“Duke made a conscious decision to explore new opportunities, new models of care and payment,” said Dev Sangvai, MD, MBA, the executive director for Duke Connected Care, associate chief medical officer (ACMO) for Duke University Health System and medical director for DukeWELL (a physician-run population health program for Duke employees and dependents). “We dipped our toe in the water [with Duke Connected Care] with the questions, ‘what are we going to learn from it? What is going to make us a credible citizen in the new health care economy?’”

Not all ACOs have the backing of a major health system as they get off the ground – a definite advantage for Duke Connected Care in both know-how and start-up time.

“Duke had several ongoing care management programs – DukeWELL for the employee population and a few other commercial arrangements, and NPCC [Northern Piedmont Community Care] for Medicaid,” said Eugenie ‘Genie’ Komives, MD, Senior Medical Director for Duke Connected Care. “We also have a robust inpatient care management center for the typical hospital functions like discharge planning and transitions of care. When we moved into the Medicare patient population, we saw the need to enhance the skills and focus of our existing programs (particularly DukeWELL and NPCC) to help serve our Medicare (aging, geriatric, frail) populations.”

Duke Connected Care participates in the Centers for Medicare and Medicaid Services (CMS) Medicare Shared Savings Program (MSSP). Early this year Duke Connected Care contracted with Cigna to become one of the insurance company’s 10 collaborative care initiatives in the Carolinas. The partnership with Cigna benefits over 16,000 individuals covered by a Cigna health plan and receiving care through Duke Connected Care network physicians.

So far, Duke Connected Care encompasses nine practices including small physician groups, a solo practitioner, Duke University Affiliated Physicians and Lincoln Community Health Center, a Federally Qualified Health Center (FQHC) right down the street from Duke University Health System. Together this represents more than 1,200 Duke and select community physicians. Ten to 15 percent of the patients seen through Duke Connected Care are not attributable to the Duke system, Sangvai said.

“We are unique in being a ‘quaternary’ medical center,” Komives said. “Our ACO includes our primary care network, our entire network of Duke specialists (oncology, transplant, nephrology, etc) as well as Lincoln Community Health Center. Much of our attribution comes from patients who are referred in for care from those specialists. We may also have a higher proportion of dual eligible patients than many ACO’s. Both of these aspects create different challenges in terms of patient risk (medical and socioeconomic) than other ACO’s. Understanding how to address patients who become attributed through high cost specialty care as well as those with complex social needs are both challenges for us.”

By the same token, Duke Connected Care benefits from the full spectrum of closely aligned specialists and facilities like post-acute care services.

“If we were able to take full opportunity of [the spectrum of services], it may allow us to develop improved care pathways and processes that may be more of a challenge for a primary-care only ACO,” Komives said. “One example of this is the work we are doing with chronic kidney disease – developing analytic models to predict patients at high risk of rapid progression and using care managers and nephrology virtual consultations to reduce that risk.”

Like other ACO start-ups, physician engagement is key as well as a robust data sharing system. Both take time and resources. Duke Connected Care started with a bit of an advantage with data analytics.

“We had robust analytic shops to manage Medicaid and employed/commercial populations mostly focused on closing gaps in care for chronic illnesses like diabetes, and wellness quality metrics like mammograms,” Komives said, adding that there is an on-going commitment to improve in this area. “We have been working to enhance [the data analytics] to better predict patients who need individual high-touch care management to prevent hospitalizations, re-admissions, ED visits, progression to end-stage renal disease, etc. We have also been working to expand our analysis of variations in care from the inpatient space (where it has been very well developed) into outpatient episodes of care.”

Sangvai notes that while Duke could have “artificially created a set-up for success” with Duke Connected Care, instead the organization is being allowed to develop as organically and independently as possible in the community it serves.

Duke Connected Care was not among those North Carolina ACOs to receive shared savings last year, their first year in the MSSP, but did well in the quality metrics reporting.

“It’s hard work,” Sangvai said. From the broad perspective, Duke Connected Care’s progress has been an affirmation of the ACO approach, he said. On the granular level, however, there will always be numerous issues to address each day.

