From left: Christina Miles of Aon Hewitt, David Van Houtte of Aetna, Dr. Katherine Schneider of Delaware Valley ACO and Dr. Greg Carroll of GOHealth Urgent Care
Accountable care is supposed to be about paying for value. But six years after passage of the Affordable Care Act heralded the shift away from fee-for-service, Dr. Greg Carroll, corporate clinical leader of GOHealth Urgent Care, has an important question: “Where’s the value?”
That was the subject of a lively panel discussion at MedCity CONVERGE this week in Philadelphia.
“We really need to get to the level of what motivates behavior change,” said Carroll. After all, everybody is a little bit different in what motivates them, Carroll explained, and the movement to performance-based payment requires behavior change on multiple levels.
Those paying the bulk of the bills in healthcare for patients not old enough for Medicare — employers, via insurance premiums — don’t seem to get value-based healthcare yet.
Christina M. Miles, senior vice president for delivery system transformation at human resources consulting firm Aon Hewitt, presented some eye-opening data from a 2015 company survey. Just 11 percent of respondents said they “fully understand” healthcare provider performance from a cost perspective, while 9 percent said the same about provider performance from a quality standpoint.
In each case, more than 31 percent were not even aware of clinically integrated performance initiatives within their company plan’s healthcare networks, Miles said. “In most cases, the majority of employers just aren’t there.”
A Deep-dive Into Specialty Pharma
A specialty drug is a class of prescription medications used to treat complex, chronic or rare medical conditions. Although this classification was originally intended to define the treatment of rare, also termed “orphan” diseases, affecting fewer than 200,000 people in the US, more recently, specialty drugs have emerged as the cornerstone of treatment for chronic and complex diseases such as cancer, autoimmune conditions, diabetes, hepatitis C, and HIV/AIDS.
Those in on the front lines are not discouraged, though. “Value-based contracting is one of our key corporate pillars at Aetna,” said David Van Houtte, of the payer’s Accountable Care Solutions division.
Aetna currently puts about 40 percent of its total healthcare dollars into value-based contracts, Van Houtte said. The goal is to have that at 75 percent by 2020.
That aggressive shift parallels efforts at the federal level. The Centers for Medicare and Medicaid Services has said it wants 85 percent of all Medicare fee-for-service reimbursements tied to quality or value by the end of 2016, including shifting 30 percent of reimbursements to alternative payment models — think bundled payments or Accountable Care Organizations. The goals rise to 90 percent and 50 percent, respectively, by 2018.
Miles said to “be encouraged” that for the first time, CMS is driving much of the evolution.
It has providers rethinking what they do, for sure.
“My full-time job is basically change management,” said Dr. Katherine Schneider, president and CEO of Delaware Valley ACO, comprising Main Line Health, Jefferson University and Hospitals, Holy Redeemer Health System, Doylestown Health, and Magee Rehab in the Philadelphia area. It’s one of 77 ACOs contracting with Aetna, she said, and the organization also participates in the Medicare Shared Savings Program.
The hope for Delaware Valley ACO was to get 5,500 lives in MSSP in its first year. The organization actually enrolled 35,000 the first year, and now is above 130,000, plus 100,000 more commercially insured members in ACO programs. Participating organizations earned $6.5 million from CMS for saving Medicare $13 million last year, Schneider said.
She offered some words of advice to those contemplating their own ACOs. “The ACO is all about the C. It’s the care model that matters,” Schneider said.
“We’re very primary care-centric even though we’re part of an integrated health system,” she added.
Miles also emphasized primary care and prevention. “The hospital bed becomes a cost center rather than a profit center,” she said. The same is true about the emergency department.”
“We tend to forget the patient,” Miles said. “They’re the end user.”
Miles noted that employers today are hesitant to require their employees to choose a PCP, a throwback to the unpleasant HMO era. She surmised that it may be time to go there again.
“We have to keep our eyes on the True North here,” Miles said. That’s the Triple Aim of safer care, improved population health and lower costs.
Photo: Meghan Uno/Breaking Media
