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5 Years On: A Bird's Eye Look at Improvement under ACA
Ashish K. Jha, MD, MPH
February 26, 2015
+ Background
The ACA has two goals:
Expand Coverage
Fix the healthcare
delivery system
+
Why delivery reform?
+ Total U.S. healthcare spending, 2013:$2.9 trillion
Source: Centers for Medicare & Medicaid Services
$4,881
$5,243
$5,694
$6,129
$6,508
$6,887
$7,265
$7,652
$7,944$8,175
$8,428$8,698
$8,996
$9,255
$3,000
$4,000
$5,000
$6,000
$7,000
$8,000
$9,000
$10,000
Per Capita National Health Expenditures
+
-22% -31%
-12%
-14% -13% -51%
+37%
$0
$2
$4
$6
$8
$10
$12
$14
$162001 2010
What’s the cost of high costs?
Changes in MA state spending, 2001-2010 (in billions)
+ Quality is suboptimal
1 in 4 seniors injured during hospitalization*
Each year:
1.8 million hospital-acquired infections
4th leading cause of death
1.5 million preventable injuries due to medications
A top10 cause of death
Large variations in use of effective services
Patient experience often suboptimal
*Source: OIG, HHS, Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries
+ Why do we have cost and
quality problems?
+ Multiple theories
Fragmentation
How we pay for care (FFS, lack of incentives)
Inadequate transparency
Inadequate competition
Inadequate patient “skin in the game”
+ The ACA & Delivery Reform
Change how we pay for things
Hospital readmissions reduction program
Value-based purchasing
Hold providers accountable
Patient-centered medical home
Accountable Care Organizations
Centrally manage innovation
CMMI
+So is the ACA working?
…
+ What are the facts?
+ Readmissions Reduction Program
Up to 3% penalty for high readmission rate
2/3 of hospitals penalized each of the 3 years
Penalty seems to be making a difference
+ Good News: Readmissions are down
19.0%
17.8%
15.0%
16.0%
17.0%
18.0%
19.0%
20.0%
21.0%
22.0%
2007 2008 2009 2010 2011 2012 2013
Medicare 30-day all-cause readmission rate
Source: Centers for Medicare & Medicaid Services
ACA
+ HITECH Act: Incentives for EHRs
Signed into law in 2009 by President Obama
Incentives for “meaningful use” of Health IT
Through 2013: Incentives seem to be working
+ Use of EHRs among U.S. hospitals
9.1%11.9%
15.2%
26.6%
44.6%
59.8%
0%
10%
20%
30%
40%
50%
60%
70%
2008 2009 2010 2011 2012 2013
Basic or Comprehensive EHR
Incentives
Start
+ Value-based purchasing aka P4P
Up to 2% of Medicare payments tied to:
Broad set of quality measures:
Processes
Outcomes
Patient Experience
Efficiency
Impact underwhelming
+
11.2%
8.1%
8.6%
0%
2%
4%
6%
8%
10%
12%
Mortality rates for Acute MI, CHF and Pneumonia
Mortality rate for VBP conditions
ACA
+ Patient experience, hospitalsPercentage of patients who rated their hospital highly
63%64%
66%
67%
69%
70%71%
50%
55%
60%
65%
70%
75%
80%
2007 2008 2009 2010 2011 2012 2013
ACA
+ Big lesson across three programs:
Incentives work when:
They are sizable
Narrowly tailored
Easily measured
Transparently designed
+ What’s happening with ACOs?
+ACOs: What are they?
CMS Definition: “ACOs are groups of
doctors, hospitals, and other health care
providers, who come together voluntarily to
give coordinated high quality care to the
Medicare patients they serve”
Simple Definition:
Group of providers that take responsibility
for a population
+ACOs come in 2 main flavors:
Pioneers Big
Risk-sharing, moving towards capitation
Many of the premier organizations (Partners, etc.)
Shared-savings program Smaller
Less risk-sharing
+ Good News: Number of ACOs up
146
252
366
455
0
50
100
150
200
250
300
350
400
450
500
2012 2013 2014 2015
Source: Health Affairs Blog; Centers for Medicare & Medicaid Services
15-20% of Medicare Beneficiaries in an ACO
+ How are ACOs doing?
+ Pioneer ACOs by Year 2
32 Pioneers initially signed up
13 dropped out or switched to SSP
Of the 19 remaining:
4 generated shared losses
2 broke even
13 generated shared savings
+ SSPs: Financial Performance at Year 1
5
77
40
92
6
0
10
20
30
40
50
60
70
80
90
100
Losses > 10% Losses 1-10% Broke even(savings/losses
<1%)
Savings 1-10% Savings >10%
Nu
mb
er
of
AC
Os
*Compared to target
+ What about quality?
