I am excited to share this Q&A about the National Rural ACO and our work with ACOs that was recently featured in the HCPLAN Newsletter.
The National Rural ACO pools knowledge, patients, and resources so that independent community health systems can participate in new population health-based reimbursement models. Lynn Barr, MPH, Chief Transformation Officer, spoke with a member of the CAMH team on July 28.
[CAMH]: What is the National Rural ACO’s goal, and what key approaches are you using?
Barr: We focus only on rural communities. Though 20% of Medicare beneficiaries get care in rural America, these health systems are far behind in population health management. Many have not done care coordination, performance measurement, etc. Our goal is to help them make improvements in quality and cost. For example, their aggregate quality scores in 2014 were 60%. We want to get to 70-75% in year two and 80-90% in year three. We also aim to reduce costs by 10% within the first three-year cycle. For 2016, we’re putting in applications to CMS for 26 rural ACOs with 179 health systems in 32 states. Our biggest goal is getting people started on the journey of population health management. We are very excited about that.
Our first step is to set up care coordination in each community. Every member hires a care coordinator. This is great for the patients, and it helps lower costs and improve quality. Second, we add annual wellness visits. A provider can hit 11 quality scores in an annual visit. About 5O% of our members haven’t been doing annual wellness visits. It’s a billing issue. In other fee-for-service clinics, when a patient comes in for a regular visit, the provider can also do the wellness visit and bill for both. Rural providers and Federally Qualified Health Centers aren’t allowed to bill separately. That’s a huge disincentive. The third component is reducing Emergency Department (ED) utilization. Rural beneficiaries use the ED for primary care because rural providers aren’t available 24/7. Fifty percent of rural ED visits are for primary care. Total ED utilization per beneficiary is 20% higher than the national average. We want to bring that down significantly. Another component is analytics. We provide data to support the other three components. It makes a big difference. For example, we found that the cost of home health in one of our ACOs is $1000 per month, while the national average is just $300. There is a great opportunity to make a difference.
[CAMH]: Who can join? Is there a typical profile of a member?
Barr: All our members are “community health systems.” Typically there is one hospital with a group of affiliated physicians. Our goal is to take that delivery network and integrate it with others to improve performance and coordinate care.
[CAMH:] How much variety is there across your ACOs and why?
Barr: Rural providers are very diverse. Our hospitals range from 4 to 250 beds. Our communities have anywhere from 175 to 8,000 attributed patients, with the average being about 1,000 attributed lives.
[CAMH:] To what extent are rural health systems’ challenges unique?
Barr: One of the biggest differences is size. Almost all of these health systems don’t have the minimum 5000 attributed beneficiaries, which is why we need to combine them. They have extremely limited capital; lack of funding is a huge barrier. They also have very little IT infrastructure, so we have to provide it for them. Almost all have electronic health records. Rural providers are right up with the rest of the country for EHR adoption, but their EHRs are very simple. We use the Lightbeam Health population management system to pull all their claims data together with their clinical data. Data is critical. We get It to them quickly and show them how to use it. Their care coordination program is built around claims data.
[CAMH]: Are the components of your ACO approach different from what might work in urban ACOs?
Barr: Yes, they are very different from urban ACOs. The top rural health system concerns are building relationships with patients and building secondary and tertiary networks. They have few or no networks and highly fragmented care. For example, the 175 patients in our smallest community with were seen in 75 different Part A facilities in the last 2 years. Our focus is around engaging the community and, as a result, improving cost and quality. Urban ACO communities are huge. You can’t really understand the concept of community until you live and work in a rural hospital. Everyone shows up for a hospital board meeting and cares about their providers. In small communities, patients have deep relationships with their providers. We can succeed and thrive by serving their needs.
Urban ACOs don’t focus on community per se, because the ACO is just one of many players in town. Their patients change providers more often, so they focus on services they deliver and how to maximize cost and quality improvements. Our biggest advantage is that the patient population tends to be more stable. They may go other places for care, butthey tend to come back home. For example, if we do a good job on colorectal screening, we can wipe outcolorectal cancer in our town. That is very satisfying. Also, our approach wouldn’t work so well in urban settings where there is competition. There isn’t competition among our rural health systems, so it is easier to build collaboration. On the other hand, we are similar to urb an ACOs, insofar as this is a lot of hard work for everyone.
Barr: Our first ACO started in the 2014 performance year. By end of the first year, it had reduced utilization in every category except physician visits. It is too early to tell for the others. We only have 90 days of data so far, but there are some promising trends.
[CAMH] What in your mind are the most important lessons you’ve learned so far about standing up and running ACOs in rural health systems?
Barr: We changed the program quite a bit after the first year. We initially thought start up would be simpler. It takes a lot more interaction than we had assumed. We had to increase staffing to work more closely with each partner. It is more labor intensive, but rewarding. We really appreciate the support we are getting from the CMS Center for Medicare and Medicaid Innovation. We feel that they are committed to helping rural providersand to our success.