Levers of Successful ACOs

The Health Care Transformation Task Force interviewed high-performing Accountable Care Organizations (ACOs) to assess structures and strategies that led to their success. Although each organization had differing approaches and experiences, common themes emerged in three major categories: 1) Achieving High-Value Culture, 2) Proactive Population Health Management, and 3) Structures for Continuous Improvement.

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Part 1: Identifying the Levers of Successful ACOs

The Health Care Transformation Task Force (HCTTF) designed and conducted a qualitative study analyzing the elements of ACO success. The reports below detail that work, describing key findings across a number of domains, while this introductory report provides background, detailed methodology, and ACO selection criteria. The findings represent the experiences of select high-performing ACOs, including HCTTF and non-HCTTF members. The objective of this resource is to move beyond high-level themes to provide a tactical guide for understanding, prioritizing, and implementing the levers of ACO success.  The HCTTF recommends that ACOs and other health care stakeholders leverage these resources to:

  • Evaluate proficiency across key activities;
  • Educate organizations about the importance of these key activities; and
  • Prioritize improvement efforts based on unique needs.

Part 2: Achieving a High-Value Culture

Perhaps the most elusive yet most important element for achieving long-term success is developing a culture conducive to value. Having a high-value culture means that all levels of the organization –particularly the leadership – demonstrate an internally-motivated commitment to excellent patient outcomes (quality) that are achieved at the lowest possible cost. This category represents the underlying current that drives all improvement efforts, by ensuring the ACO objectives are prioritized at every level of the organization.

As true with most other elements, approaches to developing and maintaining a strong culture will vary from organization to organization. Still, all studied ACOs have pursued similar channels for engaging individuals across the organization:

  • Involvement by senior decision-makers (i.e., governance bodies) in ACO operations
  • Physician and community practice engagement
  • Expanded clinical partnerships

Part 3: Proactive Population Health Management

Unsurprisingly, common to all studied ACOs is a dedication to proactive population health management. Managing the health of a defined population across the continuum of care requires a complete paradigm shift for most providers, as well as the development of new systems and processes. While challenging to learn and implement, population health management is the cornerstone of all accountable care success. In addition to its foundational importance for accountable care, population health management and its various components were mentioned most frequently in the interviews, and were said to have the greatest impact on practice transformation. 

While population health approaches can take many forms, most ACOs studied had developed analogous operational elements. Those fundamentals – which are detailed in a separate report – include:

  • Systems for identifying high-risk patients
  • General care management functions
  • Specific disease management programs

Part 4: Structure for Continuous Improvement

To be successful under any value-based payment model requires a strong supporting infrastructure, but this is especially true of ACOs. The nature of this care model, combined with the added complexity of multiple providers with disparate systems and multiple payers with different requirements, makes careful investments in infrastructure a principal strategic decision for organizations participating in ACOs. In combination with workforce resources, this is the backbone of all performance improvement. A successful ACO leverages its supporting structure to learn about its organization, its people, its performance, and its patients, and then uses that information to create feedback loops for continuous learning and system improvement. ACOs identified essential elements that support continuous improvement:

  • Operational infrastructure for performance measurement
  • Tying performance to compensation and network contracts
  • Participation in shared learning opportunities

Project Background


Value-based payment models have proliferated over the past several years in an attempt to address the unsustainably high costs and variable outcomes of health care in the U.S., and to test innovative models to solve these particular challenges and promote high-quality, low-cost care. While there are several approaches to value-based payment, accountable care organizations (ACOs) have been the most popular vehicle for value-based payment model adoption to date, with over 923 ACOs covering approximately 32.4 million lives across the country in 2017. ACOs can take a variety of forms, differing by provider configuration, contracted payers, payment methods, and more. While approaches to ACO implementation vary, the principles of population health management remain the same. Now, several years into the accountable care movement, health care stakeholders are closely studying the structures and behaviors of existing ACOs to learn about the attributes of successful organizations.

Recognizing the importance of identifying and disseminating these success levers, the Health Care Transformation Task Force (HCTTF) designed and conducted a nearly 12-month qualitative study analyzing the elements of ACO success. This report details that work, outlining research methods and describing key findings across a number of domains. The information contained in this paper represents the experiences of select ACOs, including HCTTF and non-HCTTF members, and is supported by additional evidence found in the current literature.