“We’re part of an academic medical center and it’s a credit to Duke — they could have hung their hat on a lung transplant program, but they’re committed to the community and compelling us to do this work,” Sangvai said.

“The number of [practices that are part of the] MSSP program and the number of ACOs in the state is great for North Carolina,” Sangvai said. “It shows the willingness from many to think differently and think of what’s right for North Carolina. Sure, there are challenges, but overall, it’s a good time for health care in North Carolina.”

Philip Brown, MD, President of Wilmington Health

Governor McCrory and Secretary of the NC Department of Health and Human Services Aldona Wos, MD, visited Wilmington Health last summer as part of their statewide tour of accountable care organizations (ACOs). The McCrory administration supports Medicaid reform that incorporates accountable or value-based care, and the visiting officials wanted to learn how this emerging model works on the ground and in the trenches.

Wilmington Health, as well as Cornerstone Health Care in High Point and Triad HealthCare Network in Greensboro, the other ACOs the governor and secretary visited, proved an excellent example. A physician-owned, multispecialty group practice with more than 160 providers, Wilmington Health was able to show and tell the visiting dignitaries just how they have been able to improve quality of care, reduce costs and provide excellent patient experiences.

Philip Brown, MD, President of Wilmington Health and a vascular surgeon, was quoted in the local newspaper after the visit as saying he and his colleagues had an “outstanding” discussion with McCrory and Wos.  “We have proven through our Medicare work that it can be done: to increase quality of care at lower cost. Over time, you learn and you get better and better. It’s high time that we have better-performing practices and do what needs to be done for Medicaid.”

Wilmington Health, which has been providing health care to the Wilmington region for more than 40 years, began its transformation to value-based care about five years ago. This required a complete culture change guided by the top leadership with process improvements coming from those on the frontlines. Success also meant all members of the care team staff had to buy-into and understand the metrics used to measure the success of each innovation.

Part of the Medicare Shared Savings Program (MSSP), Wilmington Health was able to show data in 2013 that revealed a 3-year trend of substantial savings to the Medicare system and improved health outcomes for its patients. For instance, in 2012 Wilmington Health showed an average total yearly expenditure by a Medicare patient at $7,019, down nearly 12 percent from the organization’s 2010 numbers and $2,844 less than all other recent MSSP participants.

This demonstrable progress had been achieved beginning in 2008, when the Board of Directors, inspired by the idea of collaborative, evidence-based medicine to transform and improve on the existing system, hired new leadership and embarked on their journey toward accountable care.

The new leadership set the tone and agenda for change, while those delivering care stepped up to improve the processes to better serve the patient. For instance, the group partnered with a regional university to implement a program to assist with the coordination and reconciliation of patient medications to improve patient compliance. The pediatric division instituted a foster child outreach program to increase compliance with preventative care in this at-risk population. Family medicine providers designed a program to help patients manage their weight and chronic conditions such as diabetes. Participants in this particular program have seen an average weight loss per patient of 50 pounds.

This philosophy of process improvement coming from the “bottom up” is part of LEAN management techniques, which require the people doing the work be the ones to improve the work.

An important part of this collaboration was the formation of one of the first commercial accountable care organizations in the state with Blue Cross Blue Shield of North Carolina. Also, improved relations with the local hospital have been crucial to success.

The third central element to the transformation to a value-based model has been collecting and analyzing the data necessary to track the progress being made. An early adopter of an Electronic Medical Records (EMR) system, Wilmington Health installed special software to better mine the data in its EMR.

On a recent visit, Jonathan Hines, MD, Chief Medical Officer at Wilmington Health, proudly pointed out the charts posted in a main hallway in the clinic showing pertinent metrics for how each doctor’s total diabetic patient population was faring for the last month. There also were charts showing each physician’s percent of pneumococcal vaccination for the last month as well as other clinical quality measures.

“In the past doctors could look at patients one at a time, but they can’t look at entire groups at one time and really assess how well they’re doing,” Hines explained. “We’re making this information transparent to the individual physician so they can start to problem solve in areas where they’re not doing as well as they’d like.”

