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02.26.2020

For Physician-Led ACOs, Building Trust Brings Success with Downside Risk

by Jennifer Bresnick

After reducing ED visits by 11 percent and inpatient hospitalizations by 15 percent in 2018, the Aledade Louisiana ACO has built the foundation it needs to transition to downside risk.  Dr. Darrin Menard explains how cultural change, access to data, and personal relationships with patients foster success in the downside risk environment.

  • A proactive move toward downside risk is key for primary care providers looking to succeed in the value-based care environment

  • Putting “skin in the game” requires providers to develop a culture of trust and team-based care

  • Financial incentives, access to data, and a strong collaborative spirit can sustain independence and improve satisfaction across the practice

Primary care providers (PCPs) are finding themselves in a tough position as competing forces simultaneously increase demand for their services while making it more difficult to maintain their financial status quo.

Yet many independent PCPs are moving forward by banding together into physician-led accountable care organizations (ACOs) that focus on maximizing value while maintaining control of their clinical decision-making – and their financial destiny.

In order to succeed, primary care providers need to shift their thinking and develop strong networks of trust, accountability, and resilience to change, says Dr. Darrin Menard, a member of the Aledade Louisiana ACO and a physician leader in the Lafayette, LA region.

“Taking on downside risk as part of an ACO is definitely a challenge for our practice, but it’s not as much of a challenge as sticking with fee-for-service medicine,” he said.  “Taking on risk creates a new structure that gives independent primary care providers a chance to move forward in the right direction.” 

“ACOs are primarily about improving quality and outcomes, but they also help to stabilize and increase revenue so that a practice can focus on doing what’s right for their patients.  Downside risk models are the way to achieve those dual goals.”

With the right blend of strategies, technologies, partnerships, and relationships, primary care providers can continue to support better health for their communities within the framework of value-based care.

Making the decision to “put skin in the game” with downside risk

PCPs who choose to enter the world of accountable care are perhaps most likely to begin by exploring the Medicare Pathways to Success program, also known as the Medicare Shared Savings Program.  This initiative offers multiple entry points into value-based care based on an ACO’s composition, previous experience, and tolerance for risk.

Most ACOs can choose to spend several years in upside-only arrangements, which allow ACOs to focus on practice transformation, including the cultural adjustments necessary to adopt a proactive, population-based approach to primary care. These arrangements offer incentives for high performance without the need to repay cost overruns if the group misses its clinical or financial targets.

While all participants in Pathways to Success will eventually need to transition into downside risk arrangements, ACOs that start to feel comfortable with their performance can move into the more challenging categories more quickly.

At the start of 2020, close to 200 Medicare ACOs have embraced some level of risk, CMS Administrator Seema Verma announced recently – more than twice the number taking on risk in January of 2019.

The Aledade Louisiana ACO is one of these pioneering organizations.

“We moved to downside risk this year after a pretty intensive education process,” explained Menard.  “We had to look hard at the numbers to see if it would work for us. It was a community effort that we’ve been preparing for over the past three years of working in the ACO environment.”

“Downside risk makes us put skin in the game, which is what an ACO is all about, at the end of the day.” 

The decision was made easier by the practice transformation support and technology tools Aledade provides as a partner in accountable care, he added.

“We knew that we needed someone to help create that path of least resistance in terms of the policy and regulation, data, financial, and technical aspects of performing well in an ACO,” Menard said.  

“Aledade works hard to minimize exposure so that we can do the work we need to do in order to serve patients and get results,” he continued.  “Because we’ve had the chance to establish the fundamentals and learn how to succeed alongside a strong partner, we can keep building on that foundation and drive positive change for our patient population as we take on financial risk.”

Trust as a core competency for accountable care organizations

Menard readily acknowledges that downside risk can be a hard sell to colleagues who are skeptical about value-based care or are feeling overwhelmed about the prospect of implementing significant changes.

