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The role of care management within a pioneer ACO [PODCAST]

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In this episode, Dr. Eric Weil, Senior Medical Director for Population Health at Partners Healthcare, discusses the results of a study he co-authored which looked at how a care management program impacted utilization and cost within a pioneer ACO.
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Mike Passanante: Hi, this is Mike Passanante. And welcome back to the Hospital Finance Podcast. Today, I’m joined by Dr. Eric Weil, the co-author of a study published in the May 2017 of Health Affairs entitled Bending the Spending Curve by Altering Care Delivery Patterns: The Role of Care Management within a Pioneer ACO.

Dr. Weil is the senior medical director for Population Health Partners Healthcare in Boston, associate medical director of the Massachusetts General Physicians Organization, and associate chief of clinical affairs, Division of General Internal Medicine at the Massachusetts General Hospital.

Dr. Weil, welcome to the Hospital Finance Podcast.

Dr. Eric Weil: Thank you for having me.

Mike: So, first, can you briefly explain what a pioneer ACO is and what you and your colleagues were examining in the study?

Dr. Weil: So, an ACO more generally is a healthcare strategy that allows an organization to take risk on a specific population of patients. In this case, it was a Medicare population of patients for the sake of our study. And it is inclusive of, when possible, all components of the healthcare system.

So, for an organization such as Partners, Partners Healthcare in Massachusetts, it was inclusive of both the ambulatory and the hospital-based interventions, the hospital-based components of our programs.

An ACO tends to have an attribution methodology that links patients, at least in the case of a pioneer ACO, to a primary care provider within that system. The pioneer ACO was one of the ACO models that was laid out by Medicare. And as you can guess from the name Pioneer, it was one of their earlier models, and it was designed basically to attract and incentivize organizations to take the leap of faith into a world that’s more driven by risk in management of populations as opposed to by the traditional fee-for-service model.

Mike: And what were you examining specifically in this study?

Dr. Weil: Well, when you are managing a population of patients, you tend to develop strategies to focus on specific subsets of the population. In our case, we developed a series of interventions to particularly target our more high risk, more medically complex patients. I guess you could say it’s the top 10% most complex population of patients in our Medicare population.

We developed an intervention which has actually been in place for the past decade called the Integrated Care Management Program which includes practice-based care managers embedded into primary care practices with a set of wraparound services that are used to support those individual in the management of that complex patient population.

So, we designed a study to assess this particular group of patients, identifying different cohorts of patients enrolled in our high risk Care Management Program who are in our pioneer ACO.

Mike: Excellent! So, let’s dig into that study. Can you briefly go over your methods and explain how the Care Management Program worked at Partners?

Dr. Weil: So, the Care Management Program itself first identifies patients with high risk scores and high utilization. And “high risk scores” mean high risk for increased utilization of services within the healthcare system. We identify a cohort of patients, and then those patients are reviewed with the primary care  physicians in each of our primary care practices.

After that, they are enrolled in a program where they are assigned a nurse care manager who follows these individual patients longitudinally, assessing them for potential gaps in their care and addressing those gaps to support those nurse care managers.

We have created a set of wraparound services inclusive of social workers and pharmacists, inclusive of resource specialists to help link them into specific needs in their communities.

And then, that has been supported by a set of IT integrative resources inclusive of notification system so that our teams know when the patients are presenting to the emergency department, when they’re missing appointments, when they’re attending appointments so that there’s an opportunity for engagement.

The study actually looked at different cohorts of patients enrolled into the ICMP Program over periods of time, and then followed those cohorts of patients and compared them to the larger ACO population in an effort to see what the impacts were upon their utilization and upon their overall costs.

Mike: So, let’s talk about the study results then. You looked at emergency department visit rates for both patients who participated in the ACO and patients in the Care Management Program. What did you find?

Dr. Weil: Well, we found that just being in an ACO, just being in an accountable care organization, actually reduced emergency department visits, and for that matter, hospitalizations. Medicare spending decreased as well.

We found that for those patients who are in our pioneer ACO and were also in our high risk care management program, the ICMP program, those effects were modestly greater.

Mike:  And in the Care Management Program, there were two components that the study says were specifically designed to decrease ED visits. Can you tell us what they were and why they were so impactful?

Dr. Weil: Well, truthfully, there are many interventions that were specifically focused on reducing ED visits and in-patient visits. One of the big ones was and is post-discharge follow-up ensuring that all patients after discharge from the hospital are receiving post-discharge communications and warm hand-offs with their medical teams. And that occurs essentially on all of our patients at the time of any discharge. And this has been followed by tight follow-up with the primary care practices which are often facilitated in and of itself by the care manager or the care management team.

Another intervention is the review of frequent admissions to the hospital, the ICMP team, the care managers and with the primary care practices more broadly.

Mike: And in addition to utilization, you also looked at Medicare spending. What were the results among the study groups?

Dr. Weil: Well, the participation in the Medicare ACO was associated with a modest reduction in total healthcare cost and spending. That phenomenon, that reduction in spending, was greater in patients that were enrolled in our ICMP program. Now, it was a modest impact, but a notable one nonetheless.

Mike: And the study also discusses the importance of being able to scale care management programs and giving them time to produce results. Why are these elements so instrumental to ACO success?

Dr. Weil: Well, let me start with the latter, and then I’ll move back to the former. When you’re managing a group of high risk patients, medically complex individuals, the earliest phase of the intervention is a discovery phase. And during that discovery phase, it’s not unusual to actually have costs slightly increase and to have utilization slightly increase. And it typically takes 18 months to a full two years to actually begin to see the benefits of this type of care coordination strategy.

So, you need to be willing to deal with a little bit of increased expense upfront because, before the clinical impacts take effect, you’re going to see that. And you have to be patient enough to wait for the 2-year mark in essence to really begin to see the long-term savings occur.

Now, from the point of view of scalability, you really want to be able to impact upon the top, let’s say, 8% to 10% of your Medicare population. And you need to be able to do that in any of the ambulatory clinical settings that you have within your system.

So, if you have three or four hospitals, but you only roll out this particular strategy in two or three, or you roll it out in all of them but to differing degrees and there are significant variability in the way that the interventions occur, you are far less likely to have the type of impact that you would need to justify the type of investment in this type of infrastructure.

Mike: Do you have any recommendations for hospitals that are currently part of an ACO or are thinking about being part of an ACO?

Dr. Weil: I think that any hospital or any healthcare system that’s actually engaged in the process of becoming an ACO or being involved in one really needs to have a strategy that will specifically target populations such as the high risk medically complex population. There need to be strategies that segment out your populations not necessarily just based upon illness, but also based upon complexity. And so, one core component of that, I’d say, is high risk care management or some other targeted intervention for that population.

At the same time, you need to have cost-cutting initiatives that will manage an impact in all of your populations such as, let’s say, behavioral health integration or a medical home.

But I think that in order to be successful in this type of work, you really need to have a cost-cutting strategy and a segmented strategy. And you have to have patients, lots of patients, because in order to see these results, in order for them to come to fruition, it takes time, and it takes a lot of grit to facilitate the change management that’s necessary to make it happen in your practices.

Mike: Well, certainly, you and your colleagues were able to demonstrate both improved care as well as decreased cost which I think is directionally correct. That’s where we want the healthcare system to go.

Dr. Weil: That’s what we’re aiming for.

Mike: Dr. Eric Weil, thank you for coming by the Hospital Finance Podcast today and helping us understand more about this very unique study you were a part of.

Dr. Weil: Thanks so much for the opportunity.

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