Rural ACO Leaders Speak: What Have Been the Biggest Challenges and the Biggest Advantages to Creating Your ACO?

by Zachary Toliver

American healthcare is in the midst of a volume-to-value metamorphosis. Healthcare systems across the nation are changing workflows and cultures to better coordinate care. Value-based care delivery will require paying providers based on the quality, rather than the quantity of care they give patients. The Department of Health and Human Services has set out ambitious goals to make Medicare reimbursements value-based.

So how is a rural healthcare provider to adapt to these changes? Many are joining or building Accountable Care Organizations (ACOs). These groups of healthcare providers have come together in an attempt to stay ahead of the volume-to-value transition rather than dying under the weight of inevitable change. In this spirit, we asked rural ACO leaders about the biggest challenges and advantages they've experienced in building an ACO.

Ann Morse Abdella, Executive Director
Chautauqua Region Associated Medical Partners

"Our major challenge in the beginning was the limitations of health information technology and data aggregation needs which were clashing with one another.

It's very hard to get everyone on the same page. Some of the electronic medical records (EMRs) cannot or will not export data. This makes monitoring patients and coordinating care a challenge even still today. The data warehouses and analytics software in the early years were vaporware. It was just theory on how they would operate. ACOs were the guinea pigs for the new data software and care management infrastructure. Things are much better now, but it's not perfect.

But on the flip side, having everyone tackle all of the issues brought about by the transitioning to an ACO structure is evidence of an ACO's advantage. Everyone is growing and learning from one another. The relationships built from forming an ACO has to be one of the greatest advantages. We have providers talking with each other, negotiating with each other, and problem solving with each other in ways we never had in the past. Forming an ACO really has been a catalyst to successfully working together. We still have a lot of work to do, but the tradeoff is that people are aware of that work, and they can pick up the phone and picture a real face that goes along with tasks. It's been awesome. In the past, we may have seen little glimmers of this sort of collaboration, but it's really snowballing and growing to scale. In our community, I think it's reached a real tipping point towards real change.

We have a real pride factor in our ACO. The boost it's given to rural primary care physicians, skilled nursing, and hospitals is terrific. It's reinforcing a real confidence that they are performing with the best in the country. People in our community are receiving care that is good as it gets.

The data and tracking pieces of all of this do make a difference in people stepping back objectively and saying, 'oh my gosh, we really have moved.' When we look at numbers like depression screenings, fall screenings, or annual wellness updates, a lot of our practices never did any of that. They see flat line numbers grow to high percentages of accomplishment. It's really a beautiful thing."

Greg Paris, VP and General Manager of ACO Services
National Rural ACO

"National Rural ACO is entering its third year bringing together rural providers across the country into 23 ACOs in the Medicare Shared Savings Program (MSSP). Those 23 ACOs include more than 6,000 clinicians in 159 rural health systems covering 55 rural PPS hospitals, 92 Critical Access Hospitals, 168 Rural Health Clinics and 39 rural FQHCs serving more than 500,000 Medicare patients. The three years of experience has helped identify what's worked well and what's been a challenge.

The win is that we have 159 communities with lean forward leaders who are not waiting for the path to value-based purchasing, but who have chosen to create their own path. Call them early adopters, if you will. What they have in common is that they recognize the status quo is doomed, that value over volume is coming for all, and that they recognize that value aligns closer to their mission than the old treatment paradigms. They are bending the cost curve while strengthening the financial health of their organizations.

The challenge? Its commitment and alignment. Moving to a new care model takes a commitment, and that can be scary. Some leaders are waiting for a mandate or letting others lead the way. Some hospitals and physicians, even when they share a common mission, have difficulty aligning resources, trusting each other in a common pursuit, or getting consensus to jump in before they have to. An ACO takes a lot of cooperation and some faith that by investing in wellness opportunities, you can meet your mission and maintain financial viability.

I don't know if ACOs are the answer or only a path to the answer. What I do know is what we've done the past ten years won't work the next ten years. I know CMS has invested heavily in alternative payment models. And I know I would rather be on the leading edge than trying to play catch up."

Rebecca Rhorbach, DNP, VP of Population Health DNP
NOMS Accountable Care Organization (ACO), LLC

"We're a Medicare Shared Savings Program (MSSP) program through the Centers for Medicare and Medicaid Services (CMS), so our biggest challenge is beneficiary attribution. There's always a churn of patients, and trying to be responsible for patients that fall on and off your beneficiary list has always been a challenge. Benchmarking is another challenge. Those are probably our two biggest ones.

The advantages of becoming an ACO? Because we are an ACO and are putting that infrastructure into care management, it's given us a bit more leverage with commercial payers to negotiate contracts."

Larry E. Jones, CEO
Physicians Collaborative Trust ACO, LLC

"We wanted to give our doctors not only the ability to improve the reimbursement of the Medicare senior population, but also to let them begin training in how to deal with value-based contracting in moving from fee-for-service to fee-for-value. Once you know how to do that, you can take your network to the commercial payers and do the same thing in value-based contracts and shared savings.

Dr. Sylvia Burwell from the U.S. Department of Health and Human Services has stated that by 2018, 90 percent of Medicare beneficiaries will be in some type of quality-based program, so physicians better learn how to do this. ACOs are one product to help unite physicians in a given market-place to provide comprehensive coordinated care.

The challenges have really been that if you're a high performing network, it's difficult to achieve savings year after year based on benchmarks from assigned claims. However, in 2017, CMS will start looking at regional benchmarks and that's going to level the playing field for the well-performing ACOs and offer more saving opportunity for poor-performing ACOs."

Pam Halvorson, Lead Executive
ACO UnityPoint Health Partners

"We are at the forefront of volume-to-value care. We are helping to determine what this model should look like rather than reacting to a regulatory environment. The advantages of being a Next Generation ACO is the opportunity to innovate alongside the Center for Medicare and Medicaid Innovation (CMMI) for beneficiary enhancements that will hit Triple Aim. By that I mean, if expansions — let's say telehealth expansions for example — really show that patients did not have to use emergency rooms, that might be an important ongoing Medicare benefit to share across the country. We're helping to find real,  predictable ways to assess cost of care against an open market Medicare as compared to a Medicare Advantage. MSSP patients were coming on and off the beneficiary list on a quarterly basis but in Next Gen, you have a cohort of patients that are fairly stable. You can model analytics and get some stability in your care planning and care coordination.

The financial formulas for Medicare reimbursement will start to align physicians in particular with the Medicare Access & CHIP Reauthorization Act of 2015 (MACRA) and value-based payments. Physicians are really facing either significant rewards or penalties based on their ability to innovate, meet quality measures, and so on. These are going to get really significant, as much as 100 percent of their Medicare payments could be impacted. The administrative burden of that is enormous on a practice. However, if physicians are in ACOs, they are able to report their quality metrics and other elements through their ACO. Just the administrative requirements to stay an outside entity will be more arduous for physicians than coming into an ACO kind of structure. Those that have held back are realizing they can't function outside of these value-based contracts.

Size is certainly a challenge. It's much more difficult to move six great big regional hospital systems in exactly the same way. Particularly, many of them haven't participated in beneficiary enhancements, so they haven't done this work before. As usual, it's a close working relationship with CMMI, so we're trying to learn what works and what doesn't together. We won't see claims, analytics, or those types of aggregate information coming from Next Gen until a few months down the road. When that happens, we'll have to learn quickly about what programs were effective and what decisions worked. It's really similar to the Pioneer ACO learning."