Using the MSSP ACO Model in a PCP-centric Solution Impacts Overall Costs, Improves Care

As fee-for-service (FFS) phases out and value-based models are increasingly embraced, implementing a primary care physician (PCP)-centric solution via a Medicare Shared Savings Program (MSSP) Accountable Care Organization (ACO) model will reduce costs while improving care, according to information presented by Hymin Zucker, MD, CMO, and Amy Holm, MHA, of the Triple Aim Development Group.

There is no better way to learn the new payment system than being in an ACO, they said, citing that 30% of Medicare payments will be via alternative models by 2016, and increasing to 50% by 2018. The value-based payment modifier (VM) assesses both quality of care furnished and the cost of that care under the Medicare Physician Fee Schedule. This year, the Centers for Medicare and Medicaid Services (CMS) applied the VM to groups of physicians with 100 or more eligible professionals; next year it will be applied to groups of physicians with 10 or more, with all physicians likely to be phased in by 2017. By 2016, 30% of FFS models will be under some value-based payment and by 2018, 90%.

Physician group practice cost and expense findings have shown that increased primary care involvement impacts overall costs, giving rise to what the presenters called the PCP-centric solution. The PCP environment is moving toward full-risk contracting, which is defined as accepting a fixed payment for the delivery of all health care services for a given population. 

Risk contracting requires the ability to sort population data to define “risk readiness.” These data include beneficiary retention, patient access, workflow/office operations, quality/outcomes, cost and utilization management, and patient experience/engagement.

Preparation in this movement toward full-risk contracting requires organizing and becoming an MSSP ACO, understanding the rules required to practice accountable care, and defining the purpose and setting goals to change the culture of the PCP environment. The solution, they continued, is getting physicians to change practice culture by using a proactive approach. A proactive approach incorporates policies, procedures, principles, and standardization of processes (whereas a reactive approach analyzes what has already occurred and results in process changes).

Implementing a proactive approach should consist of a survey for risk readiness, introducing population health dynamics (eg, beneficiary retention, appropriate access, ER reduction program, readmission reduction, transition of care), and setting expectations for expense reduction. 

Sharing results of a survey of PCP offices for existing ACO practice patterns, the presenters indicated that 40% of PCPs did not know what an ACO was; 80% did not educate their staff on ACO material; 40% had answering machines directing patients to the ER if there was an emergency; and 60% worked 4 days a week only.

After impact, however, survey results showed 40% increased same-day appointments and worked 5 days per week; 45% improved their current on-call process and had a PCP answer the phone during non-office hours; and 45% had a relationship with hospitals and skilled nursing facilities (SNF), resulting in PCP notification when patients were in the ER, hospital, or SNF. All of the aforementioned steps decreased ER visits, increased patient retention, increased quality metrics, and increased Consumer Assessment of Healthcare Providers and Systems scores.

Thus, the following key performance measures should be established and are attainable by PCP efforts:

•    Beneficiary retention >70%

•    Beneficiary access to care (eg, quarterly office visits) >70%

•    Emergency utilization <500/1000

•    Readmissions for 30, 90, and 180 days <50%

•    Transitions of care: PCP office visit post discharge from hospital and SNF >70%

•    Per member per month cost reductions over time

•    Quality of care metrics (eg, annual wellness visits >70% [metric examples include flu/ pneumococcal vaccinations, weight screening, cancer screenings, etc])

These key performance measures, the presenters said, form a foundation for ACO success and assumption of risk and create competition for recognition.—M. Mihalovic