• Lessons from a Leading ACO Performer

    By Elizabeth Barker Jan 30, 2017

    Ratings for 2015 confirmed Banner Health Network as a top-performing Pioneer Accountable Care Organization participant. From aligned partnerships to investments in technology to provider and patient education, the Arizona-based organization continues in its quest to achieve the Triple Aim.

    In 2011, healthcare provider Banner Health partnered with its employed physician group as well as independent physicians to form Banner Health Network (BHN). Along with 31 other participants, the organization joined the Pioneer Accountable Care Organization (ACO) program.

    Started by the Center for Medicare and Medicaid Innovation (CMMI) and designed for health systems with experience coordinating care in this capacity, the Pioneer ACO model engages participants in exploring alternative payment models (APMs) to deliver higher-quality care along with Medicare savings. ACOs that reach designated cost and quality benchmarks share in the savings, while those that exceed their cost benchmark may owe money back to Medicare. Participants are evaluated in a total of 34 quality measures spanning four categories: patient/caregiver experience, care coordination/patient safety, preventive health, and at-risk population.

    By 2015, the fourth performance year, all but 12 ACOs had dropped out of the Pioneer program. BHN finished with an overall quality score of 95.23 percent, exceeding the average performance by about three percentage points. It also reached the highest total savings for '15, with $35,113,328, thus earning $24,578,369 in shared shavings.

    The ACO credits a substantial portion of its high performance to a team approach, including organization-wide buy-in.

    Lisa Stevens Anderson, Banner Health Network"From the first year that we were in this program, our performance on the ACO quality measures was a system-wide strategic initiative," says Lisa Stevens Anderson, vice president and CEO of BHN. "All 48,000 of our employees across Banner Health are aligned on the same strategic initiatives, and our entire organization was focused on the performance of this initiative."

    Keys to Success

    BHN in 2015 achieved a 100 percent quality rating in both care coordination/patient safety and preventive health. Comprising 5,000 providers, 13 hospitals, a cancer center, a children's medical center, and a range of clinical services, BHN has focused on alignment across its network. In addition, the ACO has reduced clinical variation and lowered costs through tactics including utilization of Medicare programs, provider and patient education, and investment in technology.

    Success in the care coordination/patient safety area, which spans 10 ratings categories that include the skilled nursing facility (SNF) 30-day all-cause readmission measure (ACO-35), stems from approaches such as post-acute support and value-based payment opportunities for partner providers. "CMS [the Centers for Medicare & Medicaid Services] and CMMI have given us some tools that have allowed us to engage with some providers in ways we weren't previously allowed to," Stevens Anderson notes.

    Applying for a waiver to the three-day SNF rule has permitted BHN providers to send Medicare beneficiaries directly to a SNF if they determine an inpatient setting isn't necessary. In addition to eliminating a coinsurance payment for the beneficiary's inpatient stay and improving care quality, this tactic allows the hospital to avoid incurring the cost of a three-day stay.

    BHN has also engaged SNF, home health, and hospice providers in quality performance metrics by utilizing a population-based payment option that CMMI provided for Pioneer ACOs to test. Providers accept a slight reduction in Medicare payments for the opportunity to earn additional revenue based on performance. BHN saw a decrease in the number and average length of SNF stays for its Medicare population, and attributed the reduction to improved coordination across its provider network.

    Robert Groves, Banner Health NetworkUsing quality-based incentives to reduce unnecessary hospital stays enhanced BHN's ability to coordinate care while improving admission and readmission rates. "From a physician's perspective, I strongly believe that quality and cost are two sides of same coin," says Robert Groves, MD, vice president of health management and chief medical officer, BHN. "The real magic is in getting barriers out of the way of physicians and other providers so that they can do the things that they know need to be done."

    Compared with previous performance years, BHN in 2015 saw significant improvement in risk-standardized, all-condition readmissions (ACO-8), admissions for chronic obstructive pulmonary disease or asthma (AHRQ Prevention Quality Indicator [PQI] #5; ACO-9), and admissions for heart failure (AHRQ PQI #8; ACO-10).

    In preventive health, which contains eight categories, BHN achieved notable improvement in influenza immunization (ACO-14), body-mass index screening and follow-up (ACO-16), breast cancer screening (ACO-20), and documentation of screening for high blood pressure and follow-up (ACO-21).

