Charles Saunders, MD
Recent results for medical practice performance in accountable care organizations (ACOs) don’t give Charles Saunders, MD, great confidence that physicians are making significant strides toward value-based care. Saunders is CEO of IntegraConnect, which has just launched a suite of electronic data management services to help oncology practices meet the requirements of the Merit-based Incentive Payment System (MIPS) and the Oncology Care Model (OCM). His company is one of many that have developed Big Data solutions in response to CMS’ demands for a better-quality experience for patients with cancer and reduced dependence on fee-for-service payment.
Practices that meet the goals for improvement in savings and outcomes will be eligible for performance incentive payments. Some physicians have argued it will be difficult for them to demonstrate improvement because they already are highly efficient, but Saunders contends that they may be mistaken. If average performance is not high to begin with, it shouldn’t take that much effort to distinguish yourself from the pack or even from your own past performance, he said in an interview. “The state of the industry is relatively low right now. Let’s say that you went to school and the average score was 30 out of 100. You’d have to get a 45 to stand out, and a 45 is still not very good,” Saunders noted.
Saunders said he has enough experience to know that his assessment is correct. Before taking the helm of IntegraConnect, he served as CEO of Healthagen, an arm of Aetna that focuses on improving the health of populations of patients. “We managed more than 70 ACOs, 350 medical homes, and several million medical lives,” he said. “It’s not that difficult to generate savings between 10% and 30% for these practices.”
The key is to work hard on bringing a few common cost drivers under control. If you can do that well, your practice will easily improve its performance, he said. The first job is to reduce the number of patients who end up in the hospital and the emergency department. The second task is to improve the timing of end-of-life services so that patients don’t die in the hospital. “These things are surprisingly not that difficult to do. It just requires a patient-focused process, a certain mindset, and a different technology. I don’t think that’s going to be difficult for practices that are motivated and that make the necessary investment to do it, and that actually step up in capabilities,” Saunders said. Along the way, patients enjoy a better healthcare experience, he noted, which is also one of the goals that CMS has established for practices to meet.
A glimmer of how oncology practices may perform with the OCM and MIPS is offered by a CMS report on ACO performance for the year 2015.1 ACOs are the forerunners to the OCM, as they encourage coordinated medical care across different provider specialties and emphasize a higher-quality experience for individual patients. The same study results garnered widely different assessments of practice performance. For its part, CMS has declared ACOs a success, partly because of the savings that have been achieved: $1.29 billion between 2012 and 2015. However, industry observers have noted that of the 392 ACOs included in the 2015 survey, just 29% (n = 115) achieved performance levels high enough to share some of the money they had saved CMS on claims payments.2 In addition, roughly one-third of the $646 million in total shared savings was achieved by only 10 of the practices surveyed, which shows that good performance was not evenly distributed and was, in fact, rare.
The overall performance was lackluster even though “the ACOs that volunteered for the program thought they were great,” Saunders said. Based on outcomes like this and his own observations, Saunders predicted the challenge of excelling in the OCM and MIPS programs is going to be an eye-opener for practices. “They’ll probably be surprised when CMS starts writing the checks that maybe they’re not as prepared as they thought they were.”
Of 195 practices enrolled in the OCM, the majority are in a 1-sided risk model of performance, which means that they do not share financial risk for failure to meet performance targets. Because CMS wants all oncology practices to share upside and downside financial risk, those in the 1-sided risk model OCM must also participate in the MIPS program of performance measurement, which involves financial incentives and penalties that are being phased in through 2026. The OCM has 7 basic requirements: practices must provide around-the-clock patient access to clinical support, use certified electronic health records (EHR) management, use performance measures and set targets, initiate patient management services, document care plans for patients, follow generally approved treatment pathways, and report on performance progress.