Care Coordination

Announcing Our New ACOs: 30 Rural Health Systems Participating In Six ACOs In Nine States In 2015

This is a proud day for the National Rural ACO.  Today, we issued a news release about our new ACOs.  Read on and you’ll see why we are so excited.

The National Rural ACO announced today it has successfully formed five additional ACOs in 2015 for rural providers following in the steps of the first ACO started in 2014. Using the organization’s unique collaborative model, fifty-two entities, including 28 rural and critical access hospitals, 42 rural health clinics, 12 federally qualified health centers and 9 private physician practices in thirty rural health systems were able to afford and qualify for the Medicare Shared Savings Program. More than 65,000 attributed Medicare beneficiaries from the states of Texas, California, Washington, Iowa, Indiana, Missouri, Oregon, Illinois and Michigan are now benefitting from the program under the care of 1,300 clinicians.

Our newest ACOs are:

  • National Rural ACO
  • Reid ACO, Suburban Health ACO
  • American Rural ACO
  • Northwest Rural ACO
  • National Rural ACO II

In almost all cases, the rural hospital sponsored the program and invited local providers to join at no charge. Although annual revenue for the hospitals ranged from $5 million to $758 million per year, and they all included employed or contracted physicians, only one applicant had enough beneficiaries to form its own ACO. All of the others joined forces to achieve the minimum number of beneficiaries and to reduce the cost of participation in proportion to what rural providers can expect to earn from the program.

The National Rural ACO provides comprehensive services including claims data access and analysis, evidence-based medicine leadership, care coordination coaching and the governance, legal and compliance services needed to succeed.

“The National Rural ACO’s unique model of collaboration is the first of its kind to enable rural providers to receive higher reimbursement for improving the care they deliver,” said Tim Putnam, CEO of Margaret Mary Hospital and chair of the board for the first National Rural ACO. “We can access the same type of powerful data, waivers and programs that urban ACOs can for about the same cost as it would be to hire one person to figure out how to get into the program.”

Please contact us if you would like more information about our new ACOs.


A Nice Note from our Chief Medical Officer about Data and Care Coordination:

We had a very productive telephone meeting regarding one of our member’s patient care opportunities this morning. The combination of Lightbeam’s data and the ability to collate with the EMR data really illuminated some opportunities for care coordination. Everyone was motivated to work together. Drilling down on individual patients locally, especially the high utilizers, is invaluable.

The two specific patient cases were interesting in that they were both very sick patients, but had very different healthcare barriers:

Patient 1. An end-of-life patient who had multiple admissions, but only 3 visits to her primary care provider.

This patient would have likely benefited from some care coordination between the discharge Planner at the hospital and the outpatient Care Coordinator to facilitate better follow-up with their PCP. This may have led to more in-depth discussions about end of life, Hospice, etc. Even if the patient or family was not interested in palliative care, it would have at least allowed for closer follow-up between hospitalizations for preventative care, medication compliance or dosing adjustments, etc. All of which could have improved the stability of this patient’s health and comfort in the months leading up to her death.

The other patient was very different, but also very sick.

Patient 2.  A chronic disease patient (COPD) who had seen multiple physicians, but was, nonetheless, admitted 8 times for COPD in the first 9 months of 2014.

The opportunities for care coordination here are certainly different, but equally important and achievable. The outpatient chart review was interesting: showing yet another admission since data collection in the spreadsheet. In this subsequent admission, the patient refused follow-up in the 3 days of respiratory worsening leading up to admission. The opportunity for a Care Coordinator to be collating all the discharge information, specialist care/recommendations, communicating with the patient and PCP with the goal of breaking down barriers to outpatient care access or novel methods for and outpatient action plan (ie corticosteroids) or redirecting care away from the ER when appropriate are obvious.

There seem to be many windows of opportunity that were identified and taking the Lightbeam data back to the Care Coordinators, hospital discharge planners and associated PCPs at the local level seems to be an actionable way to improve the patients’ care and also decrease costs.
Paul Krause, MD
Chief Medical Officer

What Makes a Care Coordination Program Great?

In August of 2014 the Commonwealth Fund published a study of 18 care coordination programs in Caring for High-Need, High-Cost Patients: What Makes for a Successful Care Management Program?  

Showing double digit improvements in all categories for the programs studied, the authors concluded that the keys to a successful care coordination program were as follows: customizing the program to the local health system; using qualitative and quantitative methods to identify patients; treating care coordination as an essential service; building trust with patients and providers; effective, specialized training; and the use of technology.

Our care coordination program was built on the same evidence evaluated for this study. It isn’t rocket science, it’s common sense. Our patients and our communities deserve this type of care and so do we.

It’s All About the Data

The best part of being in an ACO is getting the claims data from CMS. For the first time, we can measure the impact of the programs we implement to improve care and lower cost. If the data shows that we are successful, we can move on to other initiatives. If not, then we know we have to adjust our strategy. It allows us to use our resources wisely and efficiently, an absolute requirement for resource-constrained rural providers.

The main initiative we have implemented for the National Rural Accountable Care Organization has been care coordination services for the chronically ill. Every community has hired a care coordinator, trained and coached by the National Rural ACO. We use the claims data to identify high-risk patients. Our first targets for care coordination were the ED frequent flyers. We saw an immediate result from that program and have reduced our ED admissions by 5%. Since implementing this program, we have seen our avoidable admissions steadily drop.