Methodology


The HCTTF’s Accountable Care Work Group conducted a multi-step project which included, among other things, a series of in-depth interviews with leaders of successful ACOs to investigate the common structures and strategies that enable success.

It was determined that all interviewed ACOs must meet the following criteria:

• Shared savings rate ≥2%
• Quality score ≥90%
• Below-average baseline
• ≥5,000 ACO-covered lives
• More than one year under accountable care contract
• At least one commercial ACO contract (in addition to a Medicare ACO contract)
• Diverse geographic representation (preferred)

Using the PY 2015 Medicare ACO performance results and the Leavitt Partners ACO database, 21 Medicare Shared Savings Program (MSSP) and Pioneer ACOs were identified as meeting the criteria. The Work Group conducted interviews with 11 of the 21 ACOs, corresponding to over 10 hours of interviews. Within each ACO, the HCTTF interviewed senior decision-makers involved in designing and implementing accountable care-related activities across the ACO. To standardize the areas investigated, all ACOs were interviewed using the same interview guide. Interview transcripts were then coded to enable a thorough qualitative analysis. All quotes in this report draw from these interviews and written transcripts.

Acknowledgements


This is a product of the Health Care Transformation Task Force under the leadership of the Accountable Care Work Group. The Accountable Care Work Group is comprised of Task Force members and other organizations dedicated to improving the design and implementation of the ACO model in public and private payer programs. The Work Group addresses both internal operational challenges as well as public policy issues that challenge transformation efforts for health care organizations.

Task Force Submits Recommendations on Consumer Priorities to CMS

The Task Force offers recommendations to CMS on addressing consumer priorities in value-based payment and care delivery. Through input from the Advisory Group for Consumer Priorities, the Task Force identified key areas where CMS can advance these consumer priorities and principles.

Read the letter here.

Task Force Provides Comments to CMS regarding EPM Cancellation and CJR Modifications

The Task Force has submitted comments to CMS on the proposed rule Cancellation of Advancing Care Coordination Through Episode Payment and Cardiac Rehabilitation Incentive Payment Models; Changes to Comprehensive Care for Joint Replacement Payment Model (CMS-5524-P). The Task Force advocated that CMS introduce voluntary bundled payment models as soon as possible, and recognize proactive investments. Regarding the proposed modifications to CJR, the Task Force encouraged better synchronization with other Alternate Payment Models, a redefinition of the “low-volume” threshold and offered support for gainsharing and broadening the scope of the Affiliated Practitioners.

Read the comment letter here

Task Force statement for CMMI Behavioral Health Summit

The Task Force provided a statement to CMS in response to request for input for the Center for Medicare and Medicaid Innovation (CMMI) Behavioral Health Summit on September 8, 2017. Through recommendations from its Improving Cost to High Cost Patients Work Group, the Task Force identified key areas of focus for future CMMI behavioral health models.

Read the statement here.

 

Financing Integrated Social Services for the High-Need, High-Cost Population: Webinar and Resources

Caring for high-need, high-cost patients requires providers to think beyond traditional clinical settings and address the social determinants of health. Yet integrating social services into health care can be a daunting challenge that requires a clear understanding of the target population, available resources, and an effective integration model. 

Building upon the social services integration framework shared in the HCTTF’s first webinar, Integrating Social Services into Care for the High-Need, High-Cost Population, this presentation explores models for financing integrated social service models from the perspectives of two innovative provider organizations.

View the webinar recording.

Download the slide deck.

The Transformation to Value: A Leadership Guide

Webinars:

Transformation to Value: A Provider Perspective
(October 17, 2017 3:00-4:00pm ET)

Featuring Jason Dinger, Chief Innovation Officer of Ascension Health and Rick Gilfillan, MD, CEO of Trinity Health
Listen to the recording.
Download the presentation.

Transformation to Value: A Payer Perspective
(November 2, 2017 4:00-5:00pm ET)

Featuring Kevin Klobucar, Executive Vice President of Health Care Value, Blue Cross Blue Shield of Michigan and Brigitte Nettesheim, President, Transformative Markets, Aetna
Listen to the recording.
Download the presentation.


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Health care industry leaders face incredible challenges in shifting from traditional, volume-driven fee-for-service to value-based payment and care delivery.  The Health Care Transformation Task Force has created a framework to help guide decision makers in their transformation journeys, along with insights from organizations at the vanguard of value.

