare. So that would be traditional Medicare or the fee for service population. And it’s all around improving the quality of care delivered to patients and managing their cost.
So there’s a lot of different elements and I think that we’re gonna get into some of those details in a few minutes here. But at the end of the day, it’s all about improving the delivery of care for Medicare patients.
Bill Riley: Very good. And if I’m a physician, why would I care? Like, what’s interesting about an ACO?
I mean, Shelby, I know you’re with practices all the time. You know what, if you could just share your perspective on that?
Shelby Courtney: Yeah. So why an ACO and why now? I would say that now is the perfect time to join an ACO if you haven’t before, or if you’ve dabbled in it before and wanna join back in.
There’s so many different quality programs, value-based care programs out there, MIPS programs that people are currently in, and the reporting and the resources it takes to do this kind of work is getting more cumbersome. So when you join an ACO, the ACO can take a lot of that burden off of the practice so that they can really focus on the care that they give to the patients.
So when the ACO takes it on, they can help with all the reporting, the quality metrics, watching cost and utilization, what sort of resources that the ACO can supply to the practice to help take care of patients as well. So it’s more of an ACO walking alongside of a practice to help them succeed.
Bill Riley: Okay. Very good. Now as we go forward, I think it’s fair to say we’re entering a new phase or period of time as it relates to risk arrangements with CMS. So Darline, can you share your perspective on that?
Darline El Reda: So when Medicare first launched their ACOs, accountable care organizations, they launched these shared savings programs as upside only, which basically meant that providers really didn’t have money to lose in case their ACO at the end of the year didn’t generate savings for CMS. Hence the term upside only.
The savings that they generated were then shared, a part back to the house, you know, to CMS and then part back with the providers. This was intentional on behalf of CMS in the beginning, really to achieve good participation and engage providers in the concept of risk sharing and value-based care for Medicare beneficiaries.
The window, however, for upside only arrangements is rapidly closing. And ACOs are now required to advance along the tracks from upside only to arrangements where there’s both upside and downside risk.
Bill Riley: Very good. So, you know, we are in touch with any number of ACO clients, there are folks that are concerned about this, right? Because this could represent risk for them.
Darline, you had mentioned a recent article just showing how some groups are choosing to deal with this.
Darline El Reda: Yeah, there was a recent article published in January’s volume of Health Affairs that outlined some experience of ACOs largely located in rural settings that basically reaffirmed the notion that the concept of downside risk is one that’s causing angst and a little bit of fear among providers.
Because when faced with the requirement to move from ACOs that had only upside to one that had both upside and downside, a great proportion of the ACOs chose to simply sit it out and no longer participate in those arrangements. So the concern is real. The fear is real.
One has to remember that the foundation for ACOs is primary care practitioners, along with physician assistants and nurse practitioners. Those are the providers that Medicare beneficiaries are attached to in these savings models. And when we talk about care delivery, you know, primary care practices are not in a position to take on downside risk even if they wanted to.
That’s a big ask for a lot of primary care practitioners nationwide.
Bill Riley: Okay, very good. So the stakes are going up. The risk is real, but I think the opportunity for reward is real as well.
So let’s start to work our way into how we help our clients manage this risk and be successful in these programs.
So, Meghan, let’s go maybe to the next level of detail. How does an ACO make money? What defines success?
Meghan Sheridan: Sure. Yeah. So there’s kind of three key buckets. The first one that most people have their eyes on is cost of care. So your cost of care, it needs to come in below your cost benchmark.
So that’s something that CMS calculates for you. And depending on your track, you may need to reduce your cost by a certain percentage before you’re actually eligible to keep or earn any of that savings. To then add a layer of complexity the cost is risk adjusted.
So six sick patients naturally require more resources to adequately care for. CMS doesn’t wanna penalize or disincentivize ACOs from having sick patients. So instead they try to correct for that by giving each patient a risk score and then adjusting the ACO cost benchmark by that aggregated risk score. And the trick with this is you want your risk score to be accurate. So accurately reflect how complex your medical population is which ultimately gets back to accurate documentation of diagnoses by the provider.