+ Shared Savings ACO quality performanceACOs vs. PQRS participants
68.5 70.1
76.0
70.472.5 70.8
85.7
79.1
0
10
20
30
40
50
60
70
80
90
100
Diabetic HbA1c Control(<8%)
Diabetic Blood PressureControl (< 140/90)
Aspirin Use for Diabeticswith Heart Disease
ACE/ARB Therapy forPatients with CAD andDiabetes and/or LVSD
ACO
PQRS
+ Drilling down on ACOs:
Challenges and Opportunities
+ What do the ACOs look like?
+ ACO Size: Number of participating docs
37
40
12 12
0
5
10
15
20
25
30
35
40
45
<100 100- 500 501- 1,000 >1,000
Pe
rce
tna
ge
of
AC
Os
Number of Physicians
+ Participating providersACO contains:
52% 48%
HospitalYes
No
33%
67%
Home Care Agency
25%
75%
Skilled Nursing Facility
+ What are ACOs doing?
+
%
Primary care
incentive
payments for
performance
on:
%
Primary care
incentive
payments for
performance
on:
Quality
None 25
<10% 44
>10% 31
%
Primary care
incentive
payments for
performance
on:
Efficiency
None 46
<10% 29
>10% 25
%
Primary care
incentive
payments for
performance
on:
Patient
Satisfaction
None 35
<10% 46
>10% 19
Incentives for primary care docs
+ Major programmatic efforts
%
Currently in use
by majority of
ACO
participants:
%
Currently in use
by ACOs:
Electronic Health
Record96
%
Currently in use
by ACOs:
Electronic Health
Record96
Targeted Disease
Management
Programs
76
%
Currently in use
by ACOs:
Electronic Health
Record96
Targeted Disease
Management
Programs
76
Programs to Reduce
Preventable
Readmissions
84
%
Currently in use
by ACOs:
Electronic Health
Record96
Targeted Disease
Management
Programs
76
Programs to Reduce
Preventable
Readmissions
84
Case Management
for High Cost
Patients
80
+ What are ACOs doing less?
%
Currently in use
by ACOs:
%
Currently in use
by ACOs:
Messaging Between
Providers and
Patients
37
%
Currently in use
by ACOs:
Messaging Between
Providers and
Patients
37
Electronic Alerting of
PCPs when their
Patients use ER
43
%
Currently in use
by ACOs:
Messaging Between
Providers and
Patients
37
Electronic Alerting of
PCPs when their
Patients use ER
43
Programs to Reduce
Hospital Acquired
Infections
47
%
Currently in use
by ACOs:
Messaging Between
Providers and
Patients
37
Electronic Alerting of
PCPs when their
Patients use ER
43
Programs to Reduce
Hospital Acquired
Infections
47
Patient Decision Aids
for Discretionary
Procedures
22
+ Where are the challenges?
+ Challenges to implementing ACOs
% Reporting Somewhat or Very
Challenging% Reporting Somewhat or Very
Challenging
Shifting Mindset from FFS to Integrated Care 91
% Reporting Somewhat or Very
Challenging
Shifting Mindset from FFS to Integrated Care 91
Facilitating Data Exchange 91
% Reporting Somewhat or Very
Challenging
Shifting Mindset from FFS to Integrated Care 91
Facilitating Data Exchange 91
Building EHR for Population Health Management 88
% Reporting Somewhat or Very
Challenging
Shifting Mindset of doctors from FFS to
Integrated Care91
Facilitating Data Exchange 91
Building EHR for Population Health Management 88
Controlling Use When Patients Can Receive
Care Outside of ACO97
+
%
Do you
believe that
most
ACOs:
Will Improve
Quality
Yes 86
No 11
No response 3
ACOs are optimistic
%
Do you
believe that
most
ACOs:
Will Improve
Quality
Yes 86
No 11
No response 3
Will Reduce
Costs
Yes 64
No 34
No response 3
+Final thoughts
U.S. on a major effort to fix the delivery system Mix of centralized and market-based
Initial glimpse: some early successes
ACOs represent a most promising approach Some will figure it out
What are the lessons for improvement?
Will we know how to spread and scale it?
Long journey to healthcare delivery reform We are still just getting started
+ Thank you
Twitter: @ashishkjha
+ HQA composite score, nationwideACA
75%
80%
85%
90%
95%
100%
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
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