Rewarding Results: Texas Medicare ACOs Perform Promisingly
By Joey Berlin Texas Medicine December 2020

For the Medicare Shared Savings Program (MSSP) and many of the accountable care organizations (ACOs) that participated in it, 2019 was billed as a transition year.

But data released by the Centers for Medicare & Medicaid Services (CMS) in September show Texas ACOs fared quite well last year – and a number of Texas physicians and ACO officials say the savings generated are worth the gruntwork that MSSP requires.

Fifty-one Texas ACOs participated in the 2019 MSSP performance year, according to an analysis by TMA PracticeEdge. More than 60% of those ACOs – whether big or small in terms of patients served – earned shared savings and will bring money back to their health care programs as a result. A number of ACOs did so facing “two-sided,” or downside, risk arrangements – meaning they risked having to refund CMS a percentage of any losses they generated, but they also stood to gain a larger share of the savings for accepting that risk. (See “Medicare Shared Savings Program and Texas ACOs: By the Numbers,” page 43.)

For McAllen internist Monzer Yazji, MD, the MSSP results are a good indicator for the future of value-based care. He is chief medical officer of the ACO South Texas Clinical Partners, which generated millions in savings in 2019.

“The Texas Medical Association, or any kind of association in Texas or nationally, should really be pushing forward a lot of encouragement and motivation … to all physicians to start practicing this way,” Dr. Yazji said. “That should be the transition for all physicians, to start evolving in medicine and [recognizing] that value-based medicine in all health care should be the foundation of any practice in any place in the state: in rural areas, in the cities, everywhere.”

Small-ACO success – and challenges

Recognizing that’s not an easy feat for small practices, TMA PracticeEdge has worked to enable them to band together to generate the resources and infrastructure to participate in and benefit from value-based programs like MSSP ACOs. (For more information on joining an ACO through TMA PracticeEdge, visit www.tmapracticeedge.com.)

Medicare’s 2019 results show that strategy can work and save millions.

South Texas Clinical, with physicians in Laredo and McAllen serving about 7,800 patients, operates as a partnership between participating practices and Universal Health Systems hospitals. Some physicians in South Texas Clinical also participate in commercial payer-administrated value-based programs through TMA PracticeEdge’s Seven Flags ACO.

As a two-sided Medicare ACO in 2019, South Texas Clinical could earn as much as 60% of any care savings. In 2019, the ACO generated $14.8 million in savings, and got to keep $8.6 million of that. Getting there, Dr. Yazji explains, took several years of evaluative work of physicians and their patients, and getting physician buy-in.

“It was a training process that involved transforming their practices from the front office to the nurses to the physician to the billing department,” he said. “All of us need to work together to maximize. The success comes as the physician understands how important the data is: collecting and analyzing the data and working toward a value-based focus.”

Laredo family physician Luis Benavides, MD, who’s part of South Texas Clinical, notes that some of the measures MSSP requires take more time than others.

 “So we have to get physicians to see the vision of looking forward, and see how that’s going to be rewarded,” he said.

The more time-consuming quality measures, Dr. Benavides said, include making sure patients go to their annual wellness visits, and metrics on other preventive steps, such as colorectal screenings, mammograms, and vaccinations. If patients are diabetic, ensuring that they get their eyes examined is paramount.

The partnership with the hospital’s acute-care and outpatient departments – which Dr. Yazji calls “a beautiful relationship” – is a benefit.

“You want to pick a hospital that is working with you that is cost-effective, that is going to partner with you in getting things done the right way in setting up, for example, the appropriate post-hospital care that’s due,” Dr. Benavides said. “In other words, once they’re getting ready for discharge, what is the best thing for that patient? Is it a rehab unit, or is that patient adequately served in a skilled nursing facility? Or if you’re going to send them home, what are your goals in home health care and trying to achieve those in the best way possible, and not just simply give someone home health and allow them to stay on home health forever.”

For Rio Grande Valley Health Alliance (RGVHA), a physician-owned ACO with a track record of savings success dating back to its founding in 2013, last year was one of transition.

RGVHA, which has 20 physicians and serves about 5,200 patients, switched gears in the second half of 2019 to an Enhanced Track under the new Pathways to Success system. (The Pathways to Success scheme features a Basic track, in which ACOs begin as a one-sided risk model
and gradually take on higher levels of risk; and an Enhanced track, in which ACOs assume the highest level of risk and potential reward. For
more information, visit tma.tips/pathwaystosuccess.)

Throughout 2019, RGVHA stood to potentially owe Medicare big money if things did not go well – up to 75% of any losses it incurred. Instead, the ACO generated about $5.7 million in savings, keeping about $4 million of that.

Victoria Farias, CEO of the health alliance, says physician engagement is key but also notes the help of non-physician professionals who augment the doctors’ work.

“We have a team of chronic care managers that telephonically reach out to the patients that are high-risk, and then we also have care coordinators that go to the homes and help the physician to coordinate the care. That really contributes to being able to identify areas where we need to bring down costs,” she said.

The challenges RGVHA works against include a high percentage of end-stage renal disease patients and dual-eligible Medicare and Medicaid patients, who tend to have multiple comorbidities and generate higher costs than other patients.