While the aggregate information for doctors on how they’re doing with entire populations of patients is informative and can help them get a new perspective on the care they deliver, the ultimate beneficiaries are the individual patients themselves. Patient satisfaction, care coordination and prevention are all categories in which the practice is assessed by the Centers for Medicare and Medicaid Services, if the group is part of the Medicare Shared Savings Program, for instance. Improved quality not only is translating into cost savings for the system, but healthier patients.

While every accountable care organization is different and organic in how it develops, as Dr. Brown told the Governor and Secretary, “all ACOs have one commonality. We’re all trying to get at the triple aim: demonstration of quality at reduced cost in a patient-friendly environment.”

“Cone was masterful in their approach,” said Steve Neorr, vice president and executive director of THN. “Cone fully let physicians lead and drive this.”

The relationship between doctors and the hospital network, however, wasn’t always so trusting. Starting back in 2010, the real work began to create this successful partnership, which has proved itself through successful care management initiatives and shared savings through the Medicare Shared Savings Plan. THN was, in fact, the only ACO in North Carolina to exceed the threshold to achieve shared savings for the latest financial report from the Center for Medicare and Medicaid Services (CMS) in February 2014.

At first, though, it was just a group of three doctors who realized that health care as they currently were delivering it was not sustainable as to cost, access and quality. They believed that developing a local network based in the Piedmont-Triad area to serve patients and promote cost-efficient, high-quality health care across the broad provider community was key to the future of health care.

“Physicians have always been about quality and doing the right thing for their patients. That was an easy sell. The hard sell was we were telling them that now we were going to measure it,” said Thomas C. Wall, MD, the executive medical director at THN and one of the three doctors with the original vision for their community. “There also was a lack of trust between the hospital and doctors. It required a lot of relationship building.”

Wall and his colleagues set to work and initially chose 20 doctors, respected clinicians and leaders in the community who were willing to cross the old boundaries and open a dialogue with the hospital and other doctors. Three administrators from Cone also sat on the committee born out of dissatisfaction with the health care system status quo. Everyone agreed to check their egos at the door and have respectful, honest discussion, Wall said. Over hours of intense conversation, THN was born.

“It’s really a team effort,” Neorr said. “Having a hospital partner like Cone really made a difference for us. They have led the way in launching initiatives to keep people healthy and out of the hospital which is rather progressive for hospital systems. We believe strongly that Cone’s efforts combined with the efforts of THN Care Management to remove barriers to care and coordinate social services will equate to cost savings.”

Collaborative accountable care is Cigna’s approach to accomplishing the same population health goals as accountable care organizations, or ACOs. The program will benefit individuals covered by a Cigna health plan who receive care from the Boice-Willis Clinic’s 30 primary care doctors, 27 specialists and five health educators.

“The collaboration with Cigna aligns with the Clinic’s mission to provide comprehensive care and improve patient access to health care,” said Gary J. Fazio, Boice-Willis Clinic’s chief executive officer. “This program demonstrates Cigna and the Clinic’s team approach to proactive and ongoing management of patient needs.”

“We’re thrilled to continue expanding our collaborative accountable care program across the Carolinas with the addition of the Boice-Willis Clinic,” said Edward Hunsinger, M.D., Cigna’s senior medical executive for the Carolinas. “This collaboration aims to change the health care delivery system from one that focuses on volume to one that rewards physicians for quality care. Our mutual goal of creating a patient-centered system focused on prevention and wellness will result in a healthier population and lower medical costs.”

Under the program, Boice-Willis will monitor and coordinate all aspects of an individual’s medical care. Patients will continue to be treated by their current physician and automatically receive the benefits of the program. Individuals who are enrolled in a Cigna health plan and later choose to seek care from a doctor in the medical group will also have access to the benefits of the program. There are no changes in any plan requirements regarding referrals to specialists. Patients most likely to see the immediate benefits of the program are those who need help managing chronic conditions, such as diabetes, heart disease and obesity.

Critical to the program’s success are registered nurses, employed by the Boice-Willis Clinic, who will serve as clinical care coordinators and help patients with chronic conditions or other health challenges navigate the health care system. The care coordinators are aligned with a team of Cigna case managers to ensure a high degree of collaboration between the medical group and Cigna, which will ultimately provide a better experience for the individual.