To date, we have reduced per capita hospitalizations by 14%, yet our hospitals are not concerned about declining admissions and budgets. Whether that is because of increased market share, or a greater propensity to keep patients for observation locally, prior to transfer, is not yet clear. Maybe it is because inpatient services are usually less than 30% of a typical rural health system’s business. Perhaps it is a combination of all three. Regardless, we are proud of this success and the National Rural ACO member hospitals do not report feeling threatened by reduced inpatient and ED utilization.

The program I am most proud of is our evidence-based medicine program on COPD. When we began, our members were at 138% of the national average for admissions for COPD and asthma. Our Medical Director, Dr. Mark Hamed, put together an education program on the latest evidence for treating COPD. Our Vice President of Clinical Development, Mary Bittner, worked with the care coordinators to support his program. We watched our admission rate drop to 103% of the national average in nine months.

I tell people it isn’t about the shared savings, it’s about the data. The potential value of the data to help our patients and our communities is so great that I joke that I would pay CMS to participate in this program. Hospitals invest millions in technology and people in order to help patients, yet few of those investments are as powerful to improve the health of the community as the data we get from CMS, simply because we are an ACO. Of course, we also need a way to analyze that data and make it useful, and we are lucky to have found tools that enable us. Claims data is hard to obtain, organize, manage, and interpret in its raw form. It’s not about data, really, but about turning that data into information and using that information to implement new programs. When we also use that information to evaluate our programs, we have converted that information into knowledge, the holy grail of transformation.

CMMI is providing funding for hundreds of rural communities to join the Medicare Shared Savings Program in 2016, removing the last barrier for rural health systems to get on board. This is a one-time opportunity, and it has a very short fuse. CEOs should be talking to their medical staff and boards now if they want to take advantage of these dollars, in order to form an ACO and get invaluable data to support their patients.

The Critical Role of the CFO and Financial Consultants in Healthcare Reform

Many have described the transition from fee-for-service to fee-for-value for hospitals as crossing a “shaky bridge.” We are being asked to increase our spending to manage population health, resulting in preventing avoidable admissions that reduces per capita hospital revenue. It is no wonder that CFO’s are often reluctant to join ACOs.

The beauty of rural health is that the mission of a rural hospital CEO isn’t maximizing the daily census; it is serving the community’s health needs. Over time, most rural hospitals have acquired the majority of health services in town, including physician practices, skilled nursing, home health and hospice. The average rural hospital’s income is only 30% for inpatient care, with 70% of income coming from outpatient care. They have evolved into integrated delivery networks that provide about 70% of the total services that their community needs, although we do not capture anywhere near 100% of the market share for those services.

Rural hospitals also have small cash reserves, so any disruption in payment can be threatening to its survival. Our bridges are a bit shakier than most, and that is why the CFO and Financial Consultants are critical to the success of the transformation of rural health.

As we continue to implement our rural ACOs and study their impact on rural health systems, we have instituted a new role for the CFO and Financial Consultants in the transformation of the rural health system. We begin our monthly community steering committee meetings with a report from the CFO about the effect of the transition on the finances of the community health system. The hospital can and must control the rate of change so that the health system survives to serve its community for many years to come. If the bridge feels shaky, we can focus on quality, prevention and wellness visits until the system has time to adapt. We can work on our referral patterns to maximize the value of care given outside of the community.

We have to work on building local market share at the same time we help people manage their disease and keep them healthy. We have to increase primary care services and access, while still supporting the largely fixed costs of the hospital. Using the claims data provided for ACOs, we have to understand what services we could provide our patients that we don’t today, and how to increase our market share for the ones we do offer.

Beginning with our 2016 ACOs, we will have Financial Consultants at the table to hold the bridge steady while we cross to the new value-based payment models. Working side by side with the CFOs, we can create a better future for our communities with better quality of life and a thriving rural health system. Rural health systems are blessed with several great Financial Consulting firms, and the National Rural Accountable Care Organization will be announcing partnerships with these firms in the weeks to come.


Does CMS Really Hate Rural Hospitals?

We often hear in our travels the opinion that CMS wants to close rural hospitals and have everyone use urban hospitals instead. Many think that CMS believes rural hospitals are too expensive and provide low quality care. They point to the plethora of innovation models focused on urban areas, with almost no rural health system participation, unless the rural member joins as part of an urban system. Sixty percent of rural health systems are supported by local tax dollars and would rather “live free or die.”

Is it that CMS doesn’t care, or is it that they don’t know? Historically, health insurance payment innovation has always come from the private sector first. Commercial insurers created ACOs long before Medicare did. Diagnosis Related Groups (DRGs) were a commercial insurance innovation. Capitation and HMOs were tested in the private sector first. The government needs data and experience before it can implement new payment models, and the private sector is not testing new models in rural America. Furthermore, urban payment models cannot scale down to rural health systems. Everyone remembers when DRGs were implemented in rural hospitals. Hundreds of rural hospitals closed as a result. CMS is wise to be cautious.

As rural healthcare providers, we are going to have to lead innovation if we want to survive. No one else can or will do it for us. We have formed the National Rural Accountable Care Organization so that we can pool our resources, our knowledge, our lives and our ideas to create and test new payment models. The future of our communities depends on us working together. Join us.