ACO part 4: Q&A with LPACO, Dr. Joshua Lowentritt, MD

Defining success as an ACO: Q&A with Dr. Joshua Lowentritt, MD

Having detailed one model attempting to unlock shared savings through improved medication management, we thought a fitting wrap up would be a Q&A with a physician putting this model to work. Dr. Joshua Lowentritt is a practicing Internist and Chair/President of the Louisiana Physicians ACO (LPACO). Here’s what he recently shared with us as LPACO endeavors to navigate the transition from volume to value.

How do you define in success as an ACO?

From an individual physician’s perspective, a successful ACO engagement should provide access to new technologies, generate mentors and a new network of colleagues from which everyone can learn. It should also generate mutually beneficial partnerships, including ones with care coordination and medication management providers, solutions to practice management issues. Ultimately it should generate income from value-based care delivery.

As a physician, the ability to manage patients when they’re not in front of me has immense value. Closing gaps in the delivery of care including notifications of discharge and transfers, ER visits and failure to pick up critical medications helps patients and clinicians simultaneously. There are also significant associated gains to be made in population health.

From an ACO leadership perspective, success means creating revenue opportunities for partners, helping them get their population health work right, improving their quality measures and closing gaps in care. The organization as a whole should provide “wins” for the practices and predictably generate income, not be a driver of additional cost.

Measurement: Where are the holes or gaps that you found? - Even one of the largest ACOs in the country has gaps: What are the ones you discovered?

Our top need was a technology partner to not only report data, but pull it out of the EHR in a way that answers questions from data that delivers meaningful, actionable analysis. We also needed new ways to connect patients with clinics. This is where partnerships with value-minded external care coordinators and medication management companies are effective.

How do you prioritize areas of focus for improvement?

We look at cost expenditure reports for panels of Medicare patients. With good insights into the data, it tells us where we need to focus. Reducing readmission rates is the number one area to save money in medicine. Analytics also tells us we have a high post-acute care spend. To address this, we have engaged with skilled nursing, rehabilitation and home health providers. Variance analysis tells us where we need to focus your effort.

If ACO leaders can use data and variance analysis to define a problem, then they can ask questions of that problem to determine what resources, activities or interventions may be effective. Refining those questions and solutions over and over helps hardwire the process into physician behavior set.

How did you identify the right team members and/or staff who would act as project champions at participating clinics? What about partners? What are their roles? What qualities do they exhibit?

There are several perspectives and qualifications to consider. ACO leaders are basically looking for people who can also see beyond the clinic’s own four walls. They should be looking for MBAs and MHAs with clinical experience, community level experience and regional or network experience.

One MBA running a small practice in a small town is one of the most innovative people we have. He has developed RN wellness programs we are all copying.

ACO leaders should be looking for entities with strong management teams. Then their only challenge is keeping up with those teams’ questions. Look for strong salaried physician leaders with assigned non-clinical time. Lean on CEOs of large practices given the protected medical directorship time in their schedule. Typically these people are not satisfied with the status quo and are eager to improve value-based care delivery to the benefit of all concerned.

Successful ACOs leverage a mix of experience levels. Veteran physicians, clinicians and practice directors bring experience be it in a company, agency, clinic or hospital setting. They provide insights and background on what their colleagues are thinking. Younger staff are crucial to the success of the organization because they likely exhibit a great deal of independence and are eager to influence positive change. They are also apt to be a source of technological expertise because they have grown up with it: think Youtube channels and video production, data and data analytics proficiency or even a practice web page.

We look for 3-4 people at any given time in our individual medical group who are applying to medical or nursing school. They have college degrees and are motivated to work for providers like us given the access we can provide to a new network of physicians, clinicians and practice managers.

In which areas are you working with external partners?

We interact regularly with our ACO consultant for data acquisition and insights, scheduling our national meeting, rolling out program updates. Our software vendors assist with reporting. We are working on a joint venture with a home health agency, an opportunity that is income producing while improving control over care delivery. And our medication management partner is helping improve adherence rates, a proven way to improve health outcomes while reducing costs: the definition of value-based care.

What are your clinicians and patients saying about your various partnership efforts?

Clinicians and patients will always let you know when expectations haven’t been met. Providing a forum for all to be heard is an absolute necessity. This includes one on one meetings or calls with practice or clinical leads to identify pain points that need to be fixed or drill down into a highly specific topic.

What is your top advice for an ACO interested in embarking on an MSSP journey? What do you need to do first and foremost to increase the chances for success?

Let’s look at that from several angles.

Be well prepared to talk to physicians about performance metrics and data for the first time. Show them what’s critical and expected. Pull data and do an analysis with the physicians. Probe the data together to ask questions and generate clinical answers.

Always acknowledge that every practice has its strengths and weaknesses. Give them credit for always doing their best. It’s entirely possible they have never seen, let alone measured, the requisite data points for ACO engagement including shared savings programs. Focus all of your attention on problem solving. These are all bright, motivated, well-educated individuals driven by problem solving.

Do whatever is needed to build and show trust. Listen, do not preach: they will listen if the ACO leadership brings them value-based insights.

Analytics told us one of our practices had very high spending in the long term acute care (LTAC) space. This required group meetings focusing on moving some care into a less expensive location without sacrificing quality. This group achieved a $2 million run rate reduction in cost without dropping quality at all. We very conscientiously told them that we would not embarrass them. They had to trust us. And they did. Beyond the savings derived, our collective reward was a problem solved and further development of a trusting relationship on both sides.

Reprise: how will you know that you have been successful as an ACO?

Are we building a collaborative network that did not exist previously? Are our practices getting as much out (or more) than they put in? By completing our Comprehensive Primary Care Plus applications as a group, we have a better chance of being in the active group. This means an opportunity to realize per member per month reimbursements that could bring nearly $400,000 to the organization and our members compared to the control group.

But success is not just a distribution of Medicare Shared Savings. Have our practices grown their capacity to provide value-based care? Are they ready for the next change in the payment system or the next focus in care? Did we educate and lead them? Do they have new partnerships today to which they wouldn’t have had access on their own? Even if an ACO hasn’t met the goals yet, the organization can still measure success without a monetary payout. For example, if all of our practices are ready this year for MIPPS, that’s success.

About the authors
Kristin Lindsey is Senior Director of Marketing for Curant Health

The views, opinions and positions expressed within these guest posts are those of the author alone and do not represent those of Becker's Hospital Review/Becker's Healthcare. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them.

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