The care coordinators will enhance care by using patient-specific data from Cigna to help identify patients being discharged from the hospital who might be at risk for readmission, as well as patients who may be overdue for important health screenings or who may have skipped a prescription refill. The care coordinators are part of the physician-led care team that will help patients get the follow-up care or screenings they need, identify potential complications related to medications and help prevent chronic conditions from worsening.

Care coordinators can also help patients schedule appointments, provide health education and refer patients to Cigna’s clinical support programs, such as disease management programs for diabetes, heart disease and other conditions; and lifestyle management programs, such as programs for tobacco cessation, weight management and stress management.

Cigna will compensate the Boice-Willis Clinic for the medical and care coordination services it provides. Additionally, Boice-Willis may be rewarded through a “pay for value” structure if it meets or surpasses targets for improving quality and lowering medical costs.

The principles of the patient-centered medical home are the foundation of Cigna’s collaborative accountable care initiatives. Cigna then builds on that foundation with a strong focus on collaboration and communication with physician practices. Cigna has 75 collaborative accountable care initiatives in 26 states, encompassing more than 760,000 commercial customers and more than 30,000 doctors, including more than 14,000 primary care physicians and more than 16,500 specialists. Cigna launched its first collaborative accountable care program in 2008 and its goal is to have 100 of them in place with one million customers in 2014.

Collaborative accountable care is one component of the company’s approach to physician engagement for health improvement, which also includes the innovative Cigna-HealthSpringSM care model for Medicare customers. Today, well over one million Cigna and Cigna-HealthSpring customers benefit from 240 engaged physician relationships across 31 states, with more than 58,000 doctors participating, including more than 20,000 primary care physicians and nearly 38,000 specialists.

About Boice-Willis Clinic, PA
The Boice-Willis Clinic is a multi-specialty physician-owned practice consisting of over 70 providers, including both physicians and physician extenders, representing 18 medical specialties with a support staff of over 350. Since its establishment in 1914 by two surgeons, Drs. Boice and Willis, who were inspired by the then-new concept of the Mayo Clinic, it has continued to grow and is now one of the oldest and largest physician-owned practices in North Carolina. For more information relative to the Clinic, its providers and services visit www.boice-willis.com.

About Cigna
Cigna Corporation (NYSE: CI) is a global health service company dedicated to helping people improve their health, well-being and sense of security. All products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Connecticut General Life Insurance Company, Cigna Health and Life Insurance Company, Life Insurance Company of North America and Cigna Life Insurance Company of New York. Such products and services include an integrated suite of health services, such as medical, dental, behavioral health, pharmacy, vision, supplemental benefits, and other related products including group life, accident and disability insurance. Cigna maintains sales capability in 30 countries and jurisdictions, and has approximately 80 million customer relationships throughout the world. To learn more, visit www.cigna.com.

• Carolinas HealthCare System, Charlotte
• Cornerstone Health Care, High Point
• Key Physicians, Raleigh/Chapel Hill
• Novant Health, Winston-Salem
• Triad HealthCare Network, Greensboro
• Wilmington Health, Wilmington

 To read the article and a summary of what makes these ACOs special click here.

“I worry that what’s best for patients isn’t usually in the equation in health care so far in our society,” said John Rubino, MD, President of Key Physicians. “As independent physicians – and we’re trying hard to maintain that [independence] — we can choose the best place for a particular patient for their particular problem. I hope that independent physicians remain as strong advocates for their patients in choosing the right thing for them.”

The journey for Rubino and his group began about four years ago when Key Physicians’ doctors decided to pursue Patient Centered Medical Home (PCMH) designation. A few physicians left, but everyone else made the necessary changes to become identified as a PCMH. This accomplishment showed at least one insurance company, Cigna, that Key Physicians could get things done as an IPA. So about a year ago Cigna and Key Physicians entered into an accountable care arrangement. Basically, they agree if certain goals for preventive care are met, and money is saved, Key is able to keep some of that savings. A similar agreement was struck with Blue Cross and Blue Shield of North Carolina this year, and recently WakeMed and Key announced their intent to form a Medicare ACO, focused on reducing health care costs and improving quality in both the traditional Medicare program and in private insurance programs.

