Interview With ACO Physician

As part of our special edition on the state of health reform in wound care, TWC offers this exclusive Q&A with a member of the nationally distinguished Medicare Pioneer ACO.   On Jan. 1, 2012, the Centers for Medicare & Medicaid Services (CMS) launched its Pioneer Accountable Care Organization (ACO) Program, a collaborative of healthcare entities selected to participate in an initiative to examine the clinical and financial effects of a Medicare ACO shared-savings program. Overseen by the Center for Medicare & Medicaid Innovation (CMMI), the Pioneer ACO is designed to work in coordination with private payers by aligning provider incentives that will improve quality and health outcomes for patients across the ACO and achieve cost savings for Medicare, employers, and patients. Applicants were chosen to launch the ACO on Jan. 1, 2012, based on previous engagement in similar programs that featured coordinated patient care and quality metrics.   According to CMS officials, savings from both the Pioneer ACO, which is operating on a three-year pilot venture during which clinical outcomes and cost savings will be evaluated, and its Medicare Shared Savings Program, an initiative that helps eligible providers, hospitals, and suppliers form ACOs that’s currently accepting applications, have exceeded $380 million.   Today’s Wound Clinic recently spoke with Parag Agnihotri, MD, medical director, continuum of care, with Sharp Rees-Stealy Medical Group, San Diego, a facility among the 32 Pioneer ACOs. We discussed the initiatives within the Sharp HealthCare ACO, including those directly impacting wound care; the clinical and financial motives behind his ACO; the estimated success of the ACO; and the future plans for the ACO. What follows is an excerpted Q&A from our conversation.   Today’s Wound Clinic (TWC): Who are the members of your ACO?   Parag Agnihotri (PA): The Sharp HealthCare ACO includes three partners — Sharp Hospital, Sharp Rees-Stealy Medical Group, and Sharp Community Medical Group.   TWC: What has been the most significant impact on your wound program since the ACO formed?   PA: I think we are looking at a team-based model of delivering wound care in the most timely manner. It’s all about getting the right person the right care in the right time period.   We recently partnered with a clinic-based wound care specialist, but there are also many patients in the home who cannot make the journey to the wound care clinic on a regular basis, or it’s a significant burden. But because of our ACO relationship we’ve been able to build a home care program where nurse practitioners (NPs) are seeing patients in the home and providing ongoing virtual consultation through telehealth interface and providing that wound care specialty expertise so that we can avoid unnecessary hospital visits and hospitalizations. And we couldn’t have done this without the ACO or the new payment model.   TWC: What have the financial impacts been?   PA: Before the ACO, if you were seeing a non-managed care patient there was never a financial incentive for the healthcare industry to really manage the sickest of the sickest patients well. Now, from a business point of view, there is a big financial incentive to manage the sickest patient and to reduce the burden of chronic disease because of cost savings. We’re not seeing more money just for seeing these patients; it’s all about the ACO payment model and meeting quality benchmarks.   I think that what we’re seeing is an overall reduction in admissions to hospital and emergency room visits, and I’m pretty sure that there are patients with wound care issues who we’re able to also keep out of post acute care and the nursing home by caring for them at home and demonstrating the cost savings there as well.   TWC: How is your ACO payment structured?   PA: There are two ways you’re paid through the ACO relationship: On top of the traditional fee-for-service payments, if you can demonstrate that you’ve provided quality care — for example, with a wound care patient you ensured that they received a pneumonia vaccination, or their diabetes is under control, or their cardiovascular conditions are well managed — that’s a gateway into a shared-savings bucket. So, if tomorrow the wound care patient uses fewer hospital visits for patients, Medicare keeps 50% of the money and the other 50% comes back to the group. And you can apply that money in different ways, so not only do you get paid for submitting claims for Medicare-approved charges, but you get the extra incentive dollars for meeting quality standards.   TWC: How are quality measures tracked?   PA: We have 33 specific measures from CMS that we have to report to Medicare, which include preventive care, care coordination, taking care of chronic diseases, etc. We not only have to show that patients had access to care and were satisfied with their care, but things like vaccination records, their cancer screenings, fall screenings, etc.   For wound care patients, one of the most important things is nutrition, so for Medicare patients we now have to show how they’re doing with their nutritional status. Are they declining? Are they overweight? And most of the time with seniors it’s under-nutrition. So our participation in this ACO has helped us be proactive with our patients in their nutrition management.   TWC: How did CMS provide you with your ACO patients?   PA: There is a complex attribution model through which CMS assigns you patients who they believe should be part of the ACO. Based on billing data and algorithms, it’s been determined that in some form these patients have used Sharp HealthCare in prior years. At that point we reached out to all those patients who reside in the community so that we can maintain an ongoing relationship with them. Based on risk stratification we identified the top 10% of our high-risk patients, and for them we deploy different resources, whether it be a case manager, or home health nursing, or NPs.   TWC: How is the ACO aligning with healthcare reform?   PA: There are a couple care-delivery programs that we are advancing within the medical group to align with healthcare reform. One is a post acute care model based in the nursing facilities, where the goal is to make sure patients are receiving the appropriate skin care for the right duration of time. The second is a home-based program for NPs whose roles are to care for our frail seniors who are unable to get into the clinic or our younger patients who have chronic medical conditions. Transportation can be a major barrier for many patients.   We’re also looking into telehealth programs to remotely improve the lives of our patients who are living with chronic conditions.   TWC: Was your hospital responsible for hiring any of the qualified healthcare professionals who may have had independent practices as part of the ACO?   PA: The ACO has a governance board of members from Sharp Medical Group, an independent practice association, and the hospital. As part of the governance board, the hospital does have a voice in which independent practitioners can be part of the ACO. But most of them come through the Sharp Community Medical Group, which is the independent practice, and they decide who comes on board and who does not.   TWC: Are you involved in any other risk-sharing contracts with private payers?   PA: Most of our managed-care contracts are risk-sharing. We assume full risk for almost all of our commercial contracts, which means we take the full hospital risks, skilled nursing homes risk, pharmacy risks, etc. If the wound care management doesn’t go well it does affect the financial risks.