Press Release

Full Report

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Introduction: Strategic Framework

Health care industry leaders face incredible challenges in shifting from traditional, volume-driven fee-for-service to value-based care. While the public discussion is often about specific value-based payment models, the broader transformation challenges to becoming a truly value-based organization receive much less focus. Committed organizations must often make significant changes to their strategic direction and operating structures, yet leaders don’t always have a clear precedent on how to successfully guide their organizations through these changes.

The Task Force’s Path to Transformation Advisory Group created the Dimensions of Health Care Transformation Strategic Framework (“Framework”) to assist health care leaders as they design and implement their transition to value. The Framework is built on the collective experience and wisdom from organizations that are at the vanguard of value-based payment and care delivery. It reflects introspective questions that change leaders should ask in building out an effective transformation strategy. Read our introductory report to learn more about the Framework.

Strategy and Culture

Successfully changing the culture within all levels of an organization is critical to support value-based payment and care delivery, but also one of the biggest challenges in successful transformation. Culture change involves buy-in across an entire organization (i.e., clinicians, executives, administrative staff, and affiliated partners). This requires an overarching vision for transformation, dynamic and experienced leaders, and an appropriate level of organizational integration and local leadership buy-in to successfully transition within each market. Read the report to learn more about how organizations have addressed strategy and culture change in their own transformation journeys.

Structure and Investments

Structure and investments are critical to the transformation journey because they encompass the physical infrastructure and human capital requirements needed to successfully build a value-based delivery system. Finding the right balance of resources to invest in can be extraordinarily challenging, especially for organizations that are new to value-based care. Many of the executives interviewed discussed the importance of identifying highly skilled, experienced leaders to assist with the transition process. With experienced stewardship, organizations can successfully stand up their value businesses and invest intelligently in infrastructure and resources. Read the report to learn what our leaders had to say.

Operations and Accountability

For organizations that are on the path to value, making the right investments in operations and developing effective mechanisms for accountability can determine success or failure. The Task Force identified three key elements: operational alignment, financial incentives, and quality measurement. Operational alignment ensures that value objectives are managed across lines of business. Financial incentives encourage momentum and commitment from staff toward achieving common value goals. Quality measurement means effectively evaluating and measuring progress toward those value goals. Read the report to gain insight into the successes and lessons learned from transformation leaders.

Performance Management

In the fourth and final dimension of the Framework, the Task Force highlights two key components: Process and Outcomes Evaluation and Financial Modeling. Evaluating progress toward value-based care is critical for the long-term sustainability and success of any value-based initiative. Understanding when to discontinue a program due to financial unsustainability and/or poor outcomes can be just as important as identifying which programs are most likely to yield the best results and returns. For details on how organizations are evaluating progress and making informed decisions on the future of their value-based programs, read the report.

Project Background


Shifting from traditional, volume-driven fee-for-service to value based care is highly challenging, even for the most sophisticated businesses. Health care organizations committed to transforming to value-based payment and care delivery models must often make significant changes to their strategic direction and operating structures. How much work needs to be done to achieve value transformation, however, depends on many factors such as level of commitment, organizational complexity, cultural dexterity, level of change currently underway, and desired goals.

Transformation can be risky, even for those who are further along the transition to value continuum. Organizations must weigh a multitude of variables in their planning processes, and often use internal vetting practices that draw upon both internal and external shared learnings as well as return on investment (ROI) calculations to align transformational goals with current business models. In particular, shared learnings from businesses that have implemented value-based care programs are critically important to help other organizations successfully navigate opportunities and pitfalls.

The Task Force’s Path to Transformation Advisory Group created the Dimensions of Health Care Transformation Strategy Framework (Framework) to assist health care leaders as they design and implement their transition to value. The Framework is built on the collective experience and wisdom from organizations that are at the vanguard of value-based payment and care delivery. It reflects introspective questions that change leaders should ask in building out a transformation strategy.

The Framework also provides the foundation for a series of interviews, and subsequent analysis, that the Task Force conducted to provide additional context on the path to transformation continuum and allow decision makers to benchmark themselves against similar organizations that are actively moving toward value-based care.

Dimensions of Health Care Transformation Framework


The Framework helps organizations assess their transformational maturity across a set of business dimensions (vertical axis) in which they can expect to make transformative changes through three levels (horizontal axis): (1) concept; (2) execution; and (3) sustainability. This Framework charts a course for how organizations can be successful in culturally, structurally, and operationally transitioning to value-based care.