“There’s a lot of negative feeling in healthcare right now,” Menard pointed out.  “People are struggling to understand what they need to do, why they need to do it – and most importantly, how they’re going to get it all done.”

“If downside risk is perceived as just another initiative that’s being piled on top of everything else, or as something that doesn’t make sense, you’re not going to be able to build the trust and engagement you need to succeed.”

Primary care physicians are ideally positioned to be leaders in this process.  Many PCPs have deep roots in their communities and are already familiar with their colleagues’ strengths, weaknesses, and opinions on quality improvement initiatives.

These personal relationships allow physician leaders to educate their peers, generate enthusiasm for value-based care, and share best practices that can lead to the ACO’s success.

“Every practice in the Aledade Louisiana ACO knows me personally,” said Menard.  “I’ve known most of the physicians for years: either we went to medical school together or we’ve taught together, or we’ve worked together in some capacity.”

“Those connections are incredibly valuable, and I think most physicians have at least the beginnings of those networks in the communities they serve. Taking advantage of those relationships can really accelerate progress.” 

Using team-based care to support better patient outcomes

Extending that trust and community spirit past the leadership level is also vital, Menard continued. 

Value-based care depends on buy-in from every member of the organization, including nurse practitioners and physician assistants, nurses, care coordinators, medical assistants, front desk staff, office managers, and other administrators.

“I simply couldn’t do my job as a physician without the help of a very strong care team,” Menard stressed.  “They provide the scaffolding for every successful visit I have with a patient.”

“Improving outcomes is only possible when your entire care team is working like a well-oiled machine,” he said.  “Everyone has a role in sustaining meaningful relationships with patients, and your practice needs to be operating with prevention and follow-up in mind.”

For example, Menard’s practice employs an outreach coordinator whose primary job is working with high-priority patients to schedule Medicare Annual Wellness Visits and other preventive care services.

“She is extremely good at connecting with that last 10 percent of patients who just don’t see why it’s necessary to come in if they’re not feeling actively unwell,” said Menard.  “It’s a role that requires really great people skills to convince individuals that we need to build a foundation for their future health and wellness.”

“It’s the same with our care manager: she has to be involved in the care process at all the right moments in time so that she can make those transitional care visits happen and prevent readmissions.  Extending that chain of trust to your patients is absolutely essential.”

Preventive care and transitional care management are two areas that can “really move the needle in terms of outcomes and spending,” said Menard.

His ACO has already seen the results.  In performance year 2018, before moving to risk, the Aledade Louisiana ACO reduced emergency department visits by 11 percent and inpatient hospitalizations by 15 percent while saving Medicare $7 million, setting them up for future success in the next phase of participation.

By leveraging a coordinated care team and focusing on high-priority individuals, the ACO can continue foster better health for patients and create more opportunities to come out ahead with financial targets tied to incentive payments.

Sustaining independence and high quality in a challenging healthcare environment

Whether an ACO is starting with upside-only risk or making the leap into downside risk arrangements, a primary care practice should take the time to prepare itself for change and secure the support of partners who can help, Menard concluded.

“Transformation is not easy to do, and you need to be open with your people about that, because they have to realize it’s a long-term commitment,” he stated.  “But if you have a good plan in place and you have the support you need from peers and partners, you can absolutely succeed with both your financial and your clinical goals.”

Being a member of a risk-bearing ACO has helped Menard and his colleagues in Louisiana sustain their independence and continue delivering high-quality care despite the pressures affecting their community, he said. The result is better outcomes for patients, a reduction in stress for providers, and the chance to secure a brighter future for primary care.

“In the value-based world, with a great team and timely access to data, I’m able to be a better doctor than I was five years ago, because I have more time to work with my patients the way they need me to,” said Menard.

“If you’re a PCP and your current reality isn’t matching the future you have in mind for your practice and your patients, you should really start to explore the foundational elements of an ACO.  Starting now with value-based care can help you build the competencies and the trust that will lead to reaching your clinical and financial objectives.”