Anatomy of an Independent Primary Care ACO, Part I

Julian D. "Bo" Bobbitt, Jr.
Internal Medicine News

While concepts and theories can go a long way, sometimes the best way to understand something is through a concrete example. So, from time to time, ACO Insider will check in on a new accountable care organization composed of 14 independent physicians in 11 practices in McAllen, Tex.

We chose them because they share many of the same questions and concerns as quite a few of you readers: Will this work? Where do I begin? How can we do this, since we have no free time or money? How much will this cost? Will there be any shared savings? Do we have to affiliate with a hospital or a large practice? Are we too small? How do we apply for the Medicare Shared Savings Program (MSSP)? What will change in my practice?

The name of the ACO is Rio Grande Valley Health Alliance (RGVHA). It was formed in January 2012 as a "network-model" ACO, meaning that the physicians stay in their separate independent practices but participate in the ACO through contract. Its first – and as of this writing, only – ACO payer contract is with Medicare, the MSSP.

So far, there have been a number of unexpected highs and a number of unexpected lows. The primary care physicians of RGVHA hope that by sharing their story, they can help you better navigate your own ACO course.

Opportunity for primary care

Dr. Luis Delgado became intrigued by the possibility under accountable care of rewarding primary care physicians for the savings they generate while maintaining or improving quality. Instead of resisting change, he saw opportunity.

He also saw a chance to do something about McAllen’s reputation, gained through Dr. Atul Gawande’s 2009 article in the New Yorker entitled, "The Cost Conundrum." That article focused on McAllen’s Medicare health costs, which were almost twice those of its Rio Grande River neighbor, El Paso.

However, beyond having a vision, he had no know-how and no budget.

Fortunately, as readers of this column know, there is so much documented "low-hanging fruit" for primary care to generate savings through value-based care that the strategic time and expertise expenditures proved not to be significant. The legal structure and backroom business logistics for a small network-model primary care physician ACO are also relatively straightforward. RGVHA has two full-time administrative staffers, one part-time president (Dr. Delgado), and one part-time medical director (Dr. Roger Heredia).

However, the new ACO data collection, sorting, and reporting requirements were somewhat daunting – that is, until they met Dr. Gretchen Hoyle of MD Online Solutions (MDOS). Dr. Hoyle is a practicing pediatrician who spearheaded the design of a physician-friendly care management data system for her practice and found it ideal for the accountable care era. Her company targets small- to medium-sized physician-led ACOs.

MDOS was able to tailor a nimble ACO solution scaled to RGVHA’s needs, thus allowing RGVHA to supply its last missing piece in a cost-effective manner. Because she is a practicing physician, Dr. Hoyle helps interpret the data and leads a weekly data-driven staff conference call with the ACO’s nurse care coordinators.

Approved for the Medicare ACO

Despite initial fears, RGVHA found that the MSSP application process was not intimidating at all. It turned out to be a reflection of its business structure and primary care physician ACO strategy.

"If you get your game plan together ahead of time, independent primary care physicians should be successful in applying for the Medicare Shared Savings Program," stated Dr. Delgado. "We found that Medicare is supportive of this type of ACO, I guess because it sees their potential to improve health care," he said.

The Centers for Medicare & Medicaid Services does indeed support these types of ACOs, as RGVHA qualified for one of the last Advanced Payment Program grants. The CMS is so confident that these physician-led, nonmetropolitan ACOs will work, that the agency actually fronted the infrastructure and operational money to them. RGVHA was one of the last grantees of this one-time appropriation.

They began the MSSP program Jan. 1, 2013, opting not to take risk and to receive 50% of the savings they generated for the 5,000 patients attributed to them, if quality and patient satisfaction metrics are met.

‘I haven’t had this much fun practicing medicine in 10 years!’

To decide what type of initiatives to undertake, the physicians read the Physician’s Accountable Care Toolkit (profiled in an earlier column) and convened a weekend workshop. They were pleasantly surprised when they realized that so many savings and quality improvement opportunities are available to primary care physicians under accountable care – and control over the physician-patient relationship was being returned to them.

They targeted diabetes management, patient engagement, best practices for enhanced prevention and wellness, and home health management.

One physician summed up the mood when she exclaimed, "I haven’t had this much fun practicing medicine in 10 years."

As they celebrate their first year under the MSSP, how are they doing? To read more, visit Part II: Our Secret Weapon, and Our Biggest Disappointment. 

This article appears courtesy of Internal Medicine NewsBo Bobbitt is the author of Internal Medicine News "ACO Insider" column.

Bo has many years of experience assisting physicians form integrated delivery systems. He has spoken and written nationally to primary care physicians on the strategies and practicalities of forming or joining ACOs. This article is meant to be educational and does not constitute legal advice. For additional information, please contact Bo Bobbitt.



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