Placing an emphasis on case management for patients with the most serious conditions and co-morbidities has paid off for two participants in the Pioneer ACO program.
Three years after launching its Medicare Accountable Care Organizations program, also known as the Pioneer ACO program, the Centers for Medicare & Medicaid Services has published financial results and quality performance data.
The results for the program's first two years, made public by CMS on Oct. 8, show that the biggest financial winner is Montefiore Pioneer ACO in NY.
The Bronx-based academic medical center captured shared savings totaling $27.4 million during the combined first and second years of its participation. Savings in the first year totaled $14 million and in the second year, $13.41 million.
That's nearly $5 million more than the second place Pioneer ACO participant, Banner Health Network of Phoenix, AZ.
Overall in the second year of the program, CMS says participants generated $96 million, and qualified for $68 million in shared savings, with $41 million in savings to the Medicare Trust Fund.
Of the original 32 Pioneer ACOs participants, 13 have left the program. Three of the Pioneers had to pay back between $1.61 million and $2.89 million, and six other organizations received no shared savings.
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Stephen Rosenthal, vice president of Montefiore ACO's network management, says one reason his organization has had success with the program is that it practices some of the principles of population health management. Montefiore, he says, places a special focus on people with diabetes, who require intensive management. In the Bronx, one in five residents has diabetes.
"We identified those patients whose diabetes is out of control," and target them with visits from diabetes educators and periodically, house calls from physicians who just do only that full time
Cost-Effective House Calls
While Montefiore manages 25,000 Medicare beneficiaries, there are enough patients to make house calls cost effective because Montefiore actually has ACO-like contracts to manage 300,000 patients. It's still costly, says Rosenthal.
"I spend $100 million a year to manage $2 billion in expenses for those 300,000 lives," he says. That means a payroll with 1,000 employees, including case managers, clinicians, and social service workers.
"They certainly have done very well on the shared savings side," says Josh Seidman, vice president of the Avalere Health consulting group. "That's certainly something they can be proud of."
He notes, however, that the Bronx has "an inherently sicker population," which might mean that Montefiore had more patients with conditions that generally are more expensive to treat, and for whom costs could be lowered with more intensive management.
"It suggests that maybe there are some opportunities, if you're managing sicker, more complicated patients… it's more important that you figure out better ways to manage population health."
"It's an important hypothesis to test, and we're probably going to be looking more into this," Seidman says.
Provider-driven Population Health
A lot of Montefiore ACO's spending does indeed go to population health, Rosenthal says. It goes to promote healthy eating, asthma management, heart disease prevention programs, and health fairs to help its members maintain healthier lives, and sustain those programs year after year.
That approach is different from how health insurance companies traditionally approach population health issues. Payers tend to be "always thinking about whether their [enrollees] are going to be with you the next year, because there's a fair amount of turnover with insurance companies," Rosenthal says.
But patients who rack up the highest expenses— those with the most serious conditions and co-morbidities—have care plans that are individually tailored.
For example, Rosenthal says, "I'm paying attention to the fact that this woman can't go out shopping so I'm bringing food to her house, because otherwise she's not going to have an appropriate diet to manage her diabetes. And the other one, living at home with her family, isn't going to have that issue, but might have different challenges."
The job of managing 300,000 lives, including the 25,000 Medicare fee for service beneficiaries assigned to Montefiore's Pioneer ACO, is like the job of an air traffic controller, he says. Patients go in and out of high intensity monitoring throughout the year, like planes moving through controlled airspace.
Another Winner
Another shared savings winner, although much farther down on the list, is Park Nicollet Health Services of Minneapolis, which earned no shared savings in year one of the program but took back $2.09 million in year two. With infrastructure costs, that may mean the ACO program realized a very slim positive margin on its balance sheet.
Donna Zimmerman, senior vice president of government and community relations for Park Nicolet, says her organization "never set out with the Pioneer program to make money," especially since Medicare fee-for-service beneficiary costs in Minnesota are already among the lowest nationally.
The organization's leaders knew that finding savings would be tough. They joined the demonstration project because "CMS wants to move from fee-for-service to value payments to improve care, and we want to be part of that solution because it fits in with our overall philosophy," she says.
Park Nicollet's program has 14,000 attributed Medicare fee-for-service enrollees and has the advantage of being an integrated system with a health plan and a large medical group. It took time to get its programs for seniors squared away, which is why, Zimmerman says, the program lost money in the first year.
By the second year, improvements were achieved, she says, through investments in care coordination and work with skilled nursing facilities.
Home Visits from First Responders
One aspect of the Park Nicolet Pioneer ACO that has been surprisingly rewarding its use of local firefighters and paramedics as part of case management teams.
"When people are discharged from the hospital, within the first 24 hours, they get a home visit from city firefighters who come to their home and talk with them about home safety. They check a few things, [such as] if they have access to food or whether they need a hookup with Meals-on-Wheels."
"These are the individuals who will respond if someone falls at home or gets sick. They're trusted, and they're able to provide a bit of support and encouragement as well."
The program has been so successful, we're expanding it to other cities," Zimmerman says.
Pioneer ACO Defectors
Still, the field of Pioneer ACOs is thinning, with 13 of the original 32 organizations having bowed out and three of the remaining 19 opting to defer "reconciliation" until the end of the third performance period.
3 More Pioneer ACOs Say They Will Quit
Defectors often cite a lack of financial viability as one of the key reasons for leaving the program. CMS officials have indicated they may be changing some of the calculation algorithms for year three and beyond to more accurately reflect local, national, and regional spending, with which each organization is compared.