Another bucket that I wanna mention is quality. So you have to perform at a minimum level on specified quality metrics before you’re eligible to keep any of the savings. And then after you qualify your performance on those measures actually dictate the amount of savings that you get to keep. So it’s a direct multiplier.
So that’s kind of the three kind of key areas. Now you say what defines success? I’ll give you my long answer and then the short answer, the long answer is that a lot of people use this quote, “Success is when preparation meets opportunity.”
So it’s absolutely true within an ACO. When we speak of opportunity, we’re often talking about areas identified through analysis of data that if addressed would improve one or more of those three buckets that I just talked about. Cost, quality, and risk. But equally important is the preparation side.
Both in terms of the team that you’re working with and the practices that are participating. So how well does your team know the ACO space when they look at opportunities in the data? Do they know which interventions to deploy to make an impact? Do they know how big of an impact they’re able to make with those interventions?
Do they have the tools, the processes, the boots on the ground to support you and getting that work done? And quickly, because time is always ticking and we have a real minimum amount of time to make change. So that’s my long answer. Ultimately when we look at whether an ACO is successful or not, it’s did they earn shared savings?
Bill Riley: Very good, very good. And I think you just laid out for us the two key themes here. One is the importance of healthcare data and then the second is the set of interventions at the practice level, which Shelby will talk us through shortly. But why don’t we start with the data.
Darline, maybe let’s go back to you and maybe start at a high level around at, at the ACO level, then drilling down to the individual level, just the importance of data and the role it plays with an ACO.
Darline El Reda: Yes, Meghan is correct. The data is important. And what do we mean by data? So, for many providers who may be listening who are new to the ACO space when you sign up for an ACO, CMS then shares claims data that summarizes the services and the care that you are attributed, right?
Your patients that are attributed to you on your panel are receiving, whether they’re receiving the care from you, whether they’re receiving the care from other specialists, hospitals, et cetera.
And to start of the kind of journey along understanding, how do we rally our services and support our providers with the focus on achieving savings? You start by analyzing the data, understanding how providers in a ACO collectively are doing, understanding how individual practitioners are doing, understanding where patients are getting services from inside your office, outside your office, whether you referred them to other providers or not.
Understand, you know, Meghan mentioned the importance of risk. Understand if you know the severity of illness is being adequately captured, which really means are you getting credit for all the hard work that your practice team is already doing. Understanding that we can use kind of historic data, what has happened in the past with your patients and those touching your patients, so that we can monitor spend and quality and use of services and such throughout the year.
But as Meghan started to say, analytics and reporting and data is where we start. But I like to say that’s necessary, but not sufficient on its own. And what do I mean by that? It’s the next step.
So what do you do after you analyze the data and you create charts and you identify opportunities or you identify suboptimal capture of your disease burden? You know, someone’s really sick on paper according to their spend, but when you look at what’s being coded, this patient doesn’t look very sick, which impacts your benchmark.
Then we move into I think kind of the critical, like the catalyst for success, which is of the insights we see in the data, which ones are amenable to change?
Do we have interventions for them? What are the interventions? How do we deploy the strategies? How do we achieve results? Both and these interventions are sometimes strategic and sometimes tactical. How do we do it without overwhelming busy practice offices and their staff who are focused on delivery of high-quality care to their patients?
And we always want them to stay focused on that. But we want to support them in understanding what the data is telling us the opportunities are and then marrying those insights from the data with actual support. And interventions that we can deploy in a very thoughtful and specific way that will indeed give us that return on investment, right? Move the metrics.
And as Meghan said quickly, because you have only a year and it’s a calendar year and then everything starts over again, so there really isn’t a lot of time to try untested strategies or untested interventions. Providers are really busy and we need to focus the efforts on interventions that yield results.