    Major improvement in those seven categories across care coordination/patient safety and preventive health further strengthened BHN's overall quality rating. The ACO has allocated resources to educating physicians during monthly provider engagement meetings, including discussion of measures and other requirements for documentation, and incorporating these measures into its primary care physician incentive scorecard. BHN has also found value in sending direct-mail postcards to members to emphasize the importance of flu vaccinations.

    Kathleen Harris, Banner Health Network"Putting efforts into these areas pays off," says Kathleen Harris, senior director of government operations at BHN. "You've got patients who are healthier and happier and doctors who are giving better attention to preventive care and engagement for at-risk patients—and the higher the quality score, the higher the opportunity for earned savings."

    To support high performance across its delivery system, BHN has invested in technology, including electronic health records (EHRs). It also uses an in-house tool called Clinical Performance Tracker to aggregate EHR and claims information to help pinpoint any care gaps. The organization plans to transition in mid-2017 to a tool that will have the capacity to integrate electronic records with its community physician practices.

    Groves stresses the importance of maintaining "focus on quality in addition to sustainability—focus on having really good information to drive changes that will improve the opportunity to get our patients healthier in a more efficient way."

    Learning Opportunities

    Investment in technology and personnel contributed to BHN's high performance but presented challenges along the way, and although the organization's overall quality score exceeded the mean in 2015, BHN notes continued opportunities for improvement. The organization has addressed these areas by continuously focusing on alignment, updating technology, and educating patients.

    BHN has faced challenges in aligning physicians on a single EHR. Approximately 40 percent of the organization's participating primary care physicians in 2017 will use a nonaligned product. BHN will continue its efforts to streamline the number of EHRs used by its ACO providers.

    "It has been an evolution working with our physicians to update their workflow to accommodate different measurements," Groves says. "We continually refer to the value-based 'journey' because we are on a constant learning curve and believe that the organization that can keep evolving will be the one that continues to be successful."

    BHN's quality score was 87.5 percent in 2015 in the at-risk population quality category, which includes eight measures ranging from depression remission at 12 months (ACO-40) to controlling high blood pressure (ACO-28). This result was a drop-off from BHN's 2014 score of 92.5 percent, with the decrease stemming from factors that included BHN's performance in the drug management of coronary artery disease.

    "The more information an engaged patient has about their care, including necessary medication and why each drug is important, the more likely they are to use their medicines reliably and consistently," Groves says. "Our teams of clinicians and coordinators try to bridge that knowledge gap with every encounter."

    The patient/caregiver experience category, as measured by the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey, includes eight categories. Among them are getting timely care, appointments, and information (ACO-1), patients' ratings of providers (ACO-3), and stewardship of patient resources (ACO-34). Although BHN did not reach a 100 percent score, its tally of 93.44 percent was up significantly from 81.5 percent two years earlier. The organization credited this improvement to its continued investment of time and resources in the customer experience.

    "Health care is a hard system to navigate," Stevens Anderson says, "and so we do have concentrated efforts to connect more information to our beneficiaries, to our patients, at time of service to allow them to do more self-service along the way as well."

    Banner Health has redesigned its main website to become more consumer-focused, with key functionalities including help with finding doctors, services, locations, and education and support opportunities; bill payment; and the opportunity to sign up for a free monthly consumer wellness newsletter. The main website houses the MyBanner patient portal, also recently redesigned to be more consumer-focused, with functions such as scheduling appointments; messaging providers; and viewing medical history, lab results, and visit summaries.

    Informing Other Partnerships

    The ACO model requires participants to form value-based relationships with other payers. BHN has partnered with commercial insurers, including Aetna. BHN's accountable care collaboration with Aetna, known as Aetna Whole Health, began in 2011 and has resulted in total shared savings of more than $9.9 million for the Aetna Whole Health fully insured commercial membership. In 2015, overall medical costs were reduced by 11.5 percent compared with expected costs for the market, and the ACO generated more than $2.6 million in fully insured savings.

    Prioritizing value over volume, the Aetna Whole Health collaboration involves a risk-sharing agreement in which BHN earns compensation based on meeting set quality measures, including reduced hospital readmission rates, percentage of Aetna members receiving recommended preventive care and screenings, and increased access to primary care physicians. Drawing from BHN's integrated delivery system and care management expertise as well as Aetna's health IT and health plan knowledge, Aetna Whole Health has aimed to lower costs for its members while providing more-coordinated care with a focus on wellness.

