Advancing the ACO Model in Podiatry

Paradigm shifts in a profession can be subtle, taking time to be understood and appreciated. In my observation, the podiatric profession has undergone a significant paradigm shift, of which few are aware.
 
Upperline Health was the first specialty organization to be awarded an accountable care organization (ACO) contract. (For full disclosure purposes, I own stock in, and am an employee of, Upperline Health.) I am sure you are probably thinking, so what does this mean for those not affiliated with Upperline? It means more than you can imagine, but understanding why requires some background information.
 
The Center for Medicare and Medicaid Innovation’s (CMMI) stated strategy is a “goal of achieving equitable outcomes through high-quality, affordable, person-centered care.”¹ CMMI developed 5 strategic objectives to drive change in the US health care system:¹
1.    Drive accountable care
2.    Advance health equity
3.    Support innovation
4.    Address affordability
5.    Partner to achieve system transformation
 
CMMI’s white paper goal of improving quality and outcomes for Medicare and Medicaid beneficiaries is the primary endpoint, but a secondary endpoint is broader health care transformation.¹ CMMI was “created in Section 3021 of the Affordable Care Act (ACA) to test payment and delivery models expected to reduce program costs and improve or maintain the quality of care for Medicare, Medicaid, and Children’s Health Insurance Program (CHIP) beneficiaries.”¹ Congress enabled CMMI to test various models by granting them a waiver of authority for both Medicare and Medicaid (limited).
 
Each model developed during the past decade provided insight into what was working and not working during the progression towards a sustainable value-based care model. All Medicare and most Medicaid beneficiaries will be in an ACO by 2030, so the lessons learned provided a valuable roadmap for the future of health care.¹ Advancing the ACO model will include some of the stated next steps per the white paper, providing podiatric medicine and surgery an unparalleled opportunity:¹

1.    Test voluntary beneficiary alignment and attribution methodologies, benefit enhancements, and beneficiary engagement incentives to facilitate accountable care relationships between beneficiaries and care teams.

2.    Include outcome measures that are meaningful to people, such as functional status, out-of-pocket costs, and patient-reported outcomes measures (PROMs) to ensure meaningful accountability for quality improvement.

3.    Create and test combinations of risk levels, per beneficiary per month payments, and population-based and advanced payment options to increase the number of health care providers and organizations—including primary care practices and safety net providers—that can participate in accountable and total cost of care models.

4.    Test incentives to drive coordination between providers responsible for accountable care relationships and specialty providers accountable for delivering high-cost episodic and/or complex care.

5.    Test approaches that enable ACOs to manage more high-cost specialty and episodic care using lessons learned from bundled payments and other models.
 
As a primary care provider of the lower extremity and a surgical specialty, I feel podiatric medicine and surgery is uniquely positioned for the changing landscape. This duality of care provided by podiatric physicians and surgeons is potentially an essential cog in the value-based care wheel, mainly due to the complexity of our patient base. Providing cost-effective care while producing data-driven outstanding PROMs in a cost-effective treatment model for patients suffering from multiple comorbidities aligns with CMMI’s vision and mission. These population health models are a golden opportunity to solidify the profession’s future but getting access to the opportunity for the profession was an unknown.
 
Of all the other specialties in medicine, for a podiatric group to get the first specialty ACO contract and then deliver the results envisioned by CMMI is monumental for the profession. Just saying you are good at what you do is not enough. You must prove it. In the value-based care model, the proof is multifactorial and data-driven. As other key stakeholders in health care see podiatric medicine and surgery as leading surgical specialties into the new millennium, they will follow CMMI by embracing it to the fullest.

Here is an example of the support Upperline Health offers to patients.
 
The future is bright for the profession, and I am proud to be part of an organization that is integral in leading the profession into the value-based care model to benefit all my podiatric colleagues.

Dr. DeHeer is the Residency Director of the St. Vincent Hospital Podiatry Program in Indianapolis. He is a Fellow of the American College of Foot and Ankle Surgeons, a Fellow of the American Society of Podiatric Surgeons, a Fellow of the American College of Foot and Ankle Pediatrics, a Fellow of the Royal College of Physicians and Surgeons of Glasgow, and a Diplomate of the American Board of Podiatric Surgery. Dr. DeHeer is a Partner with Upperline Health and the Medical Director of Upperline Health Indiana. Dr. DeHeer discloses that he is a speaker for Paragon 28, and that he owns stock in and is employed by Upperline Health.

References
 
1. Centers for Medicare and Medicaid Services. CMS Innovation Center.

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