Bill Riley: Very good. So why don’t we jump right to that? Why don’t we skip ahead and talk about the interventions. I’m so excited that we’ve got Shelby with us here today who, Shelby, I think you yourself have done more of these practice level interventions than almost anyone at our entire company.
So, as Darline says, as Meghan teed up for us, we’ve got the data, that’s great. We have a sense of certain providers that might be struggling a little bit, okay? Then what? What and how would we actually engage with a practice and begin to make these changes?
Shelby Courtney: Right. So the data is 100% needed to do this work. So the data is absolutely imperative. And then it’s the relationship we build with a practice, the trust that we build, the assessment that we do beforehand.
So we like to know who this practice is, what are their resources, are they tech savvy? So on this, are they a beginning practice or are they an advanced practice?
And then we can deploy our interventions based on that. Some practices need a little more handholding. Some you can give them a list of activities to do and they can take care of it. So that I think is Medical Advantage’s Advantage is we meet practices where they’re at and deploy our interventions based on that.
For instance, we have practices we were talking about that struggle with risk adjustment to practices, very similar you know, in the demographic area, very similar patient population, but one where their risks are way lower than the other one where it’s on par. So we would go and deploy our, our HCC risk adjustment group to go work with that practice to see what’s going on.
Is it documentation issues? Is it coding issues? Is it their EMR or their billing company that they’re struggling with? Another practice, it may be that their EMR system is not capturing some of their quality metrics. And we work through those scenarios with them. And we have people that can do everything.
You know, it’s a soup to nuts, what Medical Advantage can do. We deploy care management services. We also will talk with specialists in the area and we’ll highlight specialty groups that we believe that our practice should be working with because they give great patient care, which means it’s appropriate care and it’s at the right place. It’s not an over-utilization, it’s not underutilization.
So all of these elements are key. Can practices do a lot of this work themselves? Absolutely. But it is so difficult to cover all of this kind of work, to figure out who your skilled nursing facilities are, who the appropriate specialists are in your area. What are my costs for services in this? And this is what Medical Advantage does.
I think the key thing that I love when doctors say, when we bring them reports, because everybody can bring a report, they can bring you a patient list, they can tell you how good you’re doing, how bad you’re doing, whatever.
What do they always say? What do you want me to do? Tell me what you want me to do. Tell me what I’m supposed to do with these patients and we break it down in such an easy level. Here are the top five things I need you to do in the next two months in order for us to move the needle. And I think that’s where Medical Advantage is great with working with the physicians.
Bill Riley: Very good. Thanks Shelby. Meghan, I know I’d love to get into one of your ACO client examples where there was just a great turnaround in terms of ED visits and ultimately hospital readmissions. So could you give us a short summary of that whole scenario?
Meghan Sheridan: Sure, yeah. We’ve got an ACO that’s in a low socioeconomic area. And just looking at some of the information available to us, there was a community needs assessment that identified a lot of social determinants of health. So we wove that into our interventions, deploying social determinants of health screening but then also really getting to know the community resources in our area.
So that we could have efficient referrals, doing some work with transition of care to make sure that people weren’t just missing a follow-up visit with their provider because they didn’t have transportation. So between all of that we were able to reduce ED visits by 18% and readmissions by 17%.
Bill Riley: Very good. Very good. Okay. Just looking at the time here, I’d like to skip ahead to commercial payer performance, so above and beyond the ACO contract. Darline, can you give your thoughts on a more holistic approach to performance?
Darline El Reda: Sure. So you know, it is very rare that we work with practices that have the luxury of serving Medicare and Medicare only patients.
We understand that those practices exist, but those are rare practices. And so what we bring to the table is a set of interventions and strategies that actually allow our physician participants to improve their performance in value-based care arrangements across lines of business, right?
So if we notice suboptimal coding for Medicare, it is very rare that coding is suboptimal for a Medicare patient but then optimal for a commercially insured patient, we just don’t see that in the real world. And so we focus on interventions that if implemented strategies, that if implemented on practice operations, that will not only help the providers succeed in their Medicare population and the ACO, but also kind of raise the level of performance across other patients.
