Enhancing Quality and Value of Care through Accountable Care Organization Relationships

By Maged Rizk, MD, MBA

As accountable care contracts have evolved from being incentive-based only to incentive- and risk-based, there is a need to manage both the quality and utilization of care provided. While many efforts to reduce unnecessary utilization have focused on inpatient admissions, emergency room visits and sub-acute care, there has been less work in the space around where specialist and specialty care opportunities can be identified and changes implemented. This article is an overview of the steps we took at Cleveland Clinic to develop a relationship between our accountable care organization (ACO) and specialty physicians.

Cleveland Clinic Medicare Accountable Care Organization and the Quality Alliance

At Cleveland Clinic, our accountable care organization (Cleveland Clinic MACO) began sharing risk in 2018. Under this model, Cleveland Clinic MACO assumes limited performance-based downside risk if it doesn’t meet a savings threshold, in addition to the opportunity to share in savings based on its quality performance.

The Cleveland Clinic MACO works in concert with our physician group, which consists of both Quality Alliance employed physicians and Quality Alliance independent physicians. The Quality Alliance is an integrated provider network comprised of independent physician practices and employed Cleveland Clinic physicians.

How Cleveland Clinic MACO interacts with both types of physicians varies because of the obligation that the ACO has to ensure that it is not engaged in activities that may be viewed as anti-competitive while promoting high-value care. This requires ensuring that our legal counsel is continuously abreast in regard to how our relationships and data are managed. For the sake of this article, we will provide an overview of ACO-physician relationships and focus on what was done to engage our Quality Alliance employed physicians.

Defining the nature of the relationship

The first step in determining the best way to structure the relationship is to understand the players. First, what type of ACO is it? Hospital based? Physician led? Private equity based? Even more important is understanding how specialists who provide care to patients are reimbursed. Are they employed? Are they independent but affiliated? Are they independent and unaffiliated?

This understanding helps but does not define what approach will work best. In the end, even if a physician or group of specialty physicians is hospital employed, much of the current incentives still focus around fee-for-service to some degree. The level of leadership buy-in required, however, will be determined by the nature of the relationships. If the specialty group or physician is employed, then a conversation with hospital leadership might be necessary. If the specialty group is independent and unaffiliated, then discussion would be at the group level.

Additionally, these factors can help determine the ability to influence change and affect the scope of what can be asked of the specialty collaboration. While data suggests that the more that primary care can do for a patient, the higher the value of care provided, in an integrated model where specialists and primary care can be incentivized around value, there may be utility in primary specialty management (specialty medical home or neighborhood) or significant co-management of complex, chronic medical conditions.

Identifying opportunities

While a significant amount of spend can be attributed to decisions made by primary providers, in some studies, up to 85% of spend can be attributed to care provided by a specialist. There is great variation in what type of quality and value-enhancing opportunities exist, but in general they can be divided into two main categories: utilization and quality.

• Utilization: There are four main types of utilization: hospital admissions, emergency room visits, Part B pharmacy spend and post-acute care spend (See Consult QD article “What is an Accountable Care Organization for more details on each of these). A significant amount of spend and low-value care is in patients who have conditions that are predominantly specialty managed.
• Quality: There are a number of metrics that are indicators of high value care that involve specialty care. These include colon and breast cancer screening, care in patients with ambulatory care sensitive conditions such as congestive heart failure, coronary heart disease, and Chronic Obstructive Pulmonary Disease. Additionally, access to specialists is a quality metric in of itself.

Developing a team-of-teams approach

While the tactics to address each of the above opportunities vary, the overall strategy is the same. We formed an ACO-specialty working team with a goal of developing a relationship of mutual respect. Our main objective is to provide the highest value care to the patient. The Cleveland Clinic MACO-specialty working team consists of administrative, finance and physician stakeholders from each of the priority specialty departments, members from the Cleveland Clinic Health System strategy office, clinical contracting and payment innovation, as well as hospital pharmacy. Additionally, stakeholders from the ACO included the director and associate directors, as well as representatives from quality, finance and medical economics.

As we engage in the clinical work, it is important that the specialty departments and the health system are aligned in our understanding of what the work entails, as well as the workflow, financial and quality implications. While high-level work is performed during meetings of the larger Cleveland Clinic MACO-specialty working team, the bulk of the work we do is performed though our teamlets with each of the specialty departments.

An example of how all the teamlets work together is seen in the osteoporosis space. Cleveland Clinic MACO’s medical economics team identified denosumab as a high-cost medication, and met with teams from the departments of pharmacy and rheumatology to assess the opportunity. Subsequently, a clinical pharmacist and physician champion from rheumatology manually reviewed the charts of ACO patients who were under the care of our employed specialists. They found that 12% of patients on denosumab might have been able to use a more appropriate medication as defined by clinical guidelines. Our finance team quantified the opportunity, and the teamlet agreed to a target reduction in denosumab use. The entire teamlet worked together to develop an education plan to target rheumatologists and primary care physicians to inform them of these efforts. The teamlet continues to meet to identify and implement other opportunities. When barriers arise, stakeholders from within the ACO-specialty team work together to identify how best to address them.

In conclusion, ACOs need to engage with those who provide specialty care if they intend to improve the value of care provided to patients. This must be done with the knowledge of how best to impact change, in a collaborative fashion that empowers specialists to engage in the work required, and must take into account the impacts that the work will create for those providers as well as for the organization with which they are affiliated.

About the author: Maged Rizk, MD, MBA, is Associate Director of Cleveland Clinic’s Accountable Care Organization, as well as Director of Business Development & Affiliations for Cleveland Clinic’s Digestive Disease & Surgery Institute.