“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.”

The Pioneer Accountable Care Organization (ACO) Model was found to generate over $384 million in savings to Medicare over its first two years, according to the independent evaluation report. This equates to an average savings of approximately $300 per participating beneficiary per year, while continuing to deliver high-quality patient care. Pioneer ACOs generated Medicare savings of $279.7 million in 2012 and $104.5 million in 2013. To date, actuarial analyses show that ACOs in the Pioneer ACO Model and the Medicare Shared Savings Program have generated over $417 million in total program savings for Medicare. The primary analyses in the evaluation are also reported in an article published in the Journal of the American Medical Association (JAMA).

Additional information about the Pioneer ACO Model and its actuarial certification can be found on the Pioneer ACO Model web page.

The Centers for Medicare & Medicaid Services (CMS) recently announced a new funding opportunity specifically for rural providers.  CMS wants to encourage providers to form Medicare Shared Savings Program (MSSP) ACOs in rural areas and areas with low ACO penetration. The ACO Investment Model (AIM) program will provide upfront and monthly funding for eligible ACOs to participate in the MSSP beginning in 2016.  The upfront and monthly per member/per month (PMPM) will provide funds to develop the infrastructure needed for population health management.

The MSSP was established to improve the quality of care for Medicare Fee-For-Service beneficiaries by promoting accountability for their care, requiring coordinated care for any service provided under Medicare FFS and encouraging investment in infrastructure and redesigned care processes. MSSP also aims to reduce unnecessary costs. Providers, hospitals and suppliers that either create or participate in an ACO may participate in this program. Those ACOs that lower their rising health care costs and simultaneously put patients first and meet performance standards on quality of care will be rewarded by the MSSP.   Click here to learn more about MSSP.

The NCMS Foundation has been working diligently over the past several years to foster development of value-driven health care models and ACOs through its Toward Accountable Care (TAC) Consortium and Initiative and the NC ACO Collaborative as well as at the General Assembly. This rural ACO initiative is the latest effort. Learn more about it here.

John Meier, MD, and Ray Coppedge, Executive Director, both of Key Physicians in Raleigh, shared information about their ACO and fielded their colleagues’ questions. Melanie Phelps, Deputy General Counsel for the NCMS and Associate Executive Director of the NCMS Foundation and the person who convenes the NC ACO Collaborative, gave a brief overview of the current status of ACOs in North Carolina. Bo Bobbitt, a partner at Smith Anderson law firm in Raleigh, who has spearheaded development of a variety of toolkits for doctors interested in ACOs, provided an update on recent initiatives and announcements by the Centers for Medicare & Medicaid Services (CMS). CMS and national health insurers have accelerated the move toward value-based arrangements and have signaled their commitment to this approach through a variety of new funding opportunities. View the PowerPoint slides.

The next meeting of the ACO Collaborative is tentatively set for Thursday, September 17, at the NCMS Center for Leadership in Medicine in Raleigh. If you are interested in attending, please contact Melanie Phelps or call her at 919-833-3836.

For decades, while payers marginalized quality as a legitimate concern in health delivery, the physician community aggressively advocated for more emphasis on it. The North Carolina Medical Society (NCMS) has been working diligently for the past several years to help prepare NCMS members for this new reimbursement model through its Toward Accountable Care (TAC) Consortium and Initiative. TAC provides resources such as specialty specific toolkits to help physicians better understand what the move to quality means to them and their patients. Physicians who are knowledgeable about how quality affects payment can also participate more effectively in NCMS advocacy efforts to address shortcomings and make improvements.

The Affordable Care Act created a number of new payment models that move the needle even further toward rewarding quality. These models include ACOs, primary care medical homes, and new models of bundling payments for episodes of care. In these alternative payment models, health care providers are accountable for the quality and cost of the care they deliver to patients. Providers have a financial incentive to coordinate care for their patients – who are therefore less likely to have duplicative or unnecessary x-rays, screenings and tests. In addition, through the widespread use of health information technology, the health care data needed to track these efforts is now available.

In 2011, Medicare made almost no payments to providers through alternative payment models, but today such payments represent approximately 20 percent of Medicare payments. The goals Secretary Burwell outlined represent a 50 percent increase by 2016.

Read a new Perspectives piece in The New England Journal of Medicine from Secretary Burwell.

1)      Cape Fear Valley ACO

2)      Carolina Medical Home Network ACO (NC FQHCs)

3)      Coastal Plains Network (Vidant)

4)      CHESS (Cornerstone, Wake Forest Baptist)

5)      Mission Health Partners

6)      PACN (Pinehurst Accountable Care Network)

7)      Pioneer Health Alliance (service area includes Georgia, Kentucky, Mississippi, North Carolina, Tennessee, Virginia)

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.”

Coastal Carolina Quality Care in New Bern, Cornerstone Health Care in High Point, Wilmington Health and Triad HealthCare Network in Greensboro all placed in the top 30 ACOs overall out of the 220 nationwide reporting during this period.

Each ACO in this Medicare program reported data on 33 measures of quality for the patients they saw. These individual measures included information on such things as whether patients could easily get an appointment with their doctor; whether they received necessary immunizations or screening tests like mammography; whether the practice tried to help them stop smoking or lose weight; whether diabetic patients’ blood sugar was under control. Each measure was then grouped into four broad categories: patient satisfaction, care coordination/patient safety, preventative health and treating at-risk groups like those with diabetes or heart disease.

Coastal Carolina Quality Care was third in the nation on its overall ranking and second in care coordination. Wilmington Health was 23rd overall, Cornerstone was 25th and Triad Healthcare 30th out of the 220 reporting ACOs.

“This latest information shows that the ACO model is not only taking root in North Carolina, it is doing well. This is great news for the people of our state who have access to this innovative and quality-based brand of medical practice,” said Robert W. Seligson, CEO of the North Carolina Medical Society.

More information is available at the CMS Website along with the raw data.

“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.”