    "It's an organizational commitment to the evolving healthcare workspace where it's more about managing a population than it is about maximizing fee-for-service reimbursement," says Tom Grote, market president of Aetna's Arizona Market. "And so it's having the cultural perspective throughout the organization about this evolving approach to health care."

    The partnership has succeeded in enrolling employers such as Sun Health Senior Living, a 550-employee owner and operator of three active-destination retirement communities in Arizona. In July 2012, Sun Health Senior Living's previous carrier presented the company with an 11.6 percent premium increase, leaving fewer than half of eligible employees able to afford a plan.

    To recruit and retain staff in a competitive market, Sun Health Senior Living looked to conserve costs while also retaining medical benefits, and enrolled in Aetna Whole Health. Compared with the other carrier's 2012 rate increase, the plan saved the company 10 percent on medical premiums and decreased employees' single-coverage rates by 50 percent. The plan provided employees access to services ranging from same-day sick appointments to appointment reminders to coordinated management of health conditions.

    "We have demonstrated results in improved quality," Stevens Anderson says. "We've focused on the experience, improved cost, and grown memberships together tremendously."

    Web Exclusive: Additional Banner Health initiatives in alternative payment models

    Moving Forward

    Managing its Medicare population, BHN has demonstrated significant improvement in savings and quality since it began participating in the Pioneer ACO Model in 2012. Its aggregate and earned savings have increased by 83.9 percent, from $19,098,858 and $13,369,201, respectively, while its quality score has increased by about 33 percentage points. BHN completed its fifth year in the Pioneer ACO model on Dec. 31, with results expected in August.

    BHN’s Performance History

    Banner Health Network’s annual performance in the Pioneer ACO program.

    "It's a team sport these days," Groves notes about BHN's performance. "It's impossible to get the kind of results we got without being able to engage everybody in driving toward an improved experience, in a more sustainable strategy that takes care of our patients."

    BHN plans to build on key lessons from its ACO collaborations to deliver on the Triple Aim. With healthcare spending hitting $3.2 trillion in 2015, a year-over-year increase of 5.8 percent—the highest increase in eight years—BHN will continue to partner with CMS and commercial plans to explore ways to address these costs through APMs.

    "The problem of rapidly rising costs is not easily solved and continues to be a problem," Groves says. "We remain determined to transform health care, and that means we've got to get much more efficient, much higher in quality, and more reliable in the delivery of that quality. This ACO opportunity with CMS was really an opportunity to test out a lot of our ideas and others in the country about what might work."

    A member of Premier, a healthcare advocacy organization, BHN is closely watching for potential policy changes accompanying the new presidential administration. BHN would support opportunities to build on value-based approaches to health care in APMs, such as through further exploration of telemedicine and by better equipping beneficiaries to manage their overall health outcomes.

    Building on its previous collaboration with commercial plans and drawing from its ACO experiences, BHN has launched a joint venture with Aetna, known as Banner | Aetna. The jointly owned health plan launches in 2017 and promotes 100 percent alignment and financial accountability in support of higher-quality, effective care delivery that leads to decreased premiums for customers.

    Among the goals of Banner | Aetna is providing user-friendly technology to its customers, including by connecting Aetna's member site with BHN's patient portal so members can locate information about their health care and plan. The collaboration will continue offering access to BHN's provider network and launch a 24-hour phone service managed by BHN nurses.

    "We've been able to see BHN's strengths in the population health area through the ACO partnership, and we've been able to improve the health of the population while becoming more efficient in the way we deliver health care," Grote says.

    BHN also is expanding its collaboration with CMS, having been accepted into Track 3 of the Medicare Shared Savings Program (MSSP) and been granted a waiver of the three-day SNF rule for 2017. Involving varying levels of savings and risk compared to the Pioneer ACO Model, the MSSP gives ACOs opportunities to take on responsibility for reducing healthcare costs and enhancing the quality of care for Medicare beneficiaries.

    Embarking on these new collaborations, BHN plans to build on its previous experience, focusing on the team approach that has yielded substantial savings and better care quality. Says Stevens Anderson, "The alignment throughout the whole continuum has been the key to our success."

    Elizabeth Barker is a digital communications professional and freelance writer in Chicago. 

    Interviewed for this article:

    Lisa Stevens Anderson, vice president and CEO, BHN.

    Robert Groves, MD, vice president of health management and chief medical officer, BHN.

    Kathleen Harris, senior director of government operations, BHN.

    Tom Grote, market president, Arizona Market, Aetna.