It might not be the actual ACO design that’s driving quality improvements and savings but rather the “exit of high-cost clinicians and their patient panels”. This was the finding from a recent study published in the Annals of Internal Medicine. The study examined the beneficiary spend and quality improvements of Medicare Shared Savings Program (MSSP) ACOs across four distinct diagnostic categories. This finding was thought provoking but what really caught my attention was one of the suggested reasons for the exit of these physicians and their patients – “clinical selection”. In other words, the practice of hospital and physician group executives determining which physicians will or won’t be ACO participants.
The study caught the attention of some others as well. Several Harvard researchers contend there is bias in the study methodology, and cited previous studies that demonstrated ACO savings controlled for these types of risk selections. And NAACOS chimed in, noting that the study “is not an indictment of the real savings ACOs have generated, but further evidence of how the model is unfolding”.
Here’s my question: Why is attributing savings to clinician selection disturbing? After all, doesn’t it make intuitive sense that excluding high cost primary care clinicians from an ACO would result in increased savings for the ACO? I think it’s the study’s assertion that clinician selection is the primary, and perhaps only, determinant of savings. Taken to the extreme, the ACO should carefully select the highest value clinicians and success would be assured. At the least, it seems the selection of optimal clinicians would certainly work in the near-term. What I find disturbing is the idea that all the work ACOs are doing to improve quality, implement clinical best practices, and provide better care management of patients doesn’t seem to make a difference… immediately.
While we can debate the degree of influence, what if we accept and embrace the reality that clinician selection appears to have a significant near-term impact? Don’t we want to build high value networks of clinicians who provide care excellence while stretching the healthcare dollar? Might this be a viable way to influence those clinicians who provide the same service at a higher cost, even if it isn’t immediately? I’ve personally seen this to be true in primary care providers in an ACO, where certain providers had not made the shift to value based principles. One provider we observed averaged over twice the average number of outbound referrals a day, triggering far greater downstream spend than typical or necessary. But over time we saw improvement in high value metrics for most primary care providers. I have also seen this to be true when establishing a high value referral network of specialists and post-acute providers supporting a commercial ACO. While many of these providers were not part of the ACO, the ACOs’ success depended upon selecting high value external partners and coordinating patient care with them. Clinician selection had a profound effect on savings in this example, and external clinicians initially excluded worked to improve and earn their way back into the high value network.
Embracing both clinician selection and continuous clinician improvement as the top drivers of ACO success may be the fastest way to improve ACO savings and quality. In the context of selecting external providers to be members of the ACO’s high value referral network, it is all about clinician selection and coordinating care. The good news is that clinician performance can change and improve over time, and the high value network should be dynamic over time. Within the ACO, quality metrics, care management, referral patterns and adherence to clinical best practices can all be measured and continuously improved by primary care providers that are willing to adapt.
Our challenge is to apply what works as quickly as we can, and this study provokes needed thought around clinician selection.
Mark serves as Infina Connect's Chief Executive Officer and leading evangelist for value based care. He has seen firsthand the impact of care coordination in the hospital and post acute market while at Allscripts and now with Infina Connect's Intelligent Care Coordinator (ICC), the first referral coordination solution to be adopted by a majority of providers across a major metropolitan area. Mark is passionate about his faith and making a difference in others' lives, his family and outdoor fun like boating and hiking.