Accountable care organizations
take shape in Texas

By Kate Alfano

With CMS’ announcement of the first accountable care organizations approved to participate in the Medicare Shared Savings Program and the publication of the program’s final rule last fall, what was once an amorphous concept is now a reality that more physician groups and hospitals are buying into. And as varied as the methods to medicine, each organization brings its own approach to connect a host of physicians and other providers and meet the goals of the program.

The Medicare Shared Savings Program, the only ACO program enacted through the Affordable Care Act, encourages health care providers to coordinate a Medicare fee-for-service beneficiary’s care in a way that avoids duplication of services, prevents medical errors, and averts hospitalization, thereby slowing the rate of growth in health care spending and improving quality of care. It evokes the triple aim—to improve the health of the population, enhance the patient experience of care, and reduce the per capita cost of care. And in return for demonstrating reduced costs and increased quality, the organization is eligible to receive a share in the savings it produces.

Twenty-seven ACOs nationwide were approved in the first round of the Shared Savings Program this April, with five of those participating through the Advance Payment Initiative, an option providing advance payments to participants like rural and physician-based ACOs to help defray the costs of establishing IT and staff infrastructure. Two of the Shared Savings ACOs are in Texas: Accountable Care Coalition of Texas serving southeast Texas, and RGV ACO Health Providers serving areas in south Texas.

Thirty-two ACOs were accepted into the Pioneer ACO Model in December 2011, a program also under CMS’ purview on a similar but separate track from the Shared Savings Program. These established organizations have demonstrated their ability to coordinate care across settings and will move more rapidly from the shared savings payment model to a population-based payment model. Again, two are based in Texas—Plus! in Tarrant County and Seton Health Alliance serving Central Texas.

Many groups around the state and country have already employed the concepts of coordinated care and prevention built on a foundation of primary care to improve quality and control costs, and some will apply for future start dates in the Medicare program while others will continue to serve their public and commercial markets without joining in. CMS reports in a press release that the agency is reviewing more than 150 applications from ACOs seeking to participate in the second round of Shared Savings, to start July 1, with more than 50 applicants for the Advance Payment Initiative.

Each ACO varies widely, even among the Texas organizations. Take Accountable Care Coalition of Texas, the largest of the Shared Savings ACOs, expected to serve nearly 70,000 beneficiaries. ACC of Texas is a partnership of independent physician associations, medical groups, and health systems in the Houston and Beaumont area. It and eight others around the country were formed by Universal American health plan in partnership with community doctors treating Medicare Advantage patients. Collaborative Health Systems, a subsidiary of Universal American, provides care coordinators and other personnel.

ACC of Texas is its own legal entity owned by CHS and the medical group and, in accordance with CMS ACO guidelines, is governed by physicians, suppliers, and Medicare beneficiaries. This governing body is responsible for the overall management and operations of the ACO including compliance, quality improvement, medical management, and operational oversight. And as each Shared Savings ACO must do, ACC of Texas has established its method to reach out to and gather input from its network of providers.

That job falls partly to Miguel Franco, M.D., medical director of the ACO and of Memorial Clinical Associates in west Houston. An internist and board-certified pulmonologist himself, he listens to the physicians and makes sure their knowledge and medical experiences influence the ACO’s operations and that the organization is responsive to their needs.

“Physicians treat each patient differently,” Franco says. “And therefore, as medical director of our ACO in Texas, I don’t assume that all practices are the same and I don’t assume that every physician that calls me or that every clinical issue should be treated the same.

“One example is that not all physicians have EMRs, but if I’m interacting with a physician who is a few years from retiring and they’ve decided not to have an EMR, sometimes you have to think about additional resources to help. So if it means sending care coordinators or other staff to their office to look at charts and gather data, we can do that. It sounds antiquated, but EMR is a huge investment and at the end of the day, if we implement something for the occasional physician who may not have an EMR and it helps gather information and it helps them care for their patients, then mission accomplished.”

Access to the tools and staff that facilitate practicing whole-person, coordinated care is one big benefit of participating in the ACO, Franco says, because “in this day and age, it takes a lot more than seeing patients in the examination room.”

“One thing that brings us together, even though there are different kinds of practices, is the fact that there are resources that we can get through an ACO,” he says. “The resources would be the analytics, information to help us identify what our patients need, and care coordinators. And that helps us take the care literally into the home where we can identify specific needs that are pertinent to the patient’s care.”

ACOs participating in the program must report to CMS on quality measures relating to care coordination and patient safety, appropriate use of preventive health services, improved care for at-risk populations, and the patient experience of care. CMS monitors ACOs by analyzing claims, financial and quality data, and quarterly reports, and by performing site visits or beneficiary surveys.