“When you’re on the smaller side, it can be a little bit of a challenge if you have too many outliers, or patients that are just really high-cost,” Ms. Farias said. “With a small panel, it can be a little volatile at times. That’s a challenge as far as when you’re looking at the way that CMS calculates savings and the different benchmarking that we’re allowed.”

Big hospital, big savings

Baylor Scott & White (BSW) Quality Alliance was another ACO that switched mid-year to the new Pathways to Success system, in which it could earn – or pay back – up to 75% of its savings or losses.

Overall, the alliance generated nearly $70 million in savings in 2019, earning $34 million of that savings for itself.

But even such a large entity says it was a deliberate progression to its 2019 performance, as its physicians and other practitioners spent years getting to understand the Medicare shared savings population and deploying its programs accordingly.

Tiffany Berry, MD, the ACO’s chief medical officer, says physicians were “the heartbeat” of its work.

“Our primary care teams expanded hours and provided more convenient appointment types,” she said. “Patients with higher needs were engaged by our physicians, who collaborate with our RN care managers, social workers and pharmacists to offer robust care options and allow our team to spend more time with each patient.”

In 2018, the alliance began scaling its care management, which included care managers working with physicians to make sure the highest-risk patients had the right transitional care plan to leave the hospital, said Jenny Reed, system vice president of comprehensive care management at Baylor Scott & White Health. That effort resulted in 2018 savings, which BSW reinvested to expand its clinical programs to its entire Medicare shared savings population. That included expanding pharmacy, transportation, and community services related to social determinants of health.

“We saw a 1.2-percentage-point improvement in our quality score, we believe as a result of these efforts,” Ms. Reed said. “We also saw a 3.5% increase in engagement with primary care services. The idea that improvement or increasing engagement with the primary care doctor will lead to less hospitalizations, we actually saw in our data [in 2019].”

Ms. Reed says an ACO made up of smaller practices can be successful in MSSP: “What they lack compared to maybe Baylor Scott & White in terms of resources, they make up for in agility.

“Smaller organizations sometimes have less cumbersome processes to work through in detail,” she said. “So can they go out and hire a team of pharmacists? Maybe not. But maybe they don’t need a whole team because they’ve got such a small population. Maybe they need one pharmacist … that can act as a care manager, and that person can wear multiple hats. So it’s a different way of applying resources. But we have learned a lot over the years from small organizations who have been able to be successful.”

Worth it

Not all of Medicare’s value-based care programs, past and present, have borne fruit for smaller practices. For example, in CMS’ Merit-Based Incentive Payment System (MIPS), concern persists about the program’s fairness, whether small shops have a chance to succeed, and whether the burden it introduces is worth it. MIPS also has drawn criticism from physicians for being more about checking boxes than actual care quality. (See “An Unfair Game,” January 2020 Texas Medicine, pages 18-25, www.texmed.org/unfairgame.)

But physicians interviewed by Texas Medicine, say an MSSP ACO can be a viable alternative.

Lubbock family physician Christopher Rose, MD, a member of the Texas and New Mexico-based Covenant ACO, says for the past several years, he used his electronic health record to monitor how his practice would perform in MIPS, if it participated, compared with its participation in MSSP through Covenant.

“We did fair with MIPS,” he said. “We didn’t do stellar or great. But I think both financially and [for] ease of operations, that just for an independent physician such as myself, the ACO is working out in my favor in comparison to just doing MIPS.”

Covenant generated losses during the first half of 2019, according to CMS’ data, and must pay the agency about $689,000. It switched to a new Pathways to Success track during the second half of the year and fared better, albeit neutrally.

Michael Robertson, MD, CEO of Covenant, told Texas Medicine that the hit his ACO took during the first half of the year was due in part to benchmarking that was hurting it under the old MSSP system. Covenant made the switch to Pathways to Success mid-year, he said, because it saw that continuing in the old MSSP tracks wasn’t sustainable. He notes that Covenant’s board set up a reserve fund so that any losses the ACO incurs won’t come directly out of its physicians’ pockets.

But Covenant’s 2019 performance does indicate some room for improvement, Dr. Robertson says.

“Our composite quality score is a 96. We can’t do much better than that. We have a problem where we still have the mindset of practicing in the ‘80s even though the rules of the game are [for] 2020,” he said. “So we’ve got to do some things differently than the way we’ve always done things. We’ve got to start looking at things from a patient management standpoint and look at managing those patients a little bit more proactively, and getting our member providers to utilize some of the programs that we’ve put in place that can help them manage some of these problem patients that are resulting in some things that caused us to end up having a loss [last] year."

But Dr. Benavides, with South Texas Clinical in Laredo, says participating in MSSP has improved patient care, because the program’s measures are largely designed around quality. And the financial incentives are in line with the extra burdens, he adds.

“Part of the reason why I think that is, [is] because of all these financial incentives, whatever level of income you’re used to can remain the same, but [you] actually see less patients – which means you have more time to give that particular patient,” he said. “And if you build the right team behind you, a lot of the documentation for the measures can be achieved not by you personally, so it doesn’t take that much of your personal time, but the team that you hire around you.”