More risk, more reward: Arkansas Health Network's plan to thrive in Medicare's 'Pathways to Success' program

Over the past seven years, Arkansas Health Network has saved CMS millions of dollars through its Medicare Shared Savings ACO Program. Now the clinically integrated network is challenged with taking on more risk — with the opportunity to earn even greater rewards.

Established by its parent company — CHI St. Vincent/CommonSpirit Health — in 2014, the physician-led network was tasked with developing a transformative healthcare delivery model that would benefit providers and consumers across the state.

Under the leadership of President and CEO Bob Sarkar, AHN said it has developed an innovative, value-based model that aims to improve patients' health and well-being and reduce the cost of care in its market. Its first steps were to engage providers and their patients, helping them understand how this model of care is beneficial for their productivity and lifestyle.

"As a result, for that Medicare population, we were able to achieve high-quality care year over year, and costs have gone down tremendously," Mr. Sarkar said. In 2020, despite the effects of the COVID-19 pandemic, AHN reported a quality score of 98.19 percent, up from 92.17 percent in 2019, in the Medicare Shared Savings Program. Its innovative model of care also saved CMS $14.3 million and earned it $8.4 million in shared savings. 

Since 2014, AHN has saved CMS more than $50 million and earned shared savings of more than $26.6 million, establishing its position as the largest and most successful clinically integrated network in the state. AHN since has grown to include more than 2,900 providers and 18 hospitals, and its portfolio of managed patient lives exceeds 121,000.

The reason for its success in 2020 can be partly attributed to AHN shifting its focus to annual wellness visits, which were challenging to engage patients in after the pandemic hit. Like much of the healthcare industry, the organization pivoted to telehealth, which it used to engage patients and stay on top of providers.

"We didn't use COVID as an excuse; we took it as an opportunity," Mr. Sarkar said. In 2020, AHN reached out to Medicare-age patients to help keep them safe from infection and engaged them in annual wellness. A host of multispecialty clinicians, including nurses, social workers and pharmacists, identified at-risk patients to intervene before they became a hospital or ER case. 

More than 6,000 patients were contacted in the first two months of the initiative, which contributed to the organization's impressive quality scores and significantly reduced costs in 2020. Further, a statistical analysis of outcomes data showed the high-risk patients who received outreach from AHN during this campaign were half as likely to be diagnosed with COVID-19 in the following six months compared with those the clinically integrated network was unable to reach. 

The secret sauce for AHN's model continuing to be one of the best practices in value-based care in the industry is three-pronged, driving collaboration between providers, payers and patients. Mr. Sarkar said the concepts of collaboration and exchanging best practices are key, particularly among providers.

"Exchanging best practices is critical because every provider may not have access to the best practices," he said. "If Practice A is doing something best on certain protocols (diabetic protocols, annual wellness visits, etc.), you take those protocols and share them with Practice B. You learn and adapt; that's what has been the biggest learning experience for us."

Thinking of AHN's model as a stool with three legs, the first is an adequate network of providers who are following evidence-based medicine guidelines, Mr. Sarkar said. "Less variability of care means less variability of cost and high quality and great experience." The model comprises specialty, multispecialty, superspecialty and primary care in the provider network, arranged in such a way that they are part of the clinically integrated network exchanging best practices. 

The second leg is having a multispecialty group of clinical and social work professionals as well as associated resources to advance care management before a chronic patient becomes acute, a hospital case or an ER case. Hospitals will always be needed to care for acute and catastrophic patients, but managing these chronic patients in the outpatient setting is crucial as patients continue to voice their concerns about being treated at hospitals, according to Mr. Sarkar. 

According to a 2017 report from Premier Inc., 60 percent of annual ER visits are for people with at least one of the following chronic conditions: asthma, chronic obstructive pulmonary disease, hypertension, heart failure and behavioural health issues. "If [health systems] were following this model to receive proactive primary care, they wouldn't need to be in the ER or in the hospital setting," Mr. Sarkar said.

The final leg involves implementing a robust next-generation analytics and IT platform that integrates not only with the claims platform of the payers — which adjudicate claims and provide data each month — but also with the electronic medical records of physician offices, pharmacies, labs and radiology and getting data in near real time.

AHN uses a robust data aggregator tool that informs providers if patients are at risk of becoming a hospital case, if they have skipped their wellness visit, if they failed to pick up their medication or if they have not followed a regimen their physician outlined.

"We work as if we are part of their physician's team," Mr. Sarkar said. "We are not a silo; we become an extension of the providers, who love it because we are able to manage the frequent-flier patients outside the physician's office so physicians can focus on complex patients and the patients who really need in-person visits."

AHN's model has demonstrated its success in improving quality and reducing costs under the MSSP program but will soon be challenged to take on more risk. From Jan. 1, 2022, in the enhanced track of Medicare's "Pathways to Success" program, it will increase the risk it takes to 75 percent, up from 60 percent from 2018-21.

Although CMS is raising the stakes in 2022, more risk can mean more reward, and AHN aims to elevate its game even further to capitalize on CMS' new challenge.

That plan starts with investing in the market. AHN, in collaboration with EngageMED, a local physician practice management services company, is creating a patient referral and coordination center to keep patients within their high-quality, low-cost network, and is partnering with employers to create near-site and on-site clinics that would treat day-to-day employee issues such as cuts, broken bones, bruises, and flu. Home visits are another initiative it plans to adopt for older or chronic patients who need in-person care.

In the commercial and direct-to-employer space, although 2020 was a very challenging year, particularly with COVID-19, AHN's strength as a clinically integrated network was validated, according to Mr. Sarkar. AHN, in partnership with Arkansas Children's Care Network, achieved the highest total quality score across CommonSpirit Health for CHI St. Vincent's Employee Health Plan. Based on final quality scores, they earned 81 percent of the "at-risk" bonus.

AHN is also exploring taking on capitated risk "with the right employers, under the right terms, with certain guardrails," Mr. Sarkar said. In a capitated arrangement, AHN would be assigned a fixed amount of money per patient in advance, representing favorable financial outcomes for the health plan. At the end of the performance period, it would keep any surplus funds or bear the full risk of any deficits. 

"After payroll, the second line item of an employer is their health benefit cost, and if we can help them with our innovative model of care and best practices to keep their cost within their expectations, just imagine what a benefit that is," Mr. Sarkar said.

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