PRACTICE MANAGEMENT: THE ROAD AHEAD John I. Allen, Section Editor

Accountable Care Organizations: An Opportunity for Gastroenterologists G. Anton Decker Banner Medical Group, Phoenix, Arizona

From Gastroenterologist to Chief Medical Officer

This month’s article in the Practice Management: The Road Ahead section comes from Dr Anton Decker. Dr Decker is one of the few board certified gastroenterologists who is in a leadership position of a functioning accountable care organization (ACO). As such, his insights into ACO workings and funds flow are especially important. As we continue to note health system consolidation and changes in the formulas by which reimbursements are distributed, gastroenterology has a lot at stake. We are fortunate to have several gastroenterologists in leadership positions within large integrated delivery networks. John I. Allen, MD, MBA, AGAF Special Section Editor s a practicing gastroenterologist and Chief Medical Officer of a large medical group participating in the Pioneer Accountable Care Organization (ACO) program, I have an encouraging view of healthcare transformation. Banner Medical Group (BMG), Banner Health’s employed medical group, has a presence in 6 states and employs more than 1000 physicians. BMG is part of Banner Health Network (BHN), Banner Health’s ACO. Banner Health chose to form an ACO to maintain its competitive advantage in contemporary healthcare economics and improve patient health and experience by providing coordinated and cost-effective care. Through BHN, BMG participates in the Pioneer ACO program. My journey from a clinical gastroenterologist to a Chief Medical Officer immersed in the challenges and opportunities of healthcare reform has been exciting and educational. I will share my journey and perspective on what ACOs may mean to the practice of gastroenterology.

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Resources for Practical Application To view additional online resources about this topic and to access our Coding Corner, visit www.cghjournal.org/content/ practice_management.

I enjoyed clinical gastroenterology but became equally fascinated by the more global healthcare challenges; the United States spends an unsustainable $8402 per capita on healthcare,1 far higher than any other developed country, and yet she does not achieve superior outcomes or life expectancies. To obtain a seat at the table where healthcare delivery decisions are made, I sought out opportunities to expand my knowledge and credibility in the science of healthcare delivery: I volunteered for committees such as Quality, Electronic Medical Record, and Practice Operations. I read books and journals on healthcare economics, business, leadership, and management. When attending medical conferences, I made a point of attending talks on healthcare management, and I sought out opportunities to network with leaders in the field. Finally, I pursued a master’s degree in health administration and became certified physician executive through the American College of Physician Executives Program. Although a radical career move, the position of Chief Medical Officer of BMG provided me the opportunity to be on the forefront of healthcare reform. Before my arrival, Banner Health received approval from the Center for Medicare and Medicaid Services (CMS) to be a Pioneer ACO, 1 of 32 such ACOs in the country. Concurrent with the challenges of leading and managing a large, young medical group in 6 states, I had to rapidly learn rules of CMS ACOs and position the medical group to succeed as a component of BHN. A failed attempt at reading through the Patient Protection and Affordable Care Act (ACA)2 led me to search for articles and books on ACOs; however, most were outdated and based on 1990s managed care programs. My most useful source of information were the Abbreviations used in this paper: ACA, Affordable Care Act; ACO, accountable care organization; BHN, Banner Health Network; BMG, Banner Medical Group; CMS, Center for Medicare and Medicaid Services; EMR, electronic medical record; MSSP, Medicare Shared Saving Program. © 2014 by the AGA Institute 1542-3565/$36.00 http://dx.doi.org/10.1016/j.cgh.2014.08.009

Clinical Gastroenterology and Hepatology 2014;12:1769–1772

PRACTICE MANAGEMENT: THE ROAD AHEAD, continued administrative leaders of health plans and BHN, who had first-hand knowledge and literature of the “rule book” because they had communicated directly with CMS during the application and formation of Banner’s Pioneer ACO. My eyes were opened to the true costs of healthcare and the complexity of an uncoordinated healthcare system riddled with stakeholders.

Accountable Care Organizations A common misconception is that an ACO is a government invention or designation. An ACO is simply a group of providers who agree to be accountable for the quality, cost, and overall care of its beneficiaries. An ACO may have different ACO programs, which generally fall into 2 categories: commercial ACO programs, initiated by private payers, and government ACO programs, initiated by CMS.