“By forming an ACO of Key Physicians’ extensive primary care network and WakeMed’s inpatient and outpatient services, clinical resources and physicians, we will help facilitate patient access to a coordinated health care team focused on delivering efficient, quality care at a reasonable cost,” Rubino said in the statement announcing the partnership. “While patients will retain access to all of the region’s hospitals, they will benefit from an overall strategy to provide a more seamless experience regardless of where the care is delivered.”

These arrangements “are bringing into the health care system something that it grossly lacks – competitiveness based on quality and price,” Rubino said. “Some of the insurance companies now are telling you the prices of procedures at different places, but [patients] don’t have a sense of the quality, so they go, ‘if it costs more it must be better.’ But that is not necessarily true.”

Doctors have the expertise to evaluate the quality of the outcomes, which may not correspond to the price. Rubino said Key Physicians have identified as much as a 30 percent cost difference for the same quality procedure, leading to significant savings and equal patient outcomes.

“There are a lot of opportunities out there to do things that make a lot of sense,” he said. “We are proactively searching for those opportunities. It’s better for the health care system and our community.”

Independence is important to competition because Key Physicians – and patients — are not restricted to particular specialists or hospitals for their care. These providers need to earn Key’s “business.”

“All too much right now in our health care system locally and across the country, everybody is choosing [exclusive affiliations]. The problem is no one asks the patients about that. I can tell you, no one system is the best of everything,” Rubino said. “Whereas, more and more, the choice is made based on where you are to start with. So, if your primary care doctor [has a certain affiliation], for example, it’s very likely you’re going to refer to a doctor [with the same affiliation] whether or not that’s the best choice for that particular patient.”

Rubino is pleased with the progress Key Physicians has made toward the accountable care model and the ability to provide high quality care at lower costs.  

Moving toward the accountable care has “provided a mechanism for a number of very independently minded doctors to get together, do some good things for their patients and their community, and get a greater voice in local health care,” he said.

“This process and this project are helping to build local infrastructure and local capacity for future ACO readiness,” said Melissa Baker of the Buncombe County Health Department and Innovative Approaches, integral partners in the Collaborative. “A lot of people feel they’re part of this. It’s a grassroots, collaborative and consensus model.”

The seeds of the Collaborative were planted two years ago when three pediatric practices in Western North Carolina joined with Innovative Approaches, Community Care of Western North Carolina (CCWNC) and, the Mountain Area Health Education Center (MAHEC) to pursue the patient centered medical home (PCMH) designation. That effort was so successful that a year ago the group decided to expand to a patient centered medical “neighborhood” and pull together multiple practices — pediatric, family practice and specialists — to collaborate and improve community health. The current resources, structure and support for the on-going project are provided by Buncombe County Health and Human Services, through the Innovative Approaches grant project, Community Care of Western North Carolina, MAHEC, and a local pediatrician, Dr. Calvin Tomkins, from Asheville Pediatrics.

 “We realized we’re all in the same boat in the day-to-day work that we do. We decided that, instead of us each banging our head against the same wall each day, we could come together and somehow work toward something where everyone is doing it together,” said Carrie Pettler, Quality Improvement Specialist for Community Care of Western North Carolina. Collaborative participants “sit around the same table every Wednesday from nine to 11 and have open discussion about how to move this forward; how to make this better. I think that’s been a very organic and successful model.”

The group’s first initiative focused on asthma. The second initiative has looked at obesity. The collaborative members, working with MD Champions and Specialists, developed a work flow model that they call “the Matrix” to help each of the 15 participating practices streamline their work for the treatment and prevention of asthma and obese patients. The Matrix includes evidence based guidelines, team-based care, how to document their work through Electronic Health Records (EHR) even though the practices may use different EHR systems, clinical quality measures (such as PCMH, MU and HEDIS goals) and how to help providers get paid.

The process “helps providers glean a population health perspective,” Pettler said. They are able to do this in a “collaborative environment where they can bounce ideas off other providers, learn from people who are having successes, learn from other people’s challenges, and implement these things into a practice in a seamless way. Their time in the office is more focused on the patient and the lessons they’ve learned from the collaborative and less focused on trying to do that work individually in their practice on their provider time.”