The Framework’s current business dimensions are intended as a core set, with additional dimensions added as appropriate. The example questions and categories provided represent activities that may or may not be happening simultaneously, rather than prerequisites that must be met before an organization may move to the next level. In sum, the Framework is intended to be a dynamic tool, with additional dimensions added over time.

The first level – concept – assesses the needs of the communities or markets to be served and how health care organizations can best tailor value-based care models to serve those needs. Due to the complexities of value-based care arrangements, the concept stage requires education of, and buyin from, leadership groups and an organizational commitment to the culture change necessary to effectively implement value-based care models.

The second level – execution – involves delivering on an action plan for change, including setting a course and timeline for transitioning from fee-for-service to value-based payment models. The leadership education and buy-in from the concept stage is now shared more broadly with the organization. Cultural and operational plans are established to ensure alignment and to promote organizational accountability so that internal teams move toward achieving common goals on consistent timelines, with an established feedback loop to promote continual improvement. All dimensions from the concept stages are now operational and individual/team incentive plans – financial, cultural and/or operational – are in place to tie personal accountability to organizational commitment.

The final level – sustainability – envisions an ideal end state of organizational transformation that reflects aligned goals and objectives, as well as measurable progress toward lower costs and improved quality, outcomes and patient experience. Within the sustainability level, operational scale is achieved consistent with the desired organizational plan, but is not viewed as satisfactorily sustainable by itself.

For most organizations, “sustainability” is an aspirational destination that has not yet been fully achieved. Thus, the definition and specificity of what it means to sustain transformative efforts will likely evolve over time and will be subject to continual advancement/refinement. One constant, however, is the need for continuous improvement to remain successful in providing high-quality, affordable person-centered care.

Health care organizations’ ability to move along the transformation continuum is often dependent on external factors over which the organization has little direct control. External factors may include state insurance regulations; federal policies and requirements; local health information infrastructure; and willingness from others to partner in value-based arrangements. The confluence of these factors will dictate the overall readiness of local markets to support value-based care and will play a large role in whether organizations are able to pursue value transformation

At present, the Framework does not seek to identify specific external factors as prerequisites for, or potential impediments to transformation; rather, it recognizes that the speed and scope of transformation may be restricted by the current ecosystem in which individual health care organizations operate.

Methodology


The Task Force created the Dimensions of Health Care Transformation Framework to assist health care leaders as they design and implement their transition to value. The Framework is built on the collective experience and wisdom from member organizations that are at the vanguard of value-based payment and care delivery. It reflects questions that change leaders should ask themselves in building out a transformation strategy. The Framework was developed from a series of working sessions with the Task Force Path to Transformation Advisory Group, consisting of Task Force members, over a period of several months.

The Task Force used the Framework dimensions to craft an interview guide for members. Task Force staff sought participation from members of the Path to Transformation Advisory Group. Members had the option of participating via phone or through a written response to the interview guide. In total, the Task Force conducted interviews with 12 member organizations, corresponding to over 20 hours of interviews, and received four written responses. The breakdown was as follows:

• 3 payers (two national, one regional)
• 9 providers
• 3 partners (guide providers through value transformation)

Following interview transcription by a professional transcription service, the transcripts and written responses were qualitatively coded using Dedoose, an online coding platform, to highlight and organize key themes among member experiences and observations across each dimension. Task Force staff also completed a summary analysis to enable comparison of approaches and results for similar member organizations. All quotes in this report draw from these interview and written transcripts.

Task Force Provides Input on CMS Proposed Rulemaking on CY 2018 Updates to the Quality Payment Program

The Task Force provides input on the CMS–5522–P:  Medicare Program; CY 2018 Updates to the Quality Payment Program proposed rule addressing the Merit-based Incentive Payment System and Alternate Payment Model Incentives.

Read the full input here

Read more here about our MACRA letter in Modern Healthcare

 

Task Force statement to the PTAC

As a broad-based group of 43 health care stakeholders representing patients, purchasers, payers and providers, the Health Care Transformation Task Force (HCTTF) strongly supports the transition to value-based payment and care delivery. The HCTTF supports the important work of the Physician-Focused Payment Model Technical Advisory Committee (PTAC) to advance development of additional alternate payment models in Medicare. To show support for this initiative, the HCTTF developed a statement on the PTAC which offers recommendations to make the PTAC even more effective.

Read the statement