Becker's Hospital Review

30 Clinical Integration & ACOs Population health and the formation of ACOs ACOs were created under the Patient Protection and Affordable Care Act to im- prove quality and efficiency by linking provider reimbursement to quality met- rics and healthcare costs for an assigned population. When the systems partici- pating in the Medicare pilot programs were announced, it was noticeable: Some of the country's prestigious systems had chosen to forgo forming an ACO. The Medicare Shared Savings Program has become a popular option for hos- pitals interested in participating in a value-based care model, while limiting the risk involved. MSSP participants receive bonuses based on improving quality and cutting costs and are only responsible for their organization's losses if they participate in Track 2 of the MSSP. However, all of the 19 orga- nizations participating in the Pioneer program, another Medicare ACO pro- gram, share in both savings and losses. Although Rochester, Minn.-based Mayo Clinic, Cleveland Clinic, Danville, Penn.-based Geisinger Health System and Salt Lake City-based Intermoun- tain Healthcare could have all served as models for the Pioneer program and likely received bonuses for their participation, all four declined to apply for the Pioneer program, which caused a stir in the healthcare industry and raised concerns about the Medicare ACO model. Even with some of the major systems choosing not to participate in the Medi- care pilot programs, a Leavitt Partners analysis from June 2014 shows there were 626 ACOs as of May of last year. Of those, 329 had government contracts, 210 had commercial contracts and 74 had both types. The remaining organiza- tions hadn't released the specifics of their contracts at the time of the report. Intermountain Healthcare's choice to focus on population health without an ACO Salt Lake City-based nonprofit Intermountain Healthcare is widely known for the quality of care it provides and its efficiency. However, the 22-hospital system has chosen not to participate in the Medicare pilot programs and in- stead to pursue its own broad population health strategy. Although Intermountain is aligned with the goals of a Medicare ACO, such as following evidence-based standards, integration and coordination, the sys- tem has chosen not to form a Medicare ACO or to participate in any of the Medicare pilot programs because Intermountain was concerned the guide- lines for participation were "too prescriptive," says Joe Mott, vice president of healthcare transformation at Intermountain. In spring 2011, Intermountain's management committee announced the system's strategic direction, a shared accountability strategy. Since then, the system has been aggressively moving forward with its initiative, which today involves more than 20 teams focused on creating new competencies to enable Intermountain to manage population health. According to Mr. Mott, the system's population health strategy has three legs: following evidenced-based standards, engaging patients and aligning finan- cial incentives. There are critical technology elements to Intermountain's strategy, and the system is "on the early-end for many technology decisions," says Mr. Mott. One of those pieces of technology is the EHR. Intermountain is in the process of implementing a Cerner EHR, and the population health group is working closely with Cerner to ensure the system is fully utilizing its EHR for popula- tion health. Intermountain is also using technology to improve patient engagement. "We are testing a patient activation tool to allow patients to engage and better understand how the decisions they make impact their health," says Mr. Mott. Although technology plays a key role in Intermountain's population health strategy, Mr. Mott says perhaps the biggest shift has been in inte- grating the care management function across the system. "While we have coordinated our efforts in the past, we were really operating separate care management functions within different divisions of the system," he says. "But care management really needs to be patient-centered." To deliver such, Intermountain is looking to implement a common patient risk scoring tool and is also examining how the system assigns case managers across the system. Like CMS ACOs, Intermountain is beginning to look at physician payment models, and the system is beta testing with a payment model designed to align incentives for physicians, reducing the focus on fee-for-service payment. Even without a formal ACO, Intermountain has and will continue to focus on how to deliver high-quality care at sustainable costs. "For us, it's a mission issue," says Mr. Mott. "We are working to transform ourselves because our mission requires us to provide the highest value care we can, and we believe this model best enables us to meet that obligation." Cleveland Clinic's population health strategy Cleveland Clinic is another prestigious health system that initially made the decision not to participate in the Medicare ACO programs. However, the system has been tracking its performance on ACO quality met- rics, and it has done very well. "We have been simulating being an ACO for the last year and a half," says David Longworth, MD, chairman of the Cleve- land Clinic Medicine Institute. Based on its simulation results, Cleveland Clinic applied to CMS to form a Medicare ACO. In January, the system will be notified if it will be participat- ing in the MSSP. With a focus on population health, Cleveland Clinic has transformed the way it delivers care during its ACO simulation process. "We have begun to identify our high-risk patients and to provide proactive care coordination to try and keep them out of the ER and prevent hospital readmissions," says Dr. Longworth. The system also has 35 care coordinators who work with its high-risk popula- tion. In addition, "we have medical assistants who are helping us do pre-visit planning to identify gaps in care," says Dr. Longworth. Although Cleveland Clinic has made strides, there is still work to be done. The system wants to begin identifying rising risk patients, instead of just high-risk patients, and Cleveland Clinic is also trying to figure out how to ac- tivate patients to get them engaged in their care. The system believes making patients partners in their care is going to be vital going forward. Conclusion: Although population health is often times a term used when discussing ACOs, prestigious systems across the country have shown successful popula- tion health management doesn't require an ACO. Using their own strategies, both Cleveland Clinic and Intermountain have made great strides in the population health arena. Although Cleve- land Clinic may become an MSSP participant, both organizations are planning to continue aggressively pursuing their population health strat- egies in the future. n Succeeding at Population Health Without an ACO: How Intermountain and Others are Doing It (continued from cover) SAVE THE DATE! Becker's Hospital Review Annual Meeting May 7-9, 2015 Swissôtel - Chicago, Illinois 153 Great Health System Executives Speaking 119 Sessions - 212 Speakers To learn more visit www.BeckersHospitalReview.com To register, visit www.regonline.com/hospitalreview6thannualmeeting

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