• Three years of participation; • A minimum of 15,000 fee-for-service Medicare patients; • Adherence to a set of 33 predetermined quality measures; • An open network, meaning patients are not required to seek care in the ACO; and
• Patient assignment based on where patients get most of their primary care services.
By contrast, the Medicare Shared Savings Program model
requires only 5,000 patients and gives participants the option of a shared-savings-only track or a shared-savings-and-losses approach with higher rewards. The Seton Alliance is a physician-hospital joint venture, but
the structure is physician-led by design, says Dr. Sheff, who is also ARC’s medical director of care management and clinical integration. Physicians make up more than half of the governing board,
which includes representation from three blocks, each with veto power: ARC, Seton Healthcare, and a third block of com- munity physicians and a patient representative. Hospitals certainly have a lot to offer in terms of providing
many of the resources to help get an ACO up and running, and “no one entity can do this alone,” Dr. Sheff told Texas Medicine. “But physician leadership keeps the emphasis on patient care and brings the content knowledge of how care actually works and how care works in a given community.” That community aspect is another reason the Seton Alliance
is not exclusive to ARC or Seton physicians, he added. Nor are physicians in the ACO beholden to any one hospital facility. Because an ACO is responsible for managing a certain popula- tion of patients, the primary care relationship also provides an important link. Wherever the project takes them, Dr. Sheff says it will be a launchpad for transforming how care is delivered at ARC, and the group is pursuing commercial ACO contracts with other primary care physicians and specialists. “Our intent is to truly build an integrated network and make
a functional delivery system out of the inherent groups that are already here,” he said. The Medicare Pioneer ACOs recently concluded their first
year, so quality reporting scores are incomplete, and bench- marks are still being set. Dr. Knight, who participated in some of the early Medicare demonstration projects, said one of most important lessons learned was that “the biggest opportunity for Medicare pa- tients is in transitions of care, mostly back to the ambulatory realm, and especially in areas of complex comorbidity. And all [of the demonstration projects] had success in improving outcomes and efficiency” in that area. North Texas Specialty Physicians saw those results early on
in its ACO project. When it began in December 2011, Dr. Pickell says, home
health usage was “off the chart,” double to triple that of the Medicare Advantage patients the group has treated for years. And several thousand of their newly assigned Medicare ACO population had no identifiable primary care physician.
22 TEXAS MEDICINE July 2013
By focusing on case management and getting patients the
care they need, those statistics already have changed for the better. One of Dr. Pickell’s recently assigned patients had debilitat-
ing back pain from a construction accident a decade ago. “We discovered that he had been receiving home health care for 10 years without once having seen a primary care doctor. Why he had been receiving home health care for so long with no apparent oversight was not clear to us. But once he showed up on our panel, it was clear to us that what he needed was surgery,” and he is now improving. Like Kelsey-Seybold, NTSP essentially already had an ACO
because it cooperated with THR to take care of a Medicare Ad- vantage population under a coordinated care capitation model. That made the two organizations natural partners, he added. Hospitals in some aspects play the role of a bank in that
they help underwrite much of the capital costs of getting an ACO off the ground. They also provide much of the architec- ture and tools needed to operate, such as clinical information systems, case management capabilities, and experience nego- tiating large payer contracts. “But we absolutely view this as a partnership with physi-
cians. One thing we [hospitals] don’t do is directly take care of patients,” THR Chief Clinical Officer Daniel Varga, MD, said. The hospital also has two commercial ACOs under way us-
ing its affiliated nonprofit 501(a) health corporation physician workforce, which Dr. Varga said was one way to launch quickly, given certain contracting barriers. Once up and running, the ACO plans to include community physicians. “Almost all of the care in an ACO happens outside the walls
of the hospital,” he said, adding that all three of the hospital ACOs share governance with the doctors involved. “Physicians are going to help us guide, govern, and manage this health system. Not just admit patients to our hospitals.” Payers, too, are proving to be important players in ACOs.
Not only do they look to the coordinated models to get more bang for their buck, but they also recognize their role in pro- viding data to help physicians and hospitals attain that goal. “We view it as a better contracting model than fee-for-ser-
vice because it aligns incentives for providers to focus on the right things,” said Scott Albosta, vice-president of network per- formance management for Blue Cross and Blue Shield of Texas, one of THR’s commercial ACO partners. Mr. Albosta says THR’s purchase of a large primary care
group to facilitate care for the ACO patient population was a key piece of the puzzle. That meant that “we now have a primary care group we can attribute patients to, and in the PPO world, that means we can look back via claims and see visitation patterns” to help understand the patient population, their risks and needs, and how to improve their care in a tar- geted manner. A workgroup of physicians, nurses, and other clinicians is
doing exactly that as the budding ACO begins to define its operational and financial objectives. Because the Blues has a comprehensive claims history for the patient population, it says it can help provide a more robust picture of overall utiliza-
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