You know, think things like opportunities for suboptimal workflows or opportunities for identifying patients who haven’t been in a while and have missed some preventive screenings. Once we coach a practice and improve strategies for bringing those patients back in the door when they need to come in and for the things that they need to come in for; there is no reason that they couldn’t then deploy those same interventions and approaches for their entire patient panel. And that’s what happens. And so kind of one of these incidental outcomes of receiving support from Medical Advantage for their Medicare populations is our participants are also able to see improvement for their non-Medicare patients across the board.
And that’s just a win, a win-win, right? Keep doing what you’re doing and you’ll maximize performance in Medicare, but you’ll also improve revenue member satisfaction and delivery of care for your commercial patients at the same time.
Bill Riley: Very good. So, Meghan, Shelby, any anecdotal examples of what Darline is talking about? Where you’ve been involved, where it’s one intervention but it’s helping across multiple programs?
Shelby Courtney: I can speak to that myself too. Anytime you’re looking at processes like Darline said, you’re fixing where the root causes, it’s never just at surface level. So if you’re talking anything from something in their EMR, it’s gonna impact every health plan that they’re working with. So we don’t look at it as, we’re only gonna focus on your Medicare, but we’re working with the practice as a whole.
So, anytime you’re working in the EMR, when you’re doing documentation, billing and coding, you know, teaching them how to properly document, those are all skills we hope they carry on. Because it’s too hard to flop in and out between health plans. So you’re teaching the whole holistic way to take care of a patient no matter what health plan they’re in.
Bill Riley: Very good. Very good. Okay. As we start to wrap up here, Darline, I’d love to talk about a capability which we’re bringing to the table here, which is around covering the downside risk. If you could take us through that, please.
Darline El Reda: Yeah so when we started, we talked about moving away from the luxury of being in a value-based care contract that was upside only. Right. And that window closing. And now folks moving the contracts that have the potential for upside and downside and it’s no longer gonna be a choice. You’re going in order to compete and participate and frankly be able to work towards a larger upside, you must be willing to take some of the downside risk. Now, given the angst about this, Medical Advantage wants to remove that angst for providers.
We plan on covering the downside risk for our ACO. Participants, we do understand that many ACOs actually require their physician participants to fund a reserve pool of sorts. So kind of the bucket of money that they would set aside, should there not be savings, but not only, not be savings, but actually trigger downside risk, that’s not our approach.
We are betting on ourselves as we, you know, bet on partnering with our ACO physician members to make sure that they can stay focused on delivery of care, not miss out on the potential sharing of upside risk. and we will be covering the downside risk. So, you know no writing of checks from our providers to CMS at the end of the year.
Bill Riley: Okay. Excellent. Well, that basically takes us to the end of our time for today. Let me start by thanking our panelists. Great job. It’s always a lot of fun to do these things. I wish we could do them more often.
To you, our audience, thank you for joining us. We certainly hope that you found this information helpful and useful.
As soon as we hang up here, a survey will come up on your screen. I would ask you if you could just give us a couple of minutes and provide some feedback. These are simple questions, point and click, will just take a second, I promise. But we certainly would appreciate hearing from you.
Also there’s an area, if you’ve thought of any final questions, you can submit them there as well and if you’d like to speak to us in more detail, Darline, Meghan, Shelby, you can do that as well. And we’d love to hear from you.
So again, that’s it for today. Thanks again for joining us and we hope to see you again at a session in the future. Enjoy the rest of your day.
Medical Advantage Podcast: Thanks for joining us this week on the Medical Advantage Podcast where we discuss the ideas and technologies changing healthcare and what they mean to your organization. For more information, visit us at medicaladvantage.com and make sure to subscribe to the podcast on iTunes, Spotify, or wherever you get your podcast, so you never miss a show.