Jennifer Moore is the Chief Operating Officer of the MaineHealth Accountable Care Organisation (ACO), whose membership includes 10 acute care hospitals and over 1,500 private practice and employed physicians. Jen oversees all activities associated with the Medicare Shared Savings Program and numerous commercial ACO contracts including payer contracting, network management, data operations and analysis, performance improvement programs, and practice support activities.
- As COO for Maine ACO and also a board member for the National Association of ACOs (NAACOS), what was the rationale behind accountable care organisations and what impact have they had in the US?
ACOs were implemented in 2012 by the Centers for Medicare and Medicaid Services (CMS) to address rising health costs. Providers were not engaged in cost management strategies and ACOs changed this by driving accountability for providers, incentivising them based on cost reduction and quality outcomes.
Since their inception the impact has been mixed, but has resulted in overall savings. Engagement grew significantly and in 2012 there were under 200 accountable care organizations, and in 2018 this has grown to over 600. Our goal is to work towards achieving the “triple aim” - One – Cost reduction, two – quality improvement and three – enhanced patient experience.
Providers are incentivized to achieve population health management and patient outcomes, and the ACOs’ invest in tools to support this work. This has really been driven by the introduction of ACOs.
CMS developed the ACO model and defines success based on how many ACOs achieve cost savings but that assumes the financial targets are actuarially sound. Depending upon your starting point, the structure of the programme inhibits financial savings. It looks like ACOs are not delivering on targets but there are decreased emergency department attendance, decreased hospital admissions, decreased post-acute utilization – these are the areas the ACOs can impact. Other healthcare costs such as pharma costs are also contributing to the cost of care, but largely out of the ACOs’ control. On a net basis they are curbing the rising cost of healthcare.
- MaineHealth Accountable Care Organisation has been operating now for seven years. With 10 hospitals and 1500 healthcare providers to serve around 230,000 patients, this is a huge remit to manage. What have been some of your biggest challenges?
Number one on the list has to be data and interoperability. We operate with 1800 providers and have 35 different systems being used within our ACO so the cost involved to cross all these systems is hard. For population management data for example, 20% is always manual across primary care data- mainly from private practices. It is beneficial to include more and more providers in the pursuit of the triple aim, but as an ACO you bear the burden of reporting progress from across the organisation and interoperability makes this challenging.
The second one has to be aligning practice capabilities. As we have a broad network of providers with varied skills, some are more advanced than others so engaging them all is hard. The burden becomes increased and therefore meeting challenges is tough.
- One of the concerns here reverts back to being able to manage accountability within the system. How do you manage this and how does it work in practice?
Firstly we set annual conditions of participation which are achievable targets that all providers need to have in order for us to achieve collective success. For example, not all providers have electronic health records (EHR), so we’ve set a target that by the close of 2019, everyone needs to be on an EHR in the ACO. As a result of this requirement, we may lose some of our providers who are unable to bear the expense and administrative burden to implement an EHR.
For the second wave of accountability, we have a value oversight committee. It is organised around hospital communities (which we call ‘pods’) and each have a clinical and admin representative on the committee. The committee is responsible for reviewing data and putting forth improvement ideas to work on as multi-year priorities i.e. aim to decrease ED admissions to meet the national average. Each hospital has a local group for reviewing data and a performance improvement department provides support to the hospital communities to achieve the stated goals.
Our financial distribution model works so that when we are successful the shared saving is distributed across all the providers. The CMS awarded £10M, of which £2M went to the ACO and the rest to the providers based on quality and financial results across community, hospital, primary and speciality care.
- The UK version of ACOs, Integrated Care Systems and Organisations (ICSs and ICOs), have recently been introduced in the past year or so. What advice would you give to your UK counterparts embarking on the journey towards integrated care systems?
Keep it simple! We thought we needed to invest millions to achieve all the things we wanted to achieve but remember, you know what needs to be done. Work on half of the priorities – don’t try and boil the ocean by focusing on everything at once. If you do, things will get lost. Work smaller and focus on one thing at a time.
- You’ll be speaking at the UK Health Show to share your story. What is the one message you would like visitors to take away from your session?
I actually have two things I’d like visitors to take away. Firstly, to always bring everything back to quality – particularly with physicians. We need to focus less on cost and keep patient centred care at the heart of what we do. Secondly, don’t sacrifice the good for the perfect. If you get 80% of the data set in for example, that will be enough – there is no need to focus on the 100%.
- What are you most looking forward to about the UK Health Show 2018?
Connecting with other staff from across the board and learning from similar UK journeys