This means collecting a great amount of data, but also spreading the process and “culture” to each physician and health care provider involved.

Edwin F. Estevez, Ph.D., chief operating officer and chief administrator of RGV ACO Health Providers, the other Shared Savings ACO in Texas, says their biggest challenge to date has been integrating health information technology between the practices. They qualified for the Advance Payment model, which he says has been invaluable in helping them create the infrastructure to connect their six physicians, 10 clinics, and 18 different providers to serve an estimated 6,000 beneficiaries from Mission to Mercedes.

Though they have four different electronic medical records between the six physicians, four were the first to adopt EMRs in the Rio Grande Valley and two serve on national boards for EMRs. “Everybody is engaged. We’re already gathering data in terms of hospitalization and access for patients to the clinic, and we are engaging every single lateral or potential partner who may be involved, from specialists to pharmacies,” Estevez says. “It’s a massive moving target that requires agility and I think we have it.”

This agility comes from their size, he says. As one of the smallest ACOs in the program—the minimum number of beneficiaries an organization can have to qualify for the program is 5,000—this helps them quickly apply new guidelines among the practices. “We’re small enough to get to everybody at the same time to see some of the implementation results.”

Physician-owned and physician-driven, RGV supports the clinical autonomy of the practices while increasing interaction at all levels to achieve large-scale change. “We’re not going to dictate how to practice medicine, but we are going to dictate how to carry out our model,” Estevez says. “What we want to do is ensure that there’s an increase in communication that, bottom line, is for the patient’s benefit and also the practice’s benefit. It not only facilitates good medicine, it facilitates good business and is great patient service.”

“Our job is to ensure that we increase communication, that we integrate our work, and that we are constantly providing the resources for everybody around the patient to be able to provide the necessary information and make the patient better.”

Admittedly, the cost savings part is tricky and he couldn’t get into specifics at this early stage of the program. While they trust that the process will inherently drive costs down, “we need to benchmark,” Estevez says. “It’s like we want to lose weight, but we haven’t weighed ourselves yet.”

When considering affiliating with an ACO, he advises physicians to perform an internal operational assessment that sets up an alignment process and expectations of the ACO. “That’s not to say that some doctors or physicians are not practicing medicine correctly, but it is to say that there are going to be some adjustments that will have to be made.”

Franco, of ACC of Texas in Houston, says that achieving savings will depend on a number of factors including the data that CMS sees. “A lot of us have been taking care of patients with this focus on prevention and disease management for a long time, so we know and we see the results within our practices. But as far as the shared savings being realized and CMS identifying it, that’s to be determined.”

The important part is that more are realizing the benefit of prevention and disease management, Franco says, which is a good sign for the future. “A lot of primary care physicians have been focusing on preventive care and disease management; we’ve been very proactive with that and we know it works. We know it’s going to be the oxygen of health care reform. It’s very encouraging that we see the whole system going in that direction.”

“At the end of the day, if physicians don’t have major input in this, it’s not going to work the way it should. Our patients want physicians to make medical decisions. They don’t want it to come primarily from another source. We all have to work together. An ACO is not just physicians and other health care providers—it’s also other health care professionals—but physician input is incredibly crucial.”

Meet the four CMS-approved Texas ACOs

Accountable Care Coalition of Texas, Inc. is a partnership between independent physician associations, medical groups, and health systems in southeast Texas under the larger umbrella of Universal American and Collaborative Health Systems. The largest of the 27 Shared Savings ACOs, ACC is expected to serve nearly 70,000 beneficiaries.

RGV ACO Health Providers, LLC is comprised of six primary care group practices with 10 clinic locations serving the south Texas populations of Weslaco, Mercedes, Elsa, Donna, Mission, and surrounding communities. RGV is participating as one of five Advance Payment ACOs in this group. RGV is expected to serve over 6,000 beneficiaries.

Plus!, formerly North Texas ACO, is a partnership of Fort Worth-based North Texas Specialty Physicians, an independent physician association comprised of more than 600 family and specialty doctors serving patients in Dallas, Johnson, Parker, and Tarrant counties, and Arlington-based Texas Health Resources, one of the largest faith-based, nonprofit health systems in the country with 24 acute care and short-stay hospitals. Plus! is participating as a Pioneer ACO.

Also a Pioneer, Seton Health Alliance is a partnership of Seton Healthcare and Austin Regional Clinic, serving 11 counties in Central Texas with 13 hospitals in Austin, Round Rock, Kyle, Luling, Burnet, and Smithville, and 21 primary and specialty care outpatient clinics in Austin, Round Rock, Cedar Park, Hutto, Pflugerville, and Kyle.