Only four of the 10 participating groups in the Physician Group Practice Demonstration Project achieved savings in at least three of the five program years, and only two generated savings all five years, Premier noted.
With one exception, all the systems achieving shared savings had prior experience running a health plan. It was harder to control utilization than expected, and in one case, utilization even increased, according to Premier.
Hiller also pointed to a “halo effect” where the change in care patterns also spilled over to the non-ACO population, which meant there was a ripple effect that led to lower utilization among both ACO and non-ACO patients. Revenue also decreased faster than cost reductions, Hiller said. “It's not easy to bend the cost curve.”
But systems participating in the CMS' accountable-care organization program, which was created by the 2010 health reform law and launched last April, say there are competitive reasons for their participation.
“At the end of the day, this is a market share play; it's not a financial play,” said Charles Vignos, chief operating officer of the NewHealth Collaborative, the ACO at Summa Health System in Akron, Ohio.
The program was selected as a Medicare ACO last July and now covers 23,000 lives. ACO patients have become about 30% of participating providers' business, he noted.
Vignos detailed some of the program's limitations, such as a 28% turnover rate in the first six months, a lack of a clear start date and end dates and a data-sharing opt-out rate of 4% to 5%, which may or may not include the highest risk, costliest patients.
One central piece of the program is a clinical communications center that patients can contact when they have medical concerns. A nurse with access to the system's electronic medical records will triage the patient, and the system is working on ways to get more patients in to see a primary-care physician within 24 hours of the call (currently at about 20%).
About 75% of callers will be directed to Summa emergency departments—which is a big factor in increasing market share. Of those patients, about 24% will be admitted, with 76% treated and released, Vignos said.
Although it's still early, Vignos pointed to a “pretty significant” 2.2% reduction in healthcare expenditures within six months.
Deborah Bloomfield, chief financial officer at Mercy Health in Cincinnati, also noted that the decision to become an ACO in July was a “strategic decision,” not a financial one.
Unlike Summa, the system, part of Catholic Health Partners, does not have its own health plan. “We really needed a catalyst to get us into population health management,” Bloomfield said.
Mercy Health, which was already investing in EMRs and new care models, saw operating costs of $7 million in the first year of its ACO, about half of which were related to care coordinators. Its ACO has 22,000 attributed lives.
Bloomfield also shared results from Mercy Health's Kentucky market, which has 19 participating providers. The group was able to reduce emergency department utilization by 12% and reduce admissions by 11%. It extended office hours and increased utilization of its urgent-care centers. It also had patients call a pre-service center before going to the ED.
“What they have done in one year is amazing,” Bloomfield said. “In Paducah, in this one market, we're off double-digits in our volumes.”
She also noted that to achieve savings, providers need to focus their attention on the patients who the largest users of healthcare. “If you focus your time and attention on the top 5%,” she said, “those that really have the most issues, you really get at the majority of costs that way.”
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