Mission Hospital in Asheville has shown interest and has begun sharing their data. Their Primary Care Counsel will likely join future Collaborative meetings. The hope is to grow the Collaborative’s executive committee and governance structure to encompass all the health care stakeholders in the area, including community services.

“The Western NC Pediatric Collaborative is unique from other ACO type organizations in that public health is involved,” said Baker. “We’re looking at ways we can connect clinical providers with community resources and support.”

The existing group believes this model is scalable to more practices in the region, including adult care, and to other communities throughout the state. Funding, however, is the limiting factor for this project.

The Collaborative currently is working off of the limited resources of the three participating groups and its doctor champion, Dr. Tomkins. They are applying for grant funding as well as additional funding sources.

“There’s a lot of community buy-inand support,” Baker said, hoping that maybe another organization would be willing to continue to fund this promising work. “We’re doing this for multiple reasons — for [providers], for patients, for families, but also because the health of our community depends upon successful, viable primary care practices.”

Dr. Grace Terrell, a practicing general internist, President and CEO of Cornerstone, explains the philosophy behind Cornerstone’s adoption of this model, their experience thus far and why accountable care organizations are here to stay.

Why did Cornerstone decide to go from being a fee-for-service group to form an accountable care organization?
Dr. Terrell: Cornerstone Health Care came to the conclusion a few years ago that although we’d been very successful as a multi-specialty group in the fee-for-service world, that that model, in the long run, was not good for patients and was unsustainable. As we had more and more patients who are becoming older with chronic diseases, and we had higher and higher costs of care, we began exploring other ways that we could get ourselves into a system where we could really have the joy of practicing medicine in the right way again. So, over the course of about a three-year period of time, my physician partners and I decided we’d take the path to lead the value-based world, and really become accountable for a system of care that we believe can be both better and sustainable.

What have been the challenges along the way in changing your model of care?

Dr. Terrell: One of the challenges of being one of the first to do accountable care is that we’re having to invent it as we go along, and sometimes we make mistakes. So long as we continue to focus on the patient and what’s right for the patient, what’s best for the patient, then over time we’re starting to resolve some of those.

For example, we have a heart function clinic that’s for patients with class four heart disease. We know that if we’re able to see them in this clinic on a regular basis it keeps them out of the hospital and provides them better care. But our current payment system is fraught with arrangements where there are a lot of co-pays related to that. So part of the real issue in establishing an accountable care organization is that you’ve got to change the benefit structure, the payment system, at the same time you’re changing the way you’re providing care. So it’s a lot of work, but we’ve found that the further along we get with this, the easier it’s becoming.

The physicians at Cornerstone are passionate that we want to be part of the healthcare revolution that is better than the healthcare system we have right now. So we made time to do this. We wanted to basically roll up our sleeves and figure out how we can do a better job in terms of both controlling costs and providing higher quality for our patients. It’s not just me who’s found time to do this. It’s a whole group of 361 providers at Cornerstone that are doing this together.

What would you say to physicians who are skeptical about accountable care organizations (ACOs) as a lasting solution to an inefficient healthcare system?

Dr. Terrell: There are a lot of physicians out there, I think, that because of all they’ve been through get pretty cynical about this, and say this is the 90’s all over again. This is HMOs. The difference this time around is that our country is broke, and we have a population that is getting older. I believe that it’s absolutely crucial as a profession for physicians to lead this effort. Those physicians that hang around and wait for someone else to solve it, are, in my opinion, suffering from learned helplessness, and that may be what got us in this position to begin with. I think one of the reasons physicians have to do this is because it’s the right thing to do. And if we don’t lead it, someone else will, and I don’t think we’ll like that very much.

Besides, accountable care organizations are already here. In North Carolina we have seven acos currently. Some of them are between groups of physicians and commercial payers, and some of them are Medicare shared savings program and some of them are both. It’s not if ACOs are coming, ACOs are already here. In the US, approximately 10 percent of all patients are already being impacted by being in an ACO.

What options are available to physicians interested in starting an ACO?

