by Morgan True vtdigger.org Health care networks in Vermont known as accountable care organizations (ACOs) didn’t exceed savings targets for treating Medicare patients by enough to receive incentive payments in the first year of a federal initiative to reduce spending and improve care. Nationally, only 52 of 220 ACOs participating in the Medicare Shared Savings Program were able to reduce spending by enough to get a portion of $300 million in incentive payments from the federal government, according to the Centers for Medicare and Medicaid Services(CMS).
Medicare saved $652 million through the program, a key aspect of the Affordable Care Act’s efforts to reform payments to doctors and hospitals. But that’s only one one-thousandth of the $492 billion spent on Medicare in 2013.
Two Vermont ACOs were able to reduce Medicare spending in the first year, they said, but not by enough to get a check from the feds. A third Vermont ACO joined the program in 2014.
“You have to beat your savings target by a minimum savings rate,” said Todd Moore, CEO of OneCare Vermont, the state’s largest ACO, “It’s basically to ensure it wasn’t a fluke.”
OneCare Vermont saved $330,000 for Medicare, according to Moore, and cost the federal program $8,559 per beneficiary, $8 less than the benchmark for Vermont.
The Accountable Care Coalition of the Green Mountains (ACCGM), established by the independent physician network Healthfirst, said it saved Medicare money by a slight margin, but did not say by how much.
“We’re certainly disappointed with the first year results of the program,” said Amy Cooper, executive director of Healthfirst. “Only a quarter of ACOs participating made any return, and there’s a lot of upfront costs associated with starting an ACO.”
Vermont ACOs
• OneCare Vermont: Statewide network includes all 14 Vermont hospitals plus Dartmouth-Hitchcock Medical Center for specialty care, the Brattleboro Retreat psychiatric hospital, four community health centers, rural clinics, more than 300 primary care physicians and most specialists in the state; 52,300 attributed Medicare beneficiaries, 29,000 attributed Medicaid beneficiaries and 18,400 Blue Cross customers.
• Community Health Accountable Care: Active in 13 of 14 counties, with cities or services offered in all but Bennington County; Nine federally qualified health centers with 49 locations and 233 primary care providers; 6,000 attributed Medicare beneficiaries, 21,000 attributed Medicaid beneficiaries and 8,900 attributed Blue Cross customers. Not all of CHAC providers participate in all three shared-savings programs.
• Healthfirst — Accountable Care Collaborative of the Green Mountains: Approved statewide network, with services concentrated in the greater Burlington-area and north central Vermont; Network includes roughly 70 physicians, both primary care and specialty; 7,500 Medicare beneficiaries and 7,200 Blue Cross customers; Healthfirst does not participate in the Medicaid shared-savings program.
All three ACOs are supported by nurses and other health care workers that do not have patients attributed directly to them. For more information on ACOs and shared-savings program click here.
It’s especially challenging for an ACO made up of independent doctors to achieve savings because Medicare costs are largely driven by hospital services that its providers can’t control, Cooper said.
“We have to focus on keeping our Medicare patients as healthy as possible and out of the hospital,” Cooper said.
Both OneCare and Healthfirst said it’s difficult for doctors and hospitals in Vermont to further reduce costs past federal benchmarks because the state has focused on better care management and improving quality for years.
“We look like some of these other ACOs might, once they’ve collected all the low hanging fruit,” Moore said.
But further reducing the growth in health care costs is central to Gov. Peter Shumlin’s health care reform agenda, and he often touts ACO shared savings programs as an example of cost control.
Vermont doubled down on shared savings programs earlier this year when it became the first state to sign ACOs up for a Medicaid shared savings program and facilitated a commercial shared savings program for some Blue Cross Blue Shield customers covered through the Vermont Health Connect exchange.
Healthfirst is not participating in the Medicaid shared savings program because the benchmarks for the Medicaid population are already so low that the potential to earn savings is minimal for their doctors, Cooper said.
Moore said he’s less concerned about whether OneCare earns shared savings in the short-term, and instead is focused on “building a health care delivery system that can provide good quality and high degrees of access under a fixed growth model.”
The shared savings program includes 32 quality metrics, as well as composite scores for treating diabetes and heart disease. In the first year, ACOs were considered to have met the quality standards if they reported on all of them, and both OneCare and ACCGM were able to do that.
CMS released data showing how ACOs performed against one another on the program’s quality standards.
Of the seven quality measures for patient experience, which include things like how well doctors communicate with patients or caregivers, OneCare and ACCGM outperformed the national average for participating ACOs on five of them.
Of the eight measures for preventive care, which include things like rates for depression screenings and flu shots, OneCare was above the national average on six. ACCGM scored better than the national average on only one, which measured the proportion of patients who had their blood pressure measured in the last two years.
Both scored below average on composite measures for treating diabetes and heart disease. ACCGM scored far worse than average.
For a small ACO like ACCGM, a few sick patients can greatly impact its performance on the measures, Cooper said.
“The different measures have different value for different audiences,” said Steven Kappel, a health care economist and founder of Public Integrity, a health policy group.
“If I don’t have diabetes, how well the practice controls diabetes is of little interest to me. If I do, it’s a very important measure,” he said.
For a detailed information on how ACOs scored on quality measures click here. For details on what the quality measures are click here.