Medicare ACOs with a higher proportion of primary care physicians with patient-centered medical home experience were more likely to generate savings and demonstrate higher quality scores, according to the Patient-Centered Primary Care Collaborative's (PCPCC) 2018 Evidence Report.
Researchers grouped 333 ACOs into quartiles from no PCMH experience (Q1) to 43% PCMH primary care physicians (Q4). After adjusting for organizational and beneficiary characteristics, the relationship between PCMH PCP and higher cost outcomes was positive, with ACOs in the 2nd, 3rd and 4th quartiles averaging savings of 1.9%, 1.3% and 1.2%, respectively — notable, given that the overall savings benchmark was 0.6%.
Regarding quality, ACOs in the highest quartile of PCMH PCP share performed better in clinical quality scores related to preventative screenings, chronic management, health promotion and health status.
With 10% of the U.S. population in ACOs and almost 1,000 available around the country, these findings are widely applicable for healthcare players in both the public and private sectors as they work out new payment models amid the turbulent rise of value-based care.
This report, co-created by the PCPCC and the Robert Graham Center, coalesces two promising approaches in the space, as PCMHs and ACOs (although created separately) both exist in the same ecosystem focused on outcomes-driven care.
PCMH is a care delivery model where a patient's care is coordinated through their PCP, and the system aims to produce coordinated, team-based holistic treatment. They have become more widespread over the past decade, with nearly 500 public and private sector PCMH initiatives being tracked across the U.S., according to the report.
Introduced in 2006, ACOs are similar but more broad. They hold groups of providers across different care settings accountable for both the cost and the quality of a cohort of patients. The providers therefore share the risks and rewards of patients' health, prioritizing value.
"ACOs and patient-centered medical homes are cut out of the same cloth," said Robert Mechanic, executive director of the Institute for Accountable Care in a panel convened by PCPCC on Wednesday.
He also pointed out that, although both PCMH and ACO performance have varied in U.S. studies, a wealth of evidence supports the role of robust primary care delivery in bolstering population health, reiterating the importance of continued studies such as this report.
The study also stressed that the characteristics that lead to the success of ACOs were also pivotal to the success of advanced primary care models such as the PCMH.
The study, which is the first of its kind to examine the interaction between these two models, also identified six domains that contributed to successful ACOs, with success defined as ACOs with shared savings, improved quality or adroit use of healthcare services. The six categories were leadership and culture, prior experience, health IT, care management strategies, organization and environmental factors and incentive and payer alignment.
Regarding leadership and culture, one important factor referenced throughout the literature was physicians acting as "clinical champions," acting in leadership roles and lobbying on their patient's behalf. Diverse, collaborative governance structures were also noted as important to foster coordinated communication across the ACO, along with establishing a culture of shared commitment and accountability.
"Providing care is a service, not a building," said Ann Hwang, director of the Center for Consumer Engagement in Health Innovation. The focus should always be on the patient as a whole being, not a set of symptoms, she said.
From a provider perspective, two things are inserted into this equation, according to Farzad Mostashari, chief executive officer of Aledade: total cost of care accountability and voluntary alignment of practices. Successful ACOs must be a coalition of the willing, as the "whole dynamic of the network is incredibly powerful."
Another subject brought up in Wednesday’s panel was the mounting role of technology in health. Along with using technology to coordinate care, identify high-risk patients and track patient care beyond the ACO, the report highlighted the critical role of health IT in performance data feedback for quality improvement.
William Kassler, deputy chief health officer and lead population health officer at IBM Watson Health, said he sees such technology as an "enabling tool" for providers, stressing that "data is key for quality improvement."
When asked to identify obstacles to ACO and value-based progress, the panel was quick to provide a flurry of answers, including sluggish public policy, increasing consolidation threatening competition (a notable quote was from Mostashari, “if you’re big, you don’t have to be good") and binary or reductive analytic results.
According to Anthem vice president of provider alignment solutions Mai Pham, larger structural issues such as a fee-for-service cornerstone of American healthcare are the elephant in the room. Anthem, she said, plans to pivot to a place where it is "ready to leave some providers behind" if they fail to modernize their business models.
A 2017 evaluation of the Medicare MSSP program showed that one-third of ACOs in the program achieved savings, although they outperformed their FFS counterparts on most quality measures. These new findings, taken in tandem with past research, suggest that a foundation of advanced primary care is crucial to successful care delivery reform focused on lowering costs and keeping people healthy and out of the hospital.