Dr. Terrell: ACOs are not just about Medicare. You can have an ACO in any type of arrangement where physicians are contracted to provide care that is related to both quality and cost.

There are a number of different arrangements from an ACO standpoint, that will allow the expense of the infrastructure for an ACO to be affordable for physicians. For example, those that participate in the Medicare shared savings program that are in groups of 50 physicians or less can get some up front monies through the Medicare shared savings program. There are also a number of payers in the private world that are partnering with physicians to help set up ACOs as well as certain other organizations that are creating the ability to have infrastructure such that physicians are going to be able to do this in an affordable way.

The biggest key to success at Cornerstone is that it’s always been about the patient, and we continue to be focused on the patient and what’s right for the patient. The second biggest key is we’re very passionate about our vision statement that we want to be the model for physician-led healthcare in America. We believe that physician leadership is crucial to getting us where we want to be in healthcare.

When Coastal Carolina Health Care, P.A. (CCHC) in New Bern was considering forming an ACO, they thought, “should we do it now, or wait? There was a lot of debate around this topic,” said Stephen Nuckolls, Coastal Carolina’s CEO. “We felt that the program, while not perfect, was good enough at this point in time. If we started early we could gain from our experience. Also, there was a certain amount of fear that if we waited we’d lose a valuable learning experience.”

CCHC is based in New Bern and is comprised of 50-plus providers with 60 percent specializing in primary care. They operate out of 11 locations and their other specialties include cardiology, gastroenterology, pulmonary/critical care, hematology/oncology, and neurology. They have an integrated electronic health record (EHR) system and all of their clinicians have met the requirements to be deemed “meaningful users”. CCHC launched its ACO, Coastal Carolina Quality Care, Inc. last year and was accepted by The Centers for Medicare and Medicaid Services (CMS) in their first round with an April 1st start date and was one of five ACO’s nationwide to be accepted in this round into their Advance Payment Model. This model allows for advance payments from CMS’s Innovation Center to fund start-up costs.

Getting the doctors to buy into this model was the first and perhaps biggest hurdle to clear. “Commitment from the physicians is vital,” Nuckolls said. The process involved first educating the group’s leadership on the concept. They discussed it in depth at their annual retreat; and the physician and administrative leaderhip team went to a CMS sponsored Advance Development Learning Session (ADLS) where they heard from former CMS Secretary Don Berwick, a major impetus behind the agency’s support of such a model. CCHC’s leaders felt that CMS was committed to the program and were confident they could be successful in achieving its goals.

While there are multiple keys to operating a successful ACO, Nuckolls is convinced that the first thing that needs to happen is physician engagement in the process. “It helps change the whole culture…and helps make the care transformation needed to have a successful ACO.”

Part of that transformation for CCHC has included hiring 10 care managers to help coordinate patients’ care, a nurse navigator and working with local transportation providers to help patients without transportation get to their appointments. Nurse triage lines were made available 24/7, Urgent Care clinic hours have expanded, and more next day appointments are now offered. Increased marketing has helped patients become more aware of this enhanced access to care.

“The strategies CCHC focused on early were expanding access to patients since it would really help provide better patient satisfaction and help reduce costs,” Nuckolls said. “This model has been wonderful for our patients; especially the most fragile and those who have the greatest need for care.”

One of the ACO’s activities involves a frequent and detailed physician review of all emergency room and hospital admissions of CCHC’s attributed beneficiaries with the goal to uncover trends and opportunities to be more patient centered and cost effective.

Since implementing these changes, the practice has seen an increase in office visits by ACO beneficiaries, especially at its urgent care clinic, and a meaningful decrease in the number of emergency department visits and hospital admissions.

In order to close gaps in care and help improve certain quality measures, the group also implemented a point-of-care electronic dashboard and a more robust clinical reporting system. The dashboard allows doctors and their staff to better track and coordinate their patients’ care, while the clinical reporting system allows the group to better monitor its clinical quality measures.

Kenneth Wilkins, MD, an internist and president of CCHC, said he has made the transition and uses his patient “dashboard” with every patient. “It’s hard to change – to really convince us it’s worthwhile,” he said, but he is becoming increasingly sure the transformation to an ACO is indeed worthwhile for patients as well as doctors.