Dr Ashish Jha, Harvard School of Public Health, presenting at the Nuffield Trust Health Policy Summit, explores how change happens, drawing on examples from Accountable Care Organisations in the USA.

1. +
5 Years On:
A Bird's Eye Look at Improvement under ACA
Ashish K. Jha, MD, MPH
February 26, 2015

2. + Background
The ACA has two goals:
Expand
Coverage
Fix the
healthcare
delivery
system

3. +
Why delivery reform?

4. + 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

5. +
-22% -31%
-12%
-14% -13% -51%
+37%
$0
$2
$4
$6
$8
$10
$12
$14
$16 2001 2010
What’s the cost of high costs?
Changes in MA state spending, 2001-2010 (in billions)

6. + 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

7. + Why do we have cost and
quality problems?

8. + Multiple theories
Fragmentation
How we pay for care (FFS, lack of incentives)
Inadequate transparency
Inadequate competition
Inadequate patient “skin in the game”

9. + 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

10. +
So is the ACA working?

11. …

13. + What are the facts?

14. + 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

15. + 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

16. + 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

17. + 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

18. + 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

19. +
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

20. + Patient experience, hospitals
Percentage 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

21. + Big lesson across three programs:
Incentives work when:
 They are sizable
 Narrowly tailored
 Easily measured
 Transparently designed

22. + What’s happening with ACOs?

23. +
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

24. +
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

25. + 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

26. + How are ACOs doing?

27. + 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

28. + 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%
NumberofACOs
*Compared to target

29. + What about quality?

30. + Shared Savings ACO quality performance
ACOs vs. PQRS participants
68.5 70.1
76.0
70.4
72.5 70.8
85.7
79.1
0
10
20
30
40
50
60
70
80
90
100
Diabetic HbA1c Control
(<8%)
Diabetic Blood Pressure
Control (< 140/90)
Aspirin Use for Diabetics
with Heart Disease
ACE/ARB Therapy for
Patients with CAD and
Diabetes and/or LVSD
ACO
PQRS

31. + Drilling down on ACOs:
Challenges and Opportunities

32. + What do the ACOs look like?

33. + 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
PercetnageofACOs
Number of Physicians

34. + Participating providers
ACO contains:
52% 48%
HospitalYes
No
33%
67%
Home Care Agency
25%
75%
Skilled Nursing Facility

35. + What are ACOs doing?

36. +
%
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

37. + Major programmatic efforts
%
Currently in use
by majority of
ACO
participants:
%
Currently in use
by ACOs:
Electronic Health
Record
96
%
Currently in use
by ACOs:
Electronic Health
Record
96
Targeted Disease
Management
Programs
76
%
Currently in use
by ACOs:
Electronic Health
Record
96
Targeted Disease
Management
Programs
76
Programs to Reduce
Preventable
Readmissions
84
%
Currently in use
by ACOs:
Electronic Health
Record
96
Targeted Disease
Management
Programs
76
Programs to Reduce
Preventable
Readmissions
84
Case Management
for High Cost
Patients
80

38. + 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

39. + Where are the challenges?

40. + 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 Care
91
Facilitating Data Exchange 91
Building EHR for Population Health Management 88
Controlling Use When Patients Can Receive
Care Outside of ACO
97

41. +
%
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

42. +
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

43. + Thank you
Twitter: @ashishkjha

44. + HQA composite score, nationwide
ACA
75%
80%
85%
90%
95%
100%
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013