A Pioneer ACO One Year Later: Q & A With Presbyterian Pioneer ACO's Tracy Brewer

Presbyterian Healthcare Services in Albuquerque, N.M., is one of the 32 organizations that was chosen by the CMS Innovation Center to participate in the Pioneer accountable care organization program in December 2011. Now, nearly a year later, Presbyterian is in the thick of updating its IT infrastructure and educating the new members of its ACO.

Tracy Brewer is the lead project manager of Presbyterian Healthcare Services' ACO and has been involved in the process of becoming an ACO from the very beginning — she assisted with Presbyterian's Pioneer application. Here, she reviews the organization's first year as one of the first ACOs and shares some tips for success.

Question: Generally, how has your first year as a Pioneer ACO been?

Tracy Brewer: Things have gone well! We began receiving claims data from CMS in late March to help us manage the ACO population, so we have spent a lot of the time this year doing analysis of the population and understanding the particular health concerns and chronic conditions experienced by the population, to guide us in determining what areas we should focus on. We just this week kicked off a case management program for some of our ACO beneficiaries, focusing on making the transition from inpatient to outpatient care, which we believe will help beneficiaries avoid potentially unnecessary emergency room visits and hospital readmissions; we haven't always been able to focus programs like these on traditional Medicare beneficiaries in the past, but the Pioneer ACO program gives us the information we need to begin the work.

We also recently held an educational event for the ACO beneficiaries. We had the top leadership from the ACO present on what Presbyterian is doing and how we hope to better serve beneficiaries’ needs. We also had some entertainment, and everyone really seemed to enjoy the day.

Q: What, if any, have been the most noticeable changes for your physicians and staff since finalizing your status as a Pioneer ACO?

TB: From a day-to-day operational perspective, one of the major tasks we have completed is to flag all of the participating ACO patients in our electronic health records system. Now that we have deployed the flag in our EHR system, everyone from the front desk to the care providers can identify our ACO beneficiaries at the point of care. For those patients that we identify, we encourage the care teams to determine if they have higher-level needs that could require case management or other support services so that we can get the beneficiaries connected to those teams. Prior to becoming an ACO, we may have been able to meet some of these beneficiaries’ needs and assist patients in finding support services in the community.  Now we have an opportunity to perform a lot of that work ourselves and provide even more support to this population.

Q: What goals did you set as an ACO in the beginning of the year and how have you worked to achieve them?

TB: In the first year, we had a couple goals. One of the major ones was updating our administrative and IT infrastructure. We had to make sure we had all the operational pieces in place to function as ACO. We also completed some work on our IT infrastructure so that once we received the claims data from CMS, we could begin analysis and really get value from it. We've come to a point where we can say this goal is almost complete.

Another goal we set was to engage and educate the population that is now part of our ACO. ACOs were in the media a lot during the debate about healthcare reform, and its natural that individuals will have a variety of perspectives about what the model is and what it means to be an ACO beneficiary. We wanted to help them understand what the ACO is and the benefits it offers to them — that it is a positive resource that offers additional support, and not something that will increase costs or restrict care. In order to begin this educational process, we sent notifications to all aligned beneficiaries at the beginning of the year. We also keep a telephone hotline open and staffed by trained customer service representatives all year that can answer questions. Beneficiaries have called in and asked questions, and I think it's been a valuable tool. Most recently, we held the beneficiary event.  Educating the population is something we started tentatively and believe that next year we can dive into it in greater detail to reach more of the population. We're not there yet, but we were able to get a good start this year.

As I mentioned, we started a case management program for high-risk patients. In addition, we are working to complete an in-depth analysis of all the data provided by CMS and identify individuals with complex needs that we can reach out to proactively. We’ve also started a complex-case management program at one of our primary care practices. If the pilot program is successful, we can spread it to other practices and incorporate more beneficiaries.

Q: What challenges have you encountered as a Pioneer ACO?

TB: One challenge has been that people are not familiar with what an ACO is and what it has to offer. We have a lot of work ahead of us for education and engagement of the beneficiaries. One of the unique things about the Albuquerque market is that this is a large Medicare Advantage market. Presbyterian is an integrated system, but the ACO encompasses just our hospital and medical group. We have had some challenges with individuals seeing the Presbyterian name and associating it with the Medicare Advantage plans offered by the affiliated Presbyterian Health Plan. Many of the questions received into our telephone hotline were related to such concerns, which our trained representatives were able to address.

Another challenge has been preparing for the quality indicator reporting. The CMS Innovation Center has been working hard and diligently to get ACOs the information that they need in order to be successful, but much of the information won’t be available until the fourth quarter. As we must prepare to report on the quality metrics at the end of the year, we continue to work as rapidly as possible as information is released to ensure our readiness. But the CMS Innovation Center been a wonderful partner in this endeavor, and has been very upfront about timelines for the various activities. The Pioneer ACO program in general could have been a different experience without all of their hard work.

Q: What do you think it takes to be successful as an ACO?

TB: Having the IT infrastructure necessary to do complex analysis and get the most value from the claims data is very important. We're fortunate to have had a data warehouse in place for a number of years, partly due to the fact that as an integrated system we have built up our infrastructure for claims data from our own affiliated insurance entity. Because of that, we are familiar with claims data and have experience in how to use it to make decisions. An ACO without this infrastructure would have to build the capacity in house or find an external partner to work with, so having that IT infrastructure — including our EHR, data warehouse and claims analysis capability — really made a difference in our ability to get the most out of the data.

Also, having physician engagement can make or break an ACO. Our ACO providers consist of our employed medical group, which is a very engaged group in general. Having physician engagement is incredibly important because the physicians see the patients every day and work with the population. They have the relationship with the beneficiary, and the beneficiary trusts their doctor. As an ACO, if your providers aren't engaged and interested, you will have a lot of hurdles to overcome.

Q: What is your relationship with the other Pioneer ACOs like?

TB: That's one thing I really appreciate about participating in the program — all of the Pioneer ACOs are excited about sharing what we've learned and helping each other look for solutions. We have created a learning community with the other Pioneer ACOs. We meet regularly, either virtually, over phone or by email, and twice a year meet face-to-face with CMS Innovation Center staff in Washington DC. It has been an invaluable part of our participation in the Pioneer ACO. Some of the ACOs have shared programs they are implementing that we had not considered, but now we can see the value it could bring to all of our patient populations. It's been incredibly valuable to have.

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