The FamilyCare Medical Group in Syracuse, N.Y., considered but rejected Medicare's accountable care initiative because of a lack of needed capital.
The doctors were then approached by an insurance company with an interest in accountable care and the information technology resources the doctors needed. A deal was made.
Doctors will invest time, but not the significant cash needed for hardware, software and staffing to manage medical care for 12,000 seniors enrolled in Medicare, said Dr. David Page, medical director of the Accountable Care Coalition of Syracuse, one of Medicare's latest ACOs. “We're a bunch of primary-care doctors,” said Page, who founded the 65-physician practice. “We don't have that capital floating around.”
Medicare's launch of accountable care has proved popular, attracting small and rural providers along with the large, well-funded medical groups and health systems considered best positioned to form ACOs.
The venture has mushroomed since January, to the satisfaction of federal officials who said the growth proved naysayers wrong.
The Syracuse ACO was one of 89 new ones named last week. “And I think, contrary to some fears that were expressed last year, we have a very strong program that exceeds our goals that we had for the first year,” Jonathan Blum, principal deputy administrator and director of the Center for Medicare, told reporters.
But it has come with some snags, including delays for data that providers deem crucial to success. Doctors and hospitals found other data unnecessarily cumbersome and lobbied the CMS for a fix.
And as hundreds more organizations are expected to apply for the next round of contracts, it's still too early to know whether the ones in the program are delivering better care at lower costs, as the government intends, and whether they will be compensated for their trouble.
“Everybody needs to be patient,” Page said, “the physicians, the patients and Medicare. This is a big experiment.” Doctors need time to change how they do their jobs. “I just hope that everybody's got the intestinal fortitude so that we can change at a pace that we can accommodate,” Page said, and that will require Medicare to set realistic goals and provide education.
“If they don't nurture us properly and allow us to mature at a rate we can mature at, then we'll fail,” he said.
Roughly six months ago, Medicare reached its first contracts for accountable care. Medicare agreed to give hospitals and doctors a cut if providers saved money on treating seniors and simultaneously hit quality targets.
Thirty-two organizations agreed to the deal in January under the CMS Innovation Center's Pioneer ACO model, joining a half dozen medical groups that first tested the payment model.
Since then, the number of Medicare accountable care contracts has increased four-fold. Another 27 organizations followed in April under the shared savings program created by the Patient Protection and Affordable Care Act. The agency had significantly revised the final rules to make the program more attractive after sharp criticism of an early proposal
. Last week, 89 ACOs became the latest to sign shared savings contracts—including the Syracuse ACO—and Blum said 400 more have expressed interest in contracts for next year. “We are building a program that is strong and is growing quickly,” he told reporters last week.
Medicare's latest accountable care contracts captured a cross section of the nation's healthcare operators, including some that rely on partners to clear away obstacles to entry.
Universal American, a publicly traded Medicare Advantage and supplemental insurance provider, owns a stake in one out of every 10 Medicare ACOs. That includes the Syracuse ACO and Essential Care Partners, an ACO composed of 14 federally qualified health centers across Texas.
Essential Care Partners would not yet be an ACO under contract with Medicare without its corporate partner's data analytics capabilities, said Jose Camacho, executive director of the Texas Association of Community Health Centers and board chairman of Essential Care Partners. “Not this quickly,” he said.
Universal American will receive a share of any savings bonus that doctors earn by holding down costs, said Robert Waegelein, co-president and chief financial officer for Universal American. The company expects to apply for the next round of Medicare ACOs. “We're very bullish on this opportunity,” he said.
Among the newest Medicare ACOs, one out of four are groups of fewer than 100 doctors and do not include a hospital in the formal network. One out of 10 ACOs has more than 1,000 doctors who have formally partnered with hospitals.
In an interview, Blum said there is no limit to the number of ACOs the agency can approve from each round of applications. “I am confident we have the resources in place to support the interest,” he said.
Support and feedback about what does and does not work will be necessary for ACOs to succeed, Page said. Now, the Syracuse ACO's doctors are waiting for data from the CMS. The medical group must also adapt its electronic health record to report new measures to Medicare, Page said. And doctors will need to talk with area hospitals not included in the ACO for help coordinating care as patients enter and exit the hospital.
Medicare officials received feedback from ACOs that began April 1 after providers struggled to use data that identified patients for whom doctors would be accountable.
ACOs agree to manage medical care for a specific group of patients identified by which doctors they visit. Medicare agreed to send providers a list of the patients upfront but then failed to identify which patients visit which doctors.
“It's been an interesting couple of months,” said Dr. Morey Menacker, a primary-care doctor in Paramus, N.J., and president of the Hackensack Alliance ACO, which entered into an April 1 accountable care contract with Medicare. Frustrated comments from ACOs prompted the CMS to try again with better results.
That's not the only data hiccup Medicare ACOs have experienced.
Marilyn Tavenner, acting administrator for the CMS, said in June that the first wave of Medicare ACOs faced data delays that prompted the agency to work to streamline clinical data access, Modern Healthcare reported. “While we have a willingness to share data, it's not always as simple as we had hoped,” she said.
The CMS will review ACO performance measures, such as hospitalization and the cost of care, quarterly and annually for progress, Tavenner said. The agency will also eventually release performance measures publicly. Last week, the CMS released a proposed rule that suggested posting 2013 ACO performance data on its consumer website Physician Compare.
Blum confirmed “kinks” in the agency's data distribution and providers' ability to accept and use the information. He said the agency previously released data annually and had to overcome some hurdles to stream data to ACOs each month. He said the process had improved.
John Friend, executive director of the Arizona Connected Care board, an April ACO that includes the Tucson Medical Center, three federally qualified health centers plus 150 doctors, said participants have worked with the best intentions to address early technology snags.
All participants share the desire for a health system driven by useful data and metrics, but providers and payers still lack all the necessary components, he said. “Not everything's in place.” Medicare is grappling with how to transmit data that is useful and timely. And providers are struggling to, for the first time, format, store and use that data, he said.
Access to federal data to help doctors monitor care delivery, quality and costs factored significantly into ProMedica Physician Group's decision to apply to Medicare's accountable care effort, said Dr. Julie Tome, director of ProMedica's ACO. The 250-doctor group in Toledo, Ohio, became a Medicare ACO on July 1.
Success for doctors and hospitals hinges in part with Medicare's ability to provide timely data, said Dr. Simon Prince, president and CEO of Beacon Health Partners. The Manhasset, N.Y.-based network applied to become a Medicare ACO on July 1 without any concrete examples that Medicare could deliver.
“We really didn't have much to go on,” he said. The application was accepted. “It's sort of a leap of faith that we'll get the data we need.”
—with Rich Daly
TAKEAWAY: The rapid growth of Medicare ACOs is testing the resources of the participants and the CMS.