Terry Mills, M.D., shares a light moment with a young patient in a physician-owned multispecialty clinic in Wichita, Kan. His work there in 2008 preceded eye-opening experiences associated with accountable care organizations.
When HHS' much anticipated proposed rule on the Medicare Access and CHIP Reauthorization Act (MACRA) was released late in June, many physicians across the country heaved a sigh of relief.
Although the proposed rule needs improvement, at last there was a blueprint, of sorts, to guide the massive shift in Medicare physician payment.
There was a very different reaction from others who remain unconvinced that this future payment environment -- with its advanced payment models (APMs) and Merit-based Incentive Payment System (MIPS) tracks -- will work for them and their patients.
But what many physicians may not recognize is that they've been doing the preparatory work leading up to these changes for years.
That certainly is the case for physicians engaged in accountable care organizations (ACOs) -- defined as a group of doctors, hospitals and other health care professionals who come together voluntarily to give their patients coordinated, high-quality care.
- Family physicians who have experience with accountable care organizations (ACOs) are well prepared to tackle new payment models.
- Physicians in ACOs already have dealt with infrastructure challenges and learned to collect and report data.
- Physicians without ACO experience can begin learning skills they'll need to participate in new payment models by choosing a few clinical goals for their practice and figuring out how to measure them; physicians likely will find features built into many electronic health record systems useful in their efforts.
Perfect Timing in Tulsa
Terry Mills, M.D., is senior medical director at St. John Clinic -- part of Ascension Health's larger Tulsa, Okla.-based St. John Health System. The clinic is in its third and final year of a Medicare Shared Savings Program (MSSP) ACO.(www.cms.gov)
Mills oversees all of the clinic's primary care operations, including 130 primary care physicians and midlevel providers who care for 157,000 patients spread throughout 24 clinic sites; the ACO covers 11,000 of these patients.
He also chairs the AAFP's Commission on Quality and Practice. "I know our members are pretty anxious about MACRA; there's a lot swirling around," Mills told AAFP News.
But physicians at St. John have a leg up on what's ahead.
"At St. John, we did not necessarily expect to make money with the ACO. We expected to gain valuable critical experience," said Mills. "The ACO was seen as a way to start building the infrastructure, figure out the data collection and reporting, start aligning our physicians and, most importantly, engaging our community in order to be successful in the future," he said.
But can physicians who've not had the benefit of an ACO "boot camp" experience still succeed in these future models?
"You don't have to be in an ACO or a recognized medical home to do this," Mills insisted. "Family medicine is heart and soul about serving our patients and communities; we bring value with almost everything we do. The rub comes down to data collection and proving that value.
"If you've got four docs in a private practice, I guarantee those four doctors can sit down at lunch on Tuesday with their staff, decide on their four big clinical goals this year, and then figure out how to measure that. Those are the basics."
He was emphatic that family physicians can no longer ignore the value-based paradigm, stay on the fee-for-service hamster wheel and expect to do well. "That's not going to be a comfortable position in a couple of years," he said.
Prioritizing Patients in the Heartland
The Mosaic Life Care ACO launched in 2012 with a total of 29,000 patients. This MSSP ACO located in North Kansas City, Mo., and northwestern Missouri soon will expand south into the greater Kansas City area, including into Kansas.
It's a success story on several fronts.
In 2014, the first year of a three-year contract, Mosaic earned $5.1 million in shared savings. In 2015, Mosaic earned $2.1 million in shared savings and ranked second in the nation for quality performance.
Chef Sam Hudgins leads a cooking class at Mosaic Life Care Shoal Creek as part of the wellness and prevention patient education efforts associated with Mosaic Life Care.
Family physician and retired Air Force Brig. Gen. John Owen, M.D., is also board-certified in emergency medicine. For the past two and a half years, he has served as medical director of Mosaic's emergency department, which recorded 65,000 visits last year.
He told AAFP News that much of his time is spent helping attending physicians "provide optimal care, but in a cost-effective and patient-friendly process."
That's really what the ACO process is all about, Owen added.
One of the most effective changes has been the integration of nurse practitioners as care coordinators into the Mosaic system, he said. For instance, a nurse practitioner can make a home visit for a patient who was seen in the emergency department or one of the clinics for an exacerbation of congestive heart failure.
That's the next day -- seven days a week, 365 days a year -- to assess what could be contributing to the exacerbation, adjust medications and make active interventions.
"We've seen some of these people markedly decrease their utilization from as many as 30 hospital admissions a year and their lifestyle and quality of life improve dramatically," said Owen.
He called caring for patients within the context of the ACO "a team sport" that includes office-based care coordinators reviewing a patient's medications and care plan and then scheduling the follow-up appointments.
Accelerated scheduling of X-rays, lab tests and physical therapy is an integral part of the Mosaic experience. And patient wellness is key -- thus the inclusion of cooking and exercise classes.
Everything is aimed at increasing efficiency and patient education, Owen explained.
"You have to be ready to participate in providing optimal care as a complete team rather than the completely physician-centered process we did for years. And I was part of that -- it's what we did," he said.
"No one ever tells me I need to spend less money on our ACO patients. In fact, I'm incentivized to start programs that get them the right care. Because a good ACO will recognize that giving people the right care and doing it expeditiously and efficiently is not only going to be better for the patient, it's going to save the ACO money.
"It will also prepare physicians for participation with MACRA," Owen observed.
Edward Hett, M.D., discusses implementation of team-based care in Via Christi Health Clinics with Pete Moyer, manager of care redesign, and team member Megan Colby, L.P.N., a patient-centered medical home practice coach.
System Changes in Kansas
Some 200 physicians are part of the Via Christi Health MSSP ACO that was established in 2014 and also is in the final year of a three-year contract, with another three-year commitment planned.
Edward Hett, M.D., of Wichita, a practicing family physician for 32 years, has nurtured the ACO from the beginning.
He told AAFP News that he started his career as a solo doc, grew the practice to six physicians and then transitioned into employment with Via Christi -- another Ascension member -- where he's had various administration roles for the past 20 years.
Now Hett spends about half his time with patients and the other half as medical director for new models of care, "which includes all of the ACO work and the transformation of practice into team-based care."
Getting the health IT part right -- creating a system that could pull in both medical claims data and electronic health record (EHR) data -- was a huge hurdle.
"It's taken us into our third year to really feel like we now have a software system that can begin to put that together in a way that's meaningful for clinicians," said Hett.
Having a mature health IT system is perfect preparation for the coming MIPS, APMs and other new payment systems because the system collects the data needed to participate.
"So I think it's placed us in a really good position moving forward into 2017 and the years beyond," he said.
But what about physicians who haven't had three years of experience in an ACO and don't have a flourishing health IT system?
For physicians who've implemented an EHR -- and that's the majority of family physicians around the country -- they should immediately learn to use a disease registry, said Hett.
"Many of the EHR companies have disease registries built in, and that's the piece people will need to get up and running if they're not in an ACO," he added.
Hett reflected on the successes he attributes to the ACO. At the top of his list was the transformation of the primary care office concept into a team-based model that included shifting care coordinators and navigators out of insurance companies and into the practices.
Those important team members now "manage the care of complex patients in a way that brings all of the pieces together at a lower cost and has created a much friendlier environment for our physicians to work in," said Hett.
He counted improved patient satisfaction scores "as the biggest win we've had" with the ACO experience.
Hett encouraged his physician colleagues to stay positive. "We know patients better than anybody -- we know the practice environment and what will work and what won't work better than anyone -- and we need to use that knowledge to craft a better system for everybody," he said.
The U.S. health care system is in chaos, Hett noted. That's why now is the perfect time to ditch the entrenched and ineffective system of the past and create something new.
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