Government Accountable Care Organization Programs After the passing of the ACA, CMS initiated 2 ACO pilots: the Medicare Shared Saving Program (MSSP), administered by CMS itself, and the Pioneer ACO program, administered through the Center for Medicare and Medicaid Innovation, a CMS subsidiary.2 The goal for these ACO programs is to achieve the Triple Aim, as defined by the Institute for Healthcare Improvement: improving the patient experience (including quality and satisfaction), improving the health of populations, and reducing the per capita cost of healthcare.3 Participation in either of these programs is voluntary and requires application and approval by CMS. The Pioneer program was designed for organizations experienced with taking financial risk for a population and capable of providing coordinated care. Thirty-two organizations participated in the Pioneer program beginning January 2012. Nine organizations withdrew from the program in 2013. A detailed description of the differences between the MSSP and Pioneer Program falls outside the scope of this article. In essence, the Pioneer Program involves higher financial reward but also the greater risk of loss if no savings should be realized. Starting in year 3 of the initiative, those organizations that have earned savings during the first 2 years are eligible to move to a population-based payment arrangement and full-risk arrangements that can continue through optional years 4 and 5. Pioneer ACOs are required to develop similar outcomes-based 1770

payment arrangements with other private payers by the end of the second year. A Medicare beneficiary (patient) is aligned by CMS with an approved ACO on the basis of the beneficiary’s pattern of utilization during a 3-year alignment period. It is the ACO’s decision on how to attribute the beneficiary to a primary care provider. After CMS aligns a beneficiary with an ACO, the ACO is required to notify the beneficiary of their participation. Beneficiaries aligned with an ACO maintain full benefits under the Medicare fee-for-service system and do not need a referral to see a specialist inside or outside of the ACO. One of the key features that differentiate these modern ACOs from managed care programs in the 1990s is that patient movement is not restricted. Thus, a Pioneer ACO assumes responsibility for the total healthcare cost of the beneficiaries attributed to its providers, even though these patients may choose to see providers outside of that ACO. At first glance this seems unjust; however, it encourages the ACO to build relationships of trust with their patients on the basis of a strong primary care base and an integrated delivery model. By default, CMS shares beneficiary claims data with the ACO. The ACO must give the beneficiary written notification and the option of opting out of data sharing. Even when claims data are not shared with the ACO, the ACO is still responsible for that beneficiary’s total spend and quality outcomes. In the Pioneer program, the percentage of financial savings (up to 75%) shared with the ACO is dependent on how the ACO performs against benchmarks for each quality measure. There are 33 quality measures in the domains of patient experience, care coordination and safety, preventative health, and at-risk populations. Only 1 measure, ACO 19, directly applies to gastroenterology: the percentage of patients aged 50–75 years who receive appropriate colorectal cancer screening (fecal occult blood test during the last 12 months, flexible sigmoidoscopy during the reporting period or the 4 years prior, or colonoscopy during the reporting period or 9 years prior). The door opener for performance points that contribute to a composite score for all measures is the 30th percentile (19.91%). After this, performance points are awarded according to a sliding scale. Reasons for exceptions, such as terminal illness, total colectomy, or colorectal cancer, must be documented. Patient noncompliance is not an acceptable exception. A percentage of CMS financial savings for the beneficiaries in the ACO, with a predetermined cap, are distributed to the ACO. The ACO reimburses itself for administrative overheads and then distributes the remaining money with the providers on the basis of any prearranged agreement. CMS does not prescribe how the ACO

PRACTICE MANAGEMENT: THE ROAD AHEAD, continued distributes the savings to its providers. For example, an ACO may choose to reinvest the savings in infrastructure, distribute the savings with all its providers, or only the primary care providers. In the Pioneer model, the ACO is also at risk for financial loss up to a maximum of 15%.

Pioneer and Medicare Shared Saving Program Accountable Care Organization Results to Date By the end of year 2, ACOs in the CMS Pioneer ACO Model and MSSP generated over $372 million in program savings. In total, ACOs qualified for shared savings payments of $445 million. Pioneer ACO year 1 and 2 results have been published. In year 1 the cost of care for Medicare beneficiaries aligned with Pioneer ACOs grew by 0.3% in 2012 compared to 0.8% for non-Pioneer ACO aligned beneficiaries during the same period.4 Pioneer ACO beneficiaries outperformed the control group in 15 clinical quality measures for which comparable data are available. At the end of year 1, 9 organizations chose to leave the Pioneer Program, 7 going over to the MSSP and 2 leaving the ACO programs entirely. During the second performance year, Pioneer ACOs generated estimated total savings of over $96 million and qualified for shared savings payments of $68 million.5 The per capita growth in spending for the Pioneer ACO program was 1.4 percent, which is approximately 0.45% lower than traditional Medicare fee-for-service. At the end of year 2 Pioneer ACOs showed improvements in 28 of the 33 quality measures and experienced average improvements of 14.8 percent across all quality measures. Banner Health Network distributed Pioneer ACO savings at the end of year 1 and 2 to the networks in the ACO. BMG, as one of those networks, chose to invest these savings in infrastructure development. The MSSP ACO results from year 1 only have been published. 53 MSSP ACOs reduced spending $652 million below their targets and earned performance payments of more than $300 million. Improvement was seen in 30 of 33 quality measures. Pioneer and MSSP ACO performances have not yet formally been compared.

What Do Accountable Care Organizations Mean for Gastroenterologists? Quality and payment data are becoming increasingly transparent not only to patients but also between

providers, payers (including CMS), and health systems, which function like payers in an ACO model. CMS, private payers, and ACOs are highly motivated to meet the Triple Aim to remain financially viable and to attract new beneficiaries.6–8 When viewed from the vantage point of the ACO or payer, the enormity of this undertaking is daunting, and limited attention can be spent on each specialty because of the lack of resources. This creates the opportunity for gastroenterologists, gastroenterology groups, and their representative societies to be proactive in setting quality standards and coming forward with bundled payment options.9

Quality Measures Gastroenterology quality measures should be determined by gastroenterology societies. The appropriate use of quality data is dependent on the accuracy of the structured fields in the electronic medical record (EMR). Gastroenterologists must take a leading role in ensuring that the correct data are recorded in the EMR where they practice and that processes are in place to record the data in a timely manner. By using colorectal cancer screening as an example, there are logistical nuances that must be agreed on: (1) Who is responsible for recording the performance of colon cancer screening in the EMR, whether that is the primary care doctor, the gastroenterologist, or someone else? (2) How and where is it documented when the screening was performed at another institution? (3) Is there an automatic feed from the endoscopy reporting software into the EMR after the performance of the colonoscopy, or is this a manual process; if so, by whom? None of this can be left to chance, and practicing gastroenterologists must take a keen interest in ensuring that quality data that might affect their reported performance and their reimbursement are accurately recorded at their local institutions.

Bundled Payments Bundled payments are appealing to payers and ACOs not only because they potentially lower expenses but, more importantly, they make expenses predictable and improve ability to manage financial risk and to share this risk with providers. As an additional benefit to the healthcare system and patients, bundled payments require coordination of care. The American Gastroenterological Association convened a physician workgroup in 2012 that developed a framework for a colonoscopy bundled payment that includes the 1771

PRACTICE MANAGEMENT: THE ROAD AHEAD, continued pre-procedure, procedure, and post-procedure periods. Specific payment for the bundle was not recommended but left to the local physicians and payers to negotiate. A recent publication in this journal by Minnesota Gastroenterology reports the deployment of a colonoscopy bundle with 3 local self-insured employers; however, specifics of the financial arrangement and outcomes are not presented.8 Banner Health is presently working with the American Gastroenterological Association on colonoscopy and Crohn’s disease bundled payment options.

References 1.

Centers for Disease Control and Prevention. Healthcare Expenditure. 2010. Available at: http://www.cdc.gov/nchs/ fastats/hexpense.htm. Accessed November 11, 2013.

2.

Patient Protection and Affordable Care Act, 42 U.S.C. § 18001 et seq. (2010). H.R. 3590(2010). Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff (Millwood) 2008;27:759–769.

3. 4.

Centers for Medicare & Medicaid Services. Pioneer Accountable Care Organizations succeed in improving care, lowering costs. 2013. Available at: http://www.cms.gov/Newsroom/MediaRelease Database/Press-Releases/2013-Press-Releases-Items/2013-0716.html. Accessed November 11, 2013.

5.

Centers for Medicare & Medicaid Services. Medicare ACOs continue to succeed in improving care, lowering cost growth. 2014. Available at: http://www.cms.gov/Newsroom/Media ReleaseDatabase/Fact-sheets/2014-Fact-sheets-items/2014-0916.html. Accessed September 28, 2014.

6.

Kisloff B. Accountable care organizations. Clin Gastroenterol Hepatol 2012;10:442.

7.

Rustgi AK, Allen JI. The house of gastrointestinal medicine: how academic medical centers can build a sustainable economic clinical model. Clin Gastroenterol Hepatol 2013;11:1370–1373.

8.

Taylor IL, Clinchy RM. The Affordable Care Act and academic medical centers. Clin Gastroenterol Hepatol 2012;10:828–830.

9.

Ketover SR. Bundled payment for colonoscopy. Clin Gastroenterol Hepatol 2013;11:454–457.

Conclusion The journey from clinical gastroenterologist to a Chief Medical Officer in an institution at the forefront of healthcare reform has transformed my understanding of the complexities of healthcare economics and the practice of gastroenterology. Gastroenterology societies have long been active in successfully lobbying for their members’ and patients’ interests. In the world of ACOs and financial risk sharing, individual gastroenterologists and their practices should also become leaders of payment reform and accurate quality reporting within their local health systems. Alternatively, quality measures and payment methodologies will be developed for gastroenterologists by payers who do not have the same knowledge of what should be measured and rewarded in the care of patients with digestive diseases.

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Reprint requests Address requests for reprints to: G. Anton Decker, MBBCh, MRCP, FACG, CPE, MHA, Banner Medical Group, 1441 North 12th Street, Phoenix, Arizona 85006. e-mail: [email protected]; fax: (602) 747-4505. Conflicts of interest The author discloses no conflicts.

Accountable care organizations: an opportunity for